There are several concepts that are integral to the treatment of children's fractures. Unlike adult's fractures, many fractures in children can be managed non-operatively. The skeleton in children differs in its ability to heal more rapidly and remodel more thoroughly with ensuing growth. The growth plates, or bone producing portion of the bones disappear with skeletal maturity. Injury involving the growth plates can cause partial or complete growth arrest of that bone and subsequent limb length discrepancy or angular deformity. In treating growth plate fractures, as a general matter only two attempts to reduce a displaced fracture should be made in the emergency room. Injectable narcotics and combinations of narcotics and sedatives should be used with extreme caution in a child with any fracture which requires manipulation. Because these medications can behave unpredictably, a dose that is not giving satisfactory results should not be repeated. It is far safer to admit the child to the hospital, to splint the injury, and to treat the fracture the following day under a general anaesthetic.

The growth plates or physes are specialized areas of the immature bone composed of cartilage cells programmed to make bone. They are found at each end of the long bones, except in the metacarpals and metatarsals, where there is only one physis in each bone. The growth plates of the small bones of the hands and feet are circular. Chondrocytes or cartilage-producing cells are arranged in discrete layers. The first layer, the resting zone, is followed by the proliferation zone, the hypertrophic zone, and finally the calcified zone. Blood vessels invade this last zone, where bone is formed.

The orderly production of bone by the growth plates occurs throughout childhood. The rate of growth is fastest during the first year of life and immediately prior to adolescence. The individual's potential for growth is largely dependent upon hereditary factors and is modified by nutrition and disease.

The unique biomechanical properties of a child's bones may cause the growth plate to fail before the surrounding bone gives way. This is especially true for the ankle. Growth plate fractures occur more commonly than do ligamentous sprains or strains in children because immature ligaments are much stronger than the growth plates. Localized pain and swelling should alert the physician to the possibility of a non-displaced fracture of the distal tibia or fibula that may not be radiographically evident.

Violent injuries to the growth plates may cause cracks that exit either proximally or distally through intervening layers of cartilage cells and into the surrounding bone or even into the joint. These injuries may cause a frameshift of the specialized layers that allow bone to form across the injured area. If the bony bridge caused by the injury is small, the uninjured growth plate cells in close proximity continue to function normally, and can pull the bone bridge apart as longitudinal growth continues. If the bone bridge is more than a few millimetres, it tethers the surrounding growth plate. Such tethering causes cessation of growth at one area of the plate, but unimpeded growth at another area. The bone then grows at an angle.

Injuries to large central areas of the growth plate or to the entire plate stops all growth from that end of the bone. The severity of the problem is dependent on which bone is injured, the size of the injury, and the age of the child at the time of injury. For example, injury to the distal femur in a young child causes a leg length discrepancy of approximately 1 cm/year for the rest of skeletal growth. A 12-year-old girl who is already showing other signs of maturity has much less potential for growth from that growth plate and the same injury may not cause any significant leg length discrepancy or angular deformity.

The most universally accepted classification of growth plate injuries is the Salter-Harris classification (Fig. 1) 2512.

A Salter I injury is difficult to see radiographically. The ephiphysis is separated from the metaphysis, and may appear as a widening on radiographs, if it is visible at all. A Salter II injury is a fracture through the growth plate which exits through the metaphyseal bone, usually taking a small chip of bone with it. This radiographic finding is called the Thurston-Holland sign. A Salter III injury is a separation of the growth plate which exits through the epiphysis and, therefore, into the joint. This fracture does not usually cause growth arrest, but it can lead to post-traumatic arthritis in the joint. A Salter IV fracture transverses both the epiphysis and metaphysis and, therefore, crosses the growth plate. This injury is most likely to result in a vertical frame shift of the cartilage layers and a predisposition to growth arrest. Another serious complication of this injury is joint incongruity that can lead to post-traumatic arthritis. A Salter V injury is a crushing of the growth plate. Although it may look exactly like a Salter I injury, the mechanism of injury differs. It has a poor prognosis.

The Salter-Harris is easily understood and alerts the physician to the severity of injury, treatment needs, and prognosis.

Since medical care has become extremely specialized, the orthopaedist may be the only physician to see the signs of child abuse. A fracture that is not causing a child much distress, or that is already partially healed, may escape identification as child abuse. There should be a high index of suspicion when one sees fractures of the lower extremity in children who are not yet walking, especially near the distal femoral or tibial physes; spiral fractures which are caused by twisting especially in the upper extremities; fractures in various stages of healing in different locations; a delay in seeking medical attention; or a mechanism of injury which does not fit the fracture pattern.

Most communities have established protocols for investigating child abuse cases. The physician who doubts that the injury was accidental is required to report the findings to the designated agency. The potential for lethal injury to an abused child is real, and some studies have reported that 10 per cent of abused children eventually die as a result of abuse.

