Pediatric Fractures in Developing Bone

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 (estimated that child maltreatment will be suffered by 1 out of 8 U.S. kids).²

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 (malnutrition or iatrogenic), chronic corticosteroid use, renal or hepatic disease, genetic conditions such as osteogenesis imperfecta, renal osteodystrophy, 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.^3,4

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.⁵ 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 The ratio of fractures in boys to girls is 2.7:1.⁷   Fractures of the lower arm are the most common, accounting for 18% of all fractures, followed by finger and wrist fractures.⁶

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

The most common pediatric long bone fracture locations are forearm, femoral, and tibial.⁷

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.^6,8

High-velocity injuries such as MVAs and falls are common causes of pediatric multi-trauma with fractures.⁶ Nearly 25% of pediatric lower extremity injuries seen in the emergency department involve a fracture.⁷

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.⁵ Pediatric periosteum is thicker and stronger, which can produce a larger callus more rapidly and allow faster healing and maintenance of the bone alignment.³

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, specifically angulation and torsion.¹

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 or intraarticular 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.

• Buckle or torus fractures: occurs with compression and is a stable fracture as the bony cortex is not interrupted¹
• Greenstick fractures: incomplete fracture due to tension side failure and compression side deformity, associated with angulation
• Bowing fractures: not a true fracture, bone is bent beyond it’s typical limits
• Physeal fracture: described with Salter-Harris classification, generally the higher number are associated with increased complications
  • Type I: transverse fracture through the physis
  • Type II: most common type (75%), affects the physis and metaphysis
  • Type III: interruption in the physis and epiphysis, may involve intra-articular structures
  • Type IV: involves the physis, metaphysis, and epiphysis
  • Type V: physis crush injury^1,7
• Apophyseal avulsion

Specific secondary or associated conditions and complications

Child abuse concerns

• 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
• Multiple fractures in different stages of healing
• Epiphyseal-metaphyseal (“corner”) fractures from pulling and twisting forces
• Rib fractures
• Distal femoral metaphyseal fractures in 1 year old or younger

Complications of fracture
Acute

• Neurovascular injury – most common with supracondylar humeral fractures
• Hemorrhage
• Fat embolism
• Compartment syndrome

Chronic

• Overgrowth
• Premature growth plate fusion leading to limb length discrepancy
• Nonunion/pseudarthrosis
• Malunion
• Post-traumatic osteolysis
• Avascular necrosis
• Deep venous thrombosis or pulmonary embolism
• Refracture
• Complex regional pain syndrome

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:

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

• The child’s mood and behavior (i.e., irritable, tearful, guarding)
• 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
• Palpation: Temperature, point tenderness, and tightness
• Evaluation of the joint and distal neurologic and circulatory function: AROM and PROM, distal pulses, sensation, distal muscle strength testing
• Gait including observing whether the patient is weight bearing
• Ophthalmologic examination for suspected child abuse (rule out retinal hemorrhages or detachment), 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 low serum calcium and phosphorous coupled with an elevated alkaline phosphatase can help make the diagnosis.⁹

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.⁸

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.⁸

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.⁵

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, intra-articular fractures, and characterizing fracture patterns, such as comminuted and displaced fractures.^4,7 However, given the large doses of ionizing radiation, it should be used with caution.

MRI is sensitive to detect osseous, cartilaginous, early vascular changes, and marrow lesions. MRI can also better characterize soft tissue injuries that may accompany a fracture. ⁷ However, MRI is expensive and has prolonged scan times, requiring cooperation or sedation in children.⁴

Ultrasound is valuable in evaluating neonatal skeletal abnormalities, commonly used for hip exam.¹⁰

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.

A DEXA scan, considered the gold standard, can also be used to evaluate for bone density abnormalities that could have contributed to fracture presentation.¹¹

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.^1,5

Environmental

The physical environment plays a role in the mechanism of injury. Physically active children may sustain a fracture during sports-related activities due to 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. It is estimated that patients with CP have an annual fracture rate of double that of a normal aged matched population.¹²

The patient’s home, including exposure to secondhand smoke, nutritional access, and sun exposure, can also play a role in certain risk factors for fractures.

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.⁶ 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.¹³

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, retention of mobility, as well as 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.^5,14

Acute physeal fractures

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

Open Fractures

• Debridement, irrigation, antibiotics and reduction with stabilization

Pathological Fractures

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

Birth Fractures

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

Fractures from Child Abuse

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

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 from a fracture. Depending on the pathophysiology, involvement of a geneticist or endocrinologist 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.¹ 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.¹⁵

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.¹⁶

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.¹⁶

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 fracture diagnosis and management.¹⁷ It avoids radiation from radiographs, and it saves time by providing a real-time image. Point of care ultrasound has been utilized in emergency departments for closed reduction of pediatric forearm fractures. ¹⁸ Ultrasound as a therapeutic modality has also been used for fracture healing.

