Fractures in children
Content:
- Features of fractures in children
- Clavicle fracture
- Proximal shoulder fracture
- Distal shoulder fracture
- Fractures in toddlers
- Lateral ankle fracture
- Metatarsus fracture
- Fracture of the phalanges of the toes
- Surgical treatment of fractures in children
The children's skeletal system differs from the adult skeletal system not only in physiological, but also in biomechanical and anatomical characteristics. Therefore, the methods of diagnosis and treatment of fractures in children have their own characteristics.
A child's bones contain cartilage tissue. The periosteum in children is stronger than in adults, so it forms callus faster. The child's skeletal system absorbs more energy, children's bones have less mineral density and more porosity than adults. The increased density is provided by the presence of a large number of Havers channels. Therefore, bones in children are less elastic and less strong than in adults. Approximately 10-15% of all injuries in children end in bone fractures. With age, bones become less porous, their cortical layer thickens and becomes stronger.
Features of fractures in children
When limbs are injured, growth zones may be damaged, since the ligaments are often attached to the epiphyses of the bones. But their strength is increased by the perichondral rings and intertwining mastoid bodies. Ligaments and metaphyses are stronger than growth zones: they are more resistant to stretching. The severity of the fracture (whether it will be displaced) largely depends on the periosteum: if the periosteum is thick, this prevents closed reduction of bone fragments.
Fracture healing
The fracture healing is influenced, first of all, by the child's age, as well as by how close the injury site is to the joint and whether there are obstacles to joint movement. Anatomical reduction of fragments in fractures in children is not always necessary. During healing, bone remodeling occurs due to the resorption of old bone tissue and the formation of new one.
The younger the child, the more remodeling opportunities. If the bone deformity is close to the growth zone in the plane of motion of the joint axis, then the fracture will heal faster. Intra-articular fractures with displacements, disrupting movement in the joint, rotational fractures, fractures of the diaphysis heal worse.
Excessive growth
As the fracture heals, the bone growth zones are further stimulated by the blood flow, so long bones (such as the thigh) may become overgrown. Thus, in children under 10 years of age, a hip fracture and its subsequent healing can provoke an elongation of this bone by 1-3 cm over the next two years. In order to prevent this from happening, bone fragments are bayonet-shaped. Children over 10 years old do a simple reposition of the fragments, since their excessive growth is not so pronounced.
Progressive deformation
Bone shortening or its angular deformation can occur when the epiphyseal zones are damaged (due to their complete or partial closure). In different bones, such deformation is possible to a different degree, which depends on the possibilities of further growth of these bones.
Fast healing
In childhood, fractures heal much faster than in adults. This is due to the thick periosteum and the ability of children's bones to grow. Each year the rate of fracture healing decreases and gradually approaches the rate of bone healing in adults. Most fractures in children are treated with a closed method. The nature of bone fractures in children is determined by the physiological, biomechanical and anatomical features of their skeletal system.
Most often, children have:
- Complete fractures (when the bone breaks on both sides). Complete fractures are transverse, oblique, helical, impacted (however, a punctured fracture is not typical for childhood).
- Compression fractures occur when compression occurs along the long axis of the tubular bone. In children, a compression fracture is often localized to the metaphysis and distal radius. Such a fracture heals with simple immobilization in 3 weeks.
- A “green branch” fracture in children occurs when the bending of the bone greatly exceeds its plastic capabilities: a complete fracture does not occur, but damage occurs.
- Plastic deformity, or bending - most often, these fractures occur in the knee and elbow joints with insufficient pressure to fracture a bone.
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Epiphyseal fractures in children are divided into five types:
- a fracture in the growth zone occurs against the background of degeneration of the cell columns of the cartilage or against the background of hypertrophy;
- fracture of the growth plate (its part) - extends to the metaphysis;
- fracture of a part of the growth plate that extends to the joint through the pineal gland;
- fracture of the metaphysis, pineal gland and growth plate;
- crushing of the growth plate.
This classification allows you to choose a treatment method and predict the risk of early closure of the epiphyseal growth zones. In the treatment of fractures of the 1st and 2nd types, closed reduction is used, i.e. complete alignment of the fragments is not required (only in case of a fracture of the distal femur according to the 2nd type, complete alignment of the fragments in an open or closed way is necessary, otherwise an unfavorable outcome is possible). With the 3rd and 4th types of fractures, the growth plate and articular surface are displaced, therefore, when treating these fractures, reduction is necessary. A type 5 fracture is most often recognized by its consequences - the premature closure of the epiphyseal growth zone.
Child abuse
It so happens that bone injuries in children are caused by intentional trauma. Trauma to the ribs, shoulder blades, metaphyses of long bones or processes of the vertebrae and sternum may indicate cruelty to a child. The fact that a child has experienced abuse is evidenced by multiple fractures, which may be at different stages of healing, fractures of the vertebral bodies, epiphysis tearing, and finger fractures. A helical or non-adcondylar hip fracture may indicate intentional injury to a small child who still cannot walk.
Clavicle fracture
A fracture of the clavicle between its middle and lateral part is often observed in childhood. Such a fracture can be caused by a birth injury, a direct blow, or a fall on an outstretched arm. A clavicle fracture usually does not cause vascular or nerve damage, and the diagnosis is easily made by clinical signs and x-ray (in the upper or anteroposterior view). The fragments are displaced and found 1-2 cm on top of each other.
To treat such a fracture, a bandage is applied that covers the shoulders and prevents the displacement of the fragments. Complete alignment of the fragments is not necessary when treating a clavicle fracture. The fracture heals in 3-6 weeks. Callus can be felt in 6-12 months.
