Particularities and fractures in children

Question 1

Bone growth

Answer 1

• The growth in diameter of bones occurs by deposition of bone beneath the periosteum, named appositional bone growth
• Endochondral ossification, appears at the growth plate level, is responsible for the growth in lenght

Question 2

Physical properties of the bone in children

Answer 2

1.Is more hydrated, so it has more flexibility
2.Has a thicker periosteum and is more vasculated
3.Has a decreased bone mineral density (more porous), so it is less resistant
->
Unique fracture pattern

Question 3

Fracture healing stages 1+2

Answer 3

1. Inflammation stage
   - First 7 days
   - Hematoma forms and provides a source of hematopoietic cells capable of secreting growth factors
2. Soft callus formation
   - Next 10 days
   - Fibroblasts and mesenchymal cells migrate to the fracture site and granulation tissue forms around the fracture ends

Question 4

Fracture healing stages 3+4

Answer 4

3. Hard callus formation
   - After 2-3 weeks
   - Enchondral ossification converts soft callus to hard callus

4.Remodeling
The bone remodels in response to mechanical stress

Question 5

Frequency of fractures

Answer 5

42% of boys between 0-16 years old
27% of girls between 0-16 years old

Suffer at least 1 fracture

Question 6

The incidence of long bone fractures

Answer 6

Radius 45,1%
Humerus 18,4%
Tibia 15,1%
Clavicle 13,8%
Femur 7,6%

Question 7

Variables

Answer 7

1. Age
   - The risk for fracture increases with age, from 1 to 12 years old
2. Gender
   - Boys are much more likely to sustain a fracture than girls (2,7:1)
   - At younger ages the incidence is similary but after the age of 12, 83% of the fractures happen to boys
3. Summer>winter
4. Country side>urban area
5. The peak of the day is at 18.00

Question 8

Child specific fractures

Answer 8

Buckle fracture 
Plastic deformation 
Greenstick fracture
Toddler’s fracture 
Growth plate fracture

Question 9

Buckle fracture

Answer 9

In the metaphyseal area
The bone is more porous so it has a greater risk for compression fractures
Treatment: short cast for 3 weeks

Question 10

Plastic deformation

Answer 10

Due to the increased flexibility, the bone is more likely to bend
Treatment: long cast, 3 weeks

Question 11

Greenstick fracture

Answer 11

The bone bends and partially breaks but does not extend through the width of the bone
Treatment: reduction, long cast immobilization for 6 weeks

Question 12

Toddler’s fracture

Answer 12

Subperiosteal spiral bone fracture
Due to the thick periostum
Treatment: cast immobilization 4-6 weeks

Question 13

Growth plate fractures

Answer 13

• The most commonly used classification for physeal fractures is the Salter Harris classification
• Salter Harris fractures are classified based on the extent of fracture involvement through the physis, metaphysis and/or epiphysis

Question 14

Growth arrest

Answer 14

• Occurs by disruption of physeal blood supply or bone bridge formation
• Can be partial or complete

Question 15

Salter Harris I fractures

Answer 15

• Traverse the physis, splitting it longitudinally and separating the epiphysis from the metaphysis
• 5% of the growth plate fractures

Question 16

Salter Harris II fractures

Answer 16

• Through the physis and metaphysis
• 75% of the growth plate fractures
  Treatment: reduction and cast immobilization

Question 17

Salter Harris III fractures

Answer 17

• Involve the physis and then extend through the epiphysis and into the joint
• They have the potential to disrupt the joint surface
• Requires open reduction and internal fixation to ensure proper anatomic realignment of the joint surface
• 10% of the growth plate fractures

Question 18

Salter Harris IV fractures

Answer 18

• Involve the metaphysis, physis and epiphysis
• There may be disruption of the joint surface
• 10% of the growth plate fractures

Question 19

Salter Harris V fractures

Answer 19

• Are compression or crush injuries to the physis

- Extremely difficult to diagnose, usually only after the growth arrest appears