Fractures, Pediatric

Basics

Description

  • 20% of pediatric patients with acute traumatic injuries will have a fracture
  • Anatomy:
    • Diaphysis: Physis to physis; bone shaft
    • Epiphysis: Cartilaginous center at or near end of bone that is site of bone growth
    • Epiphyseal (growth) plate: Radiolucent line between epiphysis and metaphysis; cartilaginous
    • Metaphysis: Region of rapidly growing trabecular bone underlying base of cartilaginous growth plate; between diaphysis and epiphysis
    • Most long bones are ossified by the end of puberty
  • Fracture types not seen in adults:
    • Greenstick fracture: Incomplete fracture through cortex on opposite side of impact
    • Torus (buckle) fracture: Compression of bone of 1 cortex
    • Plastic deformity: Bowing without disruption of cortex
    • Fractures involving the physis (Salter–Harris [SH]):
  • Ligaments more resistant to injury than growth plates
  • SH classification:
    • Risk of growth disturbance increases from type I–V
    • Type I:
      • Separation of epiphysis from metaphysis without displacement or injury to the growth plate
      • Tenderness and pain at point of growth plate
      • Radiograph often normal or growth plate may appear widened
      • Growth disturbance is rare
    • Type II:
      • Metaphyseal fracture extending to physis
      • Most common SH fracture
      • Growth disturbance is rare
    • Type III:
      • Intra-articular fracture extending through the epiphysis into the physis
      • Most common site is distal tibial
      • Growth disturbance possible
    • Type IV:
      • Epiphyseal, physeal, and metaphyseal fracture
      • Lateral condyle of humerus is the most common site
      • Growth disturbance highly likely
    • Type V:
      • Crush injury to epiphyseal plate, producing growth arrest
      • Usually occurs in joints that move in only 1 plane such as knee

Etiology

  • Mechanism is useful in defining the potential and type of injury
  • Obesity and rapid growth spurts are risk factors
  • Nonaccidental Trauma (NAT):
    • Any fracture in a child <1 yr of age in whom history is not consistent with injury
    • Inconsistencies in caretaker’s account of injury
    • Injury inconsistent with child’s developmental stage
    • Fractures commonly associated with NAT: Metaphyseal “corner” and “bucket handle” fractures (pathognomonic), posterior rib fractures, long bone fractures in nonambulatory children, multiple fractures in different stages of healing, skull fractures crossing suture lines (especially in children <1 yr)
    • If identified fracture is concerning for NAT, consider head CT and skeletal survey to assess for further injury

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