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.¹⁰ Bisphosphonates may be recommended for children with recurrent extremity fractures confirmed due to low bone density.¹²

Bisphosphonates are usually administered as an IV infusion for those with osteogenesis imperfecta. Bisphosphonate therapy is also considered for children with confirmed osteoporosis by DXA scan and history of recurrent long bone fractures. It is recommended that nutritional deficiencies, therapy needs, and endocrinology evaluations should all be done prior to initiation of bisphosphonate therapy for secondary osteoporosis.¹²

References

1. Marcdante, Karen J. Kliegman RM. Schuh AM. Nelson Essentials of Pediatrics – Fractures. 9th ed. (pp. 756-758). Philadelphia: Elsevier; 2023. https://www.clinicalkey.com/#!/content/book/3-s2.0-B978032377562500198X. Accessed August 9, 2022.
2. Wildeman C., Emanuel N., Leventhal J.M., Putnam-Hornstein E., Waldfogel J., Lee H.: The prevalence of confirmed maltreatment among US children, 2004–2011. JAMA Pediatr 2014; 168: pp. 706-713
3. Calmar EA, Vinci RJ. The anatomy and physiology of bone fracture and healing. Clin Pediatr Emerg Med. 2002. doi:10.1053/epem.2002.127037
4. 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
5. Sawyer JR, Spence DD. Fractures and Dislocations In. Thirteenth Edition. Elsevier Inc.; 2016. doi:10.1016/B978-0-323-37462-0.00036-7
6. 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
7. Golshteyn G, Katsman A. Pediatric Trauma. Clin Podiatr Med Surg. 2022 Jan;39(1):57-71. doi: 10.1016/j.cpm.2021.08.001. PMID: 34809795.
8. Bachrach LK. Casting More Light on Pediatric Fractures. Pediatrics. 2019;144(2). doi:10.1542/peds.2019-1594
9. McKinley, John C. Ahmed I. Principles and Practice of Surgery. 8th ed. (pp 518-535.). Philadelphia: Elsevier; 2023. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780702082511000285?scrollTo=%23top.
10. 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
11. Bachrach LK, Sills IN, Kaplowitz PB, et al. Clinical report – Bone densitometry in children and adolescents. Pediatrics. 2011. doi:10.1542/peds.2010-2961
12. Simm PJ, Biggin A, Zacharin MR, Rodda CP, Tham E, Siafarikas A, Jefferies C, Hofman PL, Jensen DE, Woodhead H, Brown J, Wheeler BJ, Brookes D, Lafferty A, Munns CF; APEG Bone Mineral Working Group. Consensus guidelines on the use of bisphosphonate therapy in children and adolescents. J Paediatr Child Health. 2018 Mar;54(3):223-233. doi: 10.1111/jpc.13768. PMID: 29504223.
13. Escobar MA Jr, Wallenstein KG, Christison-Lagay ER, Naiditch JA, Petty JK. Child abuse and the pediatric surgeon: A position statement from the Trauma Committee, the Board of Governors and the Membership of the American Pediatric Surgical Association. J Pediatr Surg. 2019 Jul;54(7):1277-1285. doi: 10.1016/j.jpedsurg.2019.03.009. Epub 2019 Mar 21. PMID: 30948199.
14. Caruso G, Caldari E, Sturla FD, Caldaria A, Re DL, Pagetti P, Palummieri F, Massari L. Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature. Musculoskelet Surg. 2021 Dec;105(3):225-234. doi: 10.1007/s12306-020-00684-6. Epub 2020 Oct 14. PMID: 33058085; PMCID: PMC8578082.
15. 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
16. 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
17. Litrenta J, Masrouha K, Wasterlain A, Castaneda P. Ultrasound Evaluation of Pediatric Orthopaedic Patients. J Am Acad Orthop Surg. 2020 Aug 15;28(16):e696-e705. doi: 10.5435/JAAOS-D-17-00895. PMID: 32769718.
18. Scheier E, Balla U. Ultrasound-Guided Distal Forearm Fracture Reduction by Pediatric Emergency Physicians: A Single Center Retrospective Study. Pediatr Emerg Care. 2022 Feb 1;38(2):e756-e760. doi: 10.1097/PEC.0000000000002464. PMID: 34140450.

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.

Previous Revision(s) of the Topic

Mi Ran Shin, MD, Melissa Fleming, MD. Pediatric Fractures in Developing Bone. 11/8/2019

Author Disclosure

Mi Ran Shin, MD
Nothing to Disclose

Nicole Eno, MD
Nothing to Disclose

Justin Burton, MD
Nothing to Disclose