Pathological fractures occur through inherently weak areas of the bone, due to a generalized skeletal abnormality or a local defect in an otherwise normal bone. Far less force is needed to cause a fracture in these situations. Rickets is an example of generalized weakness of the growth plates that can be attributed to an inability to mineralize newly formed bone. The normal repetitive trauma of walking in a child with rickets may cause the capital femoral epiphysis to slip off the metaphysis, much like a Salter-Harris I injury.

Benign tumours, such as bone cysts occurring in the proximal or distal femur or humerus, may weaken the bone. Stress fractures may also occur through growth plates that are traversed by large tendons. These growth plates are called traction apophyses, a term which describes the type of force exerted on the physes by the tendon of the contracting muscle. For example, with the large patellar tendon inserts into the growth plate of the tibial tubercle, repetitive extension of the knee can cause stress fractures to the growth plate, which is called Osgood-Schlatter's disease.

Children who are non-ambulatory, such as those with spinal cord pathology, have bones susceptible to fracture following trivial trauma. Rolling over in bed or standing in a brace to exercise may cause fractures to the long bones of the lower extremities. Because these limbs may lack normal sensation, the fracture may not cause pain. Redness and swelling present over the extremities should prompt evaluation for pathological fracture.

Fractures may occur through areas of malignant tumours or bones that have been irradiated for tumour. While initially many of these fractures do not require different treatment, there may be a delay in healing requiring surgical treatment. Bone grafting and internal fixation may be necessary to allow healing to occur.

The proximal humerus is a common area of fracture. Fractures are usually through the metaphysis. Proximal fractures often involve the growth plate, usually as Salter II injuries exiting through the metaphysis. Because the growth plate is cone-shaped, the posterior portion of it can be mistaken for a fracture line. Healing of both metaphyseal and physeal humeral fractures is generally prompt. Since 80 per cent of the growth of the humerus occurs at the proximal growth plate, the potential for remodelling is good.

A minimally displaced fracture should be splinted for comfort. A U-shaped, padded coaptation slint splint over the shoulder and under the upper arm, next to the axilla may be used. A second splint may then be added at the forearm to keep the elbow at right angles, and the arm placed in a sling. Although displaced fractures may remodel, reduction under anaesthesia should be considered for widely displaced fractures. The proximal fragment is pulled by the strong rotator cuff muscles into abduction and external rotation. Therefore, the distal fragment must be brought up to the proximal fragment in a markedly abducted position (the salute position). A shoulder spica cast or pinning of the reduction may be required to control the long lever arm of the distal fragment.

In an older child the biceps tendon may be interposed in a widely displaced fracture making reduction difficult. Biceps tendon interposition may be one of the few indications for open treatment. Concurrent shoulder dislocation, while rare, may be seen in association with proximal humeral fractures resulting from high velocity trauma, such as a child struck by a car. A Y-view or transthoracic radiograph should be obtained to assess the location of the humeral head.

Simple bone cysts in the proximal humerus may cause pathological fracture. Ironically, the fracture itself may provide a stimulus for healing the cyst. A bone cyst found incidentally on radiographs must be either monitored or treated with cortisone injection or curretage and bone grafting. The family should be informed about the increased risk of fracture through the untreated cyst following minimal trauma.

The clavicle is the most common bone fractured in children. It lends itself to simple treatment. Most commonly the fracture is caused by a fall on to an outstretched hand or a direct blow. Following high-energy trauma to the clavicle the underlying neurovascular structures should be assessed for injury.

Following low-velocity trauma there is crepitus, tenderness, and bruising at the fracture site. The middle-third of the clavicle is most commonly fractured. Even if the fragments are displaced, anatomical reduction is not necessary in a low-energy injury. A paediatric size figure-of-eight splint tends to bring the clavicle up and to reduce the degree of deformity. If this splint is unavailable, a sling will unload the clavicle and reduce the motion at the fracture site, thereby lessening discomfort. Significantly angulated and displaced fractures should undergo closed reduction under a general anaesthetic. Open reduction and internal fixation are rarely indicated. Conservatively treated clavicle fractures usually show abundant callus formation after 2 weeks. The splint may be removed when there is no longer pain with motion of the arm. Healing of the lesion causes a large bump, which regresses in the younger child, but remains obvious in the older child.

The medial end of the clavicle is far less commonly injured. A fracture through the medial physis may be mistaken for a dislocated sternoclavicular joint. In the young child who has sustained violent trauma, there may be crepitus and tenderness, but radiographs are difficult to interpret due to the overlying structures. Callus formation occurs promptly after this injury: a sling for comfort is the only treatment necessary.