Proximal shoulder fracture
A type 2 proximal shoulder fracture in children is caused by a fall backwards while leaning on a straight arm. Such a fracture can be accompanied by damage to the nerves and blood vessels. Diagnosis is carried out using an x-ray of the shoulder girdle and humerus in lateral and anteroposterior projections.
When treating a proximal shoulder fracture, simple immobilization is used. Sometimes it becomes necessary to carry out a closed reduction of fragments. But it is not necessary to completely eliminate the deformation: it will be enough to wear a scarf or splint. Closed reduction of fragments and immobilization of the limb is necessary with a sharp displacement of fragments.
Distal shoulder fracture
One of the most common fractures is the distal shoulder fracture. This fracture can be epiphyseal, supracondylar, or transcondylar. Epiphyseal and supracondylar fractures can be caused by a fall on an outstretched arm, and an extracondylar fracture can be caused by child abuse.
The diagnosis is established using an X-ray of the limb in the posterolateral and anterior direct projections. Disruption of the connection of the shoulder with the ulna and radius, or when edema appears on the back of the elbow, indicates the presence of a transcondylar or radiologically non-rectifiable fracture. With these fractures, an attempt to move the hand causes pain and swelling. Neurological disorders may also appear: if the injury is localized near the median, radial or ulnar nerves.
For the treatment of a distal shoulder fracture, the reposition of the fragments is important. Only careful reduction can prevent deformation of the humerus and ensure normal growth. Reposition is carried out in a closed way or with the help of internal fixation of fragments, in extreme cases, open reduction is performed.
Distal fracture of the radius and ulna
Compression fractures of the radial metaphysis are also common in children. It is caused by falling on a hand with an extended hand. Sometimes such a fracture can be mistaken for a bruise, therefore, such fractures are admitted to the hospital only 1-2 days after the injury.
Diagnosis is by lateral and anteroposterior hand x-rays. For treatment, plaster is applied to the wrist joint and forearm. It grows together in 3-4 weeks.
Fracture of the phalanges of the fingers
The cause of the fracture of the phalanges of the fingers in children is most often the pinching of the fingers in the door. Hematomas that require drainage may form under the nails with such a fracture. If bleeding from under the nail bed is discovered or if the nail is partially detached, an open fracture can be diagnosed. In this case, tetanus prophylaxis and antibiotics should be used.
Diagnosis is by finger x-ray in lateral and anterior frontal projections. During treatment, a plaster cast is applied. Closed reduction of fragments is only needed when the phalanx is rotated or when it is bent.
Fractures in toddlers
A spiral fracture of the tibia (its distal third) occurs in children 2-4 years old. Such a fracture can occur when tripping over something or falling while playing. As a result, soft tissue edema appears, the child feels pain and can walk.
Diagnosis is by lateral and anterior frontal x-ray. In some cases, it is additionally necessary to do an oblique x-ray or bone scintigraphy. Treatment consists of a high plaster boot. Already after 1-2 weeks, the subperiosteal formation of bone tissue occurs, and bone fusion occurs after 3 weeks.
Lateral ankle fracture
The separation of the epiphysis of the fibula has symptoms of stretching: pain and swelling appear in the lateral region of the ankle. The diagnosis is confirmed by stress X-ray (conventional X-ray does not reveal a fracture).
Treatment of a lateral fracture of the ankle is performed by immobilizing the fibula with a plaster boot. The treatment lasts 4-6 weeks.
Metatarsus fracture
A fracture of the metatarsus can be caused by an injury to the back of the foot. At the same time, the child's soft tissues swell and a bruise appears. The diagnosis is made by x-ray of the foot in lateral and anteroposterior projections.
As a treatment, a plaster cast is used in the form of a plaster boot. If the diaphysis of the 5th metatarsal bone is fractured, the fracture may not heal. In this case, it is possible to lean on the leg only after X-ray confirmation of the presence of signs of bone fusion.
Fracture of the phalanges of the toes
Such a fracture in a child may result from an injury when walking barefoot. At the same time, bruises appear on the fingers, they swell and become painful. The diagnosis is made by X-ray. Bleeding indicates an open fracture.
In the absence of a strong displacement, closed reduction of fragments is not performed. Treatment consists in tying the diseased finger to the healthy one for several days: until the swelling subsides.
Surgical treatment of fractures in children
Surgical treatment of fractures in children is carried out in 2-5% of cases. Surgical stabilization is performed with an unstable fracture, with multiple or open fractures, with an intra-articular fracture or a fracture of the epiphyses with displacement of fragments.
There are three main surgical methods used to treat fractures in children:
- open reduction with internal fixation;
- closed reduction with internal fixation;
- external fixation.
Open reduction with internal fixation is used for intra-articular fractures, with displaced fractures of the epiphyses, with unstable fractures, with damage to blood vessels and nerves, as well as with an open fracture of the leg or hip.
Closed reduction with internal fixation is used for metaphyseal or diaphyseal fractures, for intra-articular or epiphysis fractures, as well as for fractures of the femoral neck, phalanges of the fingers or the distal part of the shoulder.
External fixation (complete immobilization of the fracture site) is done for fractures accompanied by severe burns, with an unstable fracture of the pelvis, with an open fracture of the 2nd or 3rd degree, with a fracture accompanied by damage to the nerves and blood vessels.
Author of the article: Kaplan Alexander Sergeevich | Orthopedist
Education: diploma in the specialty "General Medicine" received in 2009 at the Medical Academy. I. M. Sechenov. In 2012 completed postgraduate studies in Traumatology and Orthopedics at the City Clinical Hospital named after Botkin at the Department of Traumatology, Orthopedics and Disaster Surgery.
