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Fractures and Dislocations in Children

In children, it is more common to have fractures than it is to have ligament sprains. The growth plates have some unusual properties in that they are actually a little bit weaker than the ligaments and the bones near by, so stress that is placed toward the end of the bones will tend to fracture through the physis, through the growth plate rather than through the bones elsewhere or through the ligaments.

The patient’s will often present being unwilling to put weight on the leg or unwilling to move the leg. The x-ray on the right here is a child with a nondisplaced tibia fracture, it took about two or three days before the parents were sure there was something going on and they brought him in for us to see, but the patient was refusing to bear weight on the leg. This is a two-year-old child. It’s a little hard to see the swelling on the left, but this is what we are talking about with the child’s fractures. An injury that would cause an ankle sprain is an adult is more likely to cause a physeal fracture through the distal fibula, as that piece of the end of the fibula.

In order to confirm the diagnosis, the radiographs are helpful, although the clinical presentation still probably plays a bigger part than it does in adults. If you are going to get x-rays, you want to get x-rays in two planes and that’s because sometimes the fracture won’t show up all in one plane and sometimes you will see that the fracture is different in the two planes. You can see here an AP and lateral view, on the later view to the left, you can see that the fracture goes into the growth plate and up.

To go through a couple of terms that are used all the time in kids, you will hear referred to a torus fracture, a buckle fracture. A torus fracture is this one over here on the left, and you can see it looks like just a little wrinkle in the bone, the name torus comes from the top of the column where you just get a little bit of a break. This is a break, it’s very subtle, the prognosis is extremely good on this, but it is a fracture, just the same it will take six weeks to heal. This is what we call a green stick fracture, and the reason it’s called that, is that part of the cortex is still intact, even though the other part of the bone is broken. It’s called green stick as in a live branch that you try to break and it doesn’t break cleanly, but some of the fibers still remain connected.

You don’t see very many ligament sprains in kids, you see mostly fractures, and you can tell the difference because you can palpate the growth plate in addition to the ligament, you will find they are tender over the growth plate more so than they are at the ligament. Again, this is what the fracture is going to look like, you see this little small piece of bone here, this is a chip of the metaphyseal portion of the bone that stays with the other portion of the bone, so the fracture line goes into the metaphysis.

Here is an example of a growth arrest that occurred after a fracture, and it didn’t seem to be a very dramatic fracture. Here is an example of a Salter II fracture in the distal femur. Distal femur is the one exception to the good prognosis rule for Salter II’s. This was recognized and it was fixed with the screw across the metaphysis, nothing was crossing the growth plate, but as this healed. The patient developed a growth arrest right in here and this stopped growing, the other part continued to grow.

The treatments for this, just for information, we can go in and take out some of those areas that are connected if they are not too large. If we eliminate the tethered area and the rest of the growth plate is still alive, then it will function normally and it will start to grow again. If this doesn’t work and it doesn’t grow, then this is the device that is used as part of leg lengthening type procedures, which we as pediatric orthopaedists get involved with. These two sets of rings are driven apart by these clickers.

Here is an example of what we call growth arrest lengths, and these are kind of important to tell you later on whether there has been a problem in growth or not, this is not actually a fracture, this is a patient with Blount’s disease, but you can see here, these lines, there is one line here and one line here, these are made by the growth plate at some point in the patient’s life, and then the patient’s continue to grow since then. I want to point out that the lines are farther apart here than they are over on this side.

If you x-ray a child four to six months after they have had a fracture, what you want to see is growth arrest lines that are parallel to the growth plate. If you see that, then you know the patient has grown, they have grown uniformly and there hasn’t been any damage to the growth plate. This is also an example of what happens.

Fractures that we consider can be treated in the office, fingertip injuries. Most of the time what’s common is people get their finger caught in a door and they avulse their nail bed and the tip of the finger, we are usually treating those with dressing changes and the nail will usually regrow. You want to make sure that the bed doesn’t close down over the top, so some sort of spacer in the bed is often helpful. Usually the base of the nail matrix does not get damaged in a typical injury and the nail will regrow. Finger fractures - the key to finger fractures are the rotational alignment. All of your fingers should converge on one point, that’s at the base of your thumb, it’s marked here on the x-ray. If when you bend the finger down, the fractured metacarpal.

Nursemaid’s elbow, I am sure the pediatricians have all seen this, it occurs for a traction injury on the arm, usually the child is under four years of age. Often times when you send the child to radiology to get an x-ray, they elbow, as they position the child’s hand in supination, the dislocation will reduce and then the child will start using the arm more easily. The key to this, is that the child should feel better pretty much within a few minutes after it goes back in place and start using the arm. It doesn’t happen after you are four or five years of age, and I have never seen anybody with a long term problem with this.

Clavicle fracture, we almost always treat clavicle fractures in a sling. The figure-of-eight dressing that you may have seen at one point is very uncomfortable and only small kids will tolerate it. The older kids will loosen it and they won’t really get much pull from it anyway. There are occasionally ones that have to be operated on but it is usually because the skin is so tented.

The tibial fracture like the one I showed in the beginning, if it’s a nondisplaced tibial fracture, that’s usually going to be in two or three year-old children, those can be casted, the kids will do fine once they are in the cast.

Fibular fractures, again, nondisplaced fractures that don’t involve the joint can be treated in the office with splinting or casting, and/or crutches. We typically treat these with a couple of weeks in a cast with crutches and then we let them start weight bearing on it after about three weeks.

Metatarsal fractures, not a real big deal, the patient’s are more comfortable in a cast. We are fairly aggressive about casting some things because the patient’s are more comfortable in the cast, they don’t need it to heal, but they will feel better.