Violent trauma may cause dislocation of the sternoclavicular joint in a teenager near skeletal maturity. A CT scan will disclose the position of the clavicle relative to the sternum. A posterior dislocation may impair breathing or circulation and needs prompt reduction. Anterior dislocations are not associated with any severe morbidity. Since reductions of anterior sternoclavicular dislocations are inherently unstable and promptly redislocate, no attempt at reduction should be made.

Fractures of the lateral end of the clavicle may be mistaken for disruptions of the coracoclavicular and acromioclavicular ligaments. These ligaments are unlikely to rupture in children. Even when the fragments appear widely displaced, the inferior periosteal sleeve is intact and healing is prompt. The extremity should be splinted. Healing will occur in 2 to 3 weeks.

Since the many secondary centres of ossification at the acromion and coracoid of the scapula may be mistaken for fractures, films of the contralateral shoulder should be used as comparison. Fractures of the body of the scapula are associated with violent trauma, and the integrity of the underlying ribs and lungs as well as the neurovascular structures to the arm should be examined carefully. The shoulder and arm should be immobilized for comfort, but because of the intrinsic stability of the scapula, reduction is unnecessary. Fractures involving the glenoid, the articular surface of the scapula, tend to remodel well; there is more tolerance of traumatic joint incongruity than is the case for other joints.

While violent trauma can cause glenohumeral dislocations, the child should be evaluated for generalized ligamentous laxity. Some children are capable of voluntarily dislocating a shoulder or even a hip. Repetitive voluntary dislocation causes the capsule to stretch, thereby setting the stage for further dislocation caused traumatically by ordinary activities such as brushing the hair.

Children who sustain traumatic dislocations support the affected limb with the other hand in a position of slight abduction and external rotation. A careful neurovascular examination should be undertaken prior to reduction. The lateral radiographic view will reveal the anterior or posterior position of the head in relation to the glenoid fossa. Because full abduction for a lateral radiographic view is not possible, a transthoracic or limited axillary view may be required. Reduction is obtained with gentle traction; in an older child this can be performed quickly without sedation or muscle relaxants. The arm is placed in a sling and swathe for 3 weeks. Physical therapy to strengthen the stabilizing muscles of the shoulder should be supervised.

Large babies delivered vaginally may sustain fractures and nerve injuries to the upper extremities. If there is any difficulty delivering the baby, or if the baby is not moving a hand or arm, the examiner must determine whether there has been a fracture to the clavicle or upper extremity, a cervical nerve root or brachial plexus injury, or both. Radiographs of the clavicles and upper extremities should be obtained.

In the case of simple bone trauma, the most common fracture is to the clavicle. Crepitus to the area may be noted. The child should be handled carefully, but no splints are necessary. Healing is prompt and without complication. If radiographs show what appears to be a dislocation of the glenohumeral joint in the newborn infant, the more likely diagnosis is a Salter I fracture through the entire proximal humeral physis. An arthrogram may be used to document the injury. The treatment is to keep the arm gently restrained by a swathe to the side. Resulting varus deformity of the humerus should be monitored. Fracture of the shaft of the humerus may also be seen following difficult delivery. The treatment is also a sling and swathe and careful positioning of the infant (Fig. 8) 2520.

Nerve injury is the most serious orthopaedic consequence of difficult vaginal delivery. If the arm of the newborn appears flail, the pseudoparalysis of fracture must be differentiated from a brachial plexus or cervical root avulsion. The arm should be gently examined for response to touch. If the arm is fractured, sensation will be intact and even though the child will hold the extremity still (pseudoparalysis) to splint against pain, he will show reflexive motion to stroking the arm. The child with a nerve injury will not have normal sensation and will not respond to such stroking. Nerve conduction studies are not useful in the neonatal period. The most useful way to document the injury and to assess prognosis is by repeated clinical examinations. Injury to the lower cervical nerves, including Horner's syndrome, carries a worse prognosis. If a neurological injury has occurred, gentle passive range of motion exercises should be started to prevent contractures while awaiting spontaneous recovery. The wrist may require splinting to prevent subluxation. Erbs' palsy, which involves loss of the triceps function, will paradoxically cause a flexion contracture of elbow. However, the arm should not be splinted in abduction because abduction contractures may then occur.

The possibility of child abuse is raised when there is no logical explanation for a fractures of the shaft of the humerus in a small child. A twisting injury, such as forcefully grabbing the child's arm and pulling him, may cause a spiral fracture of the shaft.

Transverse or spiral fractures can also result from either low- or high-velocity trauma. High-velocity trauma causes significant soft tissue damage and the periosteum may not be intact, making both reduction and its maintenance difficult. The neurovascular status should be carefully assessed.

