Pediatric fractures in developing bone

Author(s): Yuxi Chen, MD, Monika Desai, MD, Phuong U. Le, DO

Originally published:09/15/2015

Last updated:09/15/2015

1. DISEASE/DISORDER

Definition

Pediatric fractures include fractures in patients ranging from the neonates to late adolescence. They are markedly different from that of adult fracture, due to distinctive anatomy and biomechanics of developing bone.1

Common fracture sites are distal radius, hand, elbow, clavical, radial and tibial shaft, foot, ankle, femur and humerus.

Etiology

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

Pathological fractures can occur due to demineralization from paralysis or disuse.2

Other conditions causing fractures that mimic radiographic signs of child abuse include osteogenesis imperfecta, osteomyelitis, Caffey disease, and fatigue fractures.1

Epidemiology including risk factors and primary prevention

Nearly 20% of injured children have a fracture. Approximately 42% of boys and 27% of girls will sustain a fracture during childhood.3

Fracture incidence increases with age from birth to a peak between ages 12 and 15 years old. Boys were more than 50% more likely than girls to sustain fracture.4

Factors contributing to fractures include: Low socioeconomic status, African American children, obesity, summer season, risk taking behavior, decreased bone density, Eating disorder, inadequate nutrition, chronic corticosteroid or performance –enhancing drugs use, smoking, and genetics.4

Injuries from sports 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.4

High-velocity injuries such as MVAs and falls are common causes of pediatric multitrauma with fractures.4

Patho-anatomy/physiology

Biomechanically different from adult bone, pediatric bone is significantly less dense, more porous and is penetrated by capillary channels. It has a lower modulus of elasticity and lower bending strength, which makes it easy to bend, allows greater energy absorption before fracture, and fracture line does not propagate as in adult.

Pediatric periosteum is thicker and stronger with function of fast healing and maintaining the bone alignment.1,2

Pediatric long bone has three regions: epiphysis, physis and metaphysic. Comparing with ligament or metaphysic, physis is the anatomic weak point and is more likely to be damaged.1

Unique pediatric fracture healing: Fracture remodeling, overgrowth and progressive deformity

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

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

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 V types) is often used. The higher the classification, the more likely is physeal arrest or joint incongruity to occur.
  3. Plastic deformation: common in the ulna
  4. Apophyseal avulsion

Specific secondary or associated conditions and complications

Child abuse concerns:

  1. Multiple fractures in different stages of healing;
  2. Epiphyseal-metaphyseal (“corner”) fractures from pulling and twisting forces;
  3. Rib fractures;
  4. 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. Reflex sympathetic dystrophy syndrome

2. ESSENTIALS OF ASSESSMENT

History

A thorough history provided by the caregiver and/or patient is critical for 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)
  2. Mechanism of injury. Was it witnessed? Is mechanism in proportion to injury and child’s developmental age?
  3. Presence of neurological or vascular complications
  4. In utero, birth, and neonatal history
  5. Familial history of fractures or bone or collagen disorders
  6. 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, etc)
  2. Inspection: swelling, asymmetric deformities or 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 heeling
  3. Palpation: Temperature, point tenderness, and tightness
  4. Evaluation of the joint and distal neurologic and circulator function: AROM and PROM, muscle tone and strength, spasticity, contracture
  5. Ophthalmologic examination for suspected child abuse (rule out retinal hemorrhages)
  6. Provocative maneuvers that are specific to bone or joint

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.

Imaging

The first line imaging study is plain radiograph (AP and lateral views) including the proximal and distal joints.  Comparison with unaffected side helps differentiate between normal growth plate vs pathologic fracture.

A complete skeletal survey is warranted for suspected non-accidental trauma.  This survey includes AP views of the entire skeleton, 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.5

CT scanning is more sensitive for detection of subtle or occult fractures, as well as characterizing fracture patterns, such as comminuted, displaced, etc.6 However, given the large doses of ionizing radiation, it should be used with caution.

MRI is sensitive to detect osseus, 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.6

Ultrasound is valuable in evaluating neonatal skeletal abnormalities, commonly used for hip exam.6

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/splinting 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.5

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 for 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.7

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 osteoporosis. Children with multiple injuries including 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 concerning for stiff joints.8

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. Debridment, 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 and Fractures from Child Abuse

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

Limiting use of bisphosphonate is recommended to children with recurrent extremity fractures due to osteoporosis.9

Coordination of care

Coordination of care between a physiatrist, an orthopedic surgeon, a physical therapist and/or an occupational therapist is recommended for a successful recovery of the child suffering a fracture.

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.

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 growth disturbance.

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 of body parts, combines physician-assessed parameters, functional abilities, and patient’s perception of pain.10

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.8

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.8

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

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. Radiography is reserved for indeterminate or complex cases.11 It is currently limited by availability of experienced personnel.

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 heavier body weights of children. Although the data supporting operative techniques are limited.

REFERENCES

  1. Well L, Sehgal K, Dormans JP. Common fractures. In: Kliegman RM, Stanton BF, Geme JWS, Schor NF, Behrman RE, Nelson Textbook of Pediatric. 19th ed. Philadephia, PA: Elsevier Inc.; 2011: 2387-2394.
  2. Calmar A, Vinci, RJ. The anatomy and physiology of bone fracture and healing. Clin Ped Emerg Med. 2002; 3(2):85-93.
  3. Hart ES, Albright MB, Rebello GN, Grottkau BE. Broken Bones: Common pediatric fractures—part I. Orthop Nurs. 2006 Jul-Aug; 25(4):251-6
  4. Mathison DJ, Agrawal D. An update on epidemiology of pediatric fractures. Pediatr Emer Care. 2010; 26(8): 594-603
  5. Canale ST, Beaty JH. Fractures and dislocations in children. In: Canale ST, Beaty JH, Eds. Campbell’s Operative Orthopedics, 12th Philadephia, PA: Elsevier Inc.; 2013: 1365-1369.
  6. Blickman H. Skeletal System. In: Blickman J, Thrall, J. Eds. Pediatric Radiology: The Requisites, 2nd ed. Louis, MO: Mosby Publishing; 1998: 196.
  7. Murphy KP, Wunderlich CA, Pico EL, Driscoll SW, Moberg-Wolf E, Rak M et al. . Orthopedics and musculoskeletal conditions. In: Alexanders MA, Mattews DJ , Eds. Pediatric Rehabilitation. 4th New York: Demos Medical Publishing; 2010: 411-412.
  8. Frick SL. Skeletal growth, development, and healing as related to pediatric trauma. In Mencio GA, Swiontkowski MF, Eds. Green’s Skeletal Trauma in Children. 5th ed. Philadelphia, PA, Elsevier Saunders; 2015: 1-14.
  9. Bachrach LK, Ward LM. Clinical review: bisphosphonate use in childhood osteoporosis. J Clin Endocrinol Metab. 2009; 94(2):400-409.
  10. Olson SA, Probe RA. Outcome Assessment in Orthopaedic. In: Browner BD, Jupiter JB, Kretteck C, Anderson PA, Eds. Skeletal Trauma: Basic Science, Management, and Reconstruction. 5th Philadephia, PA: Elsevier Inc.; 2015: 727-735
  11. Cross KP. Bedside ultrasound for pediatric long bone fractures. Clin Ped Emerg Med. 2011; 12(1):27-36.
  12. Lieber, J. and P. Schmittenbecher, Developments in the treatment of pediatric long bone shaft fractures. Eur J Pediatr Surg, 2013. 23(6):427-433.

Bibliography:

Jenny C. Evaluating infants and young children with multiple fractures. 2006; 118(3):1299-1303.

The Treatment of Pediatric Supracondylar Humerus Fractures; Evidence based guideline and evidence report. American Academy of orthopedic Surgery 2011, http://www.aaos.org/research/guidelines/SupracondylarFracture/SupConFullGuideline.pdf

Author Disclosure

Yuxi Chen, MD
Nothing to Disclose

Monika Desai, MD
Nothing to Disclose

Phuong U. Le, DO
Nothing to Disclose

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