There are inherent problems in treating fractures of the shaft of the humerus, depending on the anatomical location of the fracture. Widely displaced midshaft fractures can be difficult to control since the axilla limits the medial border of a splint. As in more proximal humeral fractures, the distal fragment must be brought to the proximal fragment, which will be externally rotated and abducted by the deltoid and rotator cuff muscles. More distal shaft fractures behave like supracondylar fractures; they require near-anatomical alignment in the varus - valgus plane to prevent cubitus varus or valgus deformity. If the fracture results from high-energy trauma and there has been extensive soft tissue damage, distal humeral skeletal pin traction can be used to obtain reduction. After the fracture has become sticky, and when swelling has diminished, closed reduction and application of a coaptation splint can be used. More than one reduction may be necessary for high-velocity injuries, in which the fragments are widely displaced. The distal fragment must be brought to the proximal fragment by bringing the arm into abduction in a splint (Fig. 10) 2523. Slight over-riding is acceptable and limb length discrepancy does not pose the same problem as for the lower extremities.

Supracondylar fractures are common in children between the ages of 4 and 8, following playground trauma. A fall on to an outstretched hand is the most common mechanism of injury. A supracondylar fracture of the humerus is not a growth plate injury; however, if improperly treated this fracture carries the risk of subsequent angular deformity if improperly treated. The major nerves and vessels traversing this area of the elbow may be injured by bone fragments at the time of injury. Careful and continual examination of the wrist and hand is required. The fingers may be warm and show good capillary refill even when the brachial artery has been disrupted. A Doppler moniter should be used if the pulses are not palpable. Prompt recognition of a vascular injury should prevent Volkmann's ischaemic contracture.

There is a potential for enormous swelling in supracondylar fractures of the humerus. This swelling can cause circulatory embarrassment and subsequent myonecrosis. Prompt reduction and treatment by internal fixation, which allows the arm to be maintained in less than 90⁰ of flexion, should be instituted. The signs and symptoms of compartment syndrome should be watched for, and fasciotomies should be performed when appropriate.

A minimally displaced, impacted, supracondylar fracture that appears only minimally displaced into a varus position, especially in a very young child, can cause significant varus deformity on subsequent growth of the elbow. True anteroposterior and lateral radiographs of both elbows must be obtained. A true anteroposterior view in which the olecranon fossa is seen en face allows accurate measurement of Baumann's angle, the angle the capitellum makes with the shaft of the humerus. This is the most reliable marker of the carrying angle of the elbow and the restoration of this angle prevents the complication of cubitus varus. Symmetrical restoration of Baumann's angle is the goal in reduction of the fracture.

Percutaneous pinning of the reduced fracture allows the elbow to be immobilized in less than 90⁰ flexion and lessens the chance of further circulatory embarrassment. This type of pinning also allows removal of the splint without loss of reduction if the arm needs to be examined or if the elbow needs to be extended to improve circulation.

The diagnosis of supracondylar fracture is not difficult. The usual history is of a fall on to an outstretched hand. Widely displaced fractures or impacted fractures with a loss of Baumann's angle should be treated by reduction and pinning in the operating room.

Vascular injuries accompanying supracondylar fractures should be repaired immediately. Examination of the hand and forearm for signs of compartment syndrome should be repeated serially for at least 48 h from the time of admission and treatment. Neuropraxia present prior to reduction should be documented; recovery is the norm in children.

Closed reduction of widely displaced fractures requires a general anaesthetic. A difference of 5⁰ Baumann's angle compared with the normal arm and less than 20⁰ of anterior or posterior angulation is the goal for an acceptable reduction. If a closed reduction is unsuccessful, open reduction should be performed. Some 15 to 20⁰ of anterior or posterior angulation can be accepted in a younger child because remodelling in the plane of motion can be expected. An initial loss of sagittal plane motion is regained as remodelling occurs. Skeletal traction through the proximal ulna may be used as a temporary measure if extenuating circumstances do not allow closed or open reduction of a significantly displaced fracture.

Permanent radiographs, not those reproduced by fluoroscopy, should be taken at the conclusion of reduction and prior to disruption of the sterile field. Baumann's angle, reduction in the anterior and posterior plane, and pin placement are assessed at that time. After 4 weeks, minimally displaced fractures may be mobilized and percutaneous pins removed from displaced fractures. In children older than 7 years, 6 full weeks of immobilization are needed.

If a closed reduction is properly performed, the risk of stiffness is less than that in an adult with the same type of injury and treatment. Open reduction is associated with some residual stiffness. When the arm is mobilized, the child should be encouraged to begin to use the arm normally. No physical therapy should be employed nor any passive force applied to the arm. Anatomical reduction is the best guarantee of full use of the elbow. Malunited fractures with severe angular deformities are treated with osteotomy.

Views of the uninjured arm must be obtained because of the large number of secondary centres of ossification at the elbow. The time of the appearance of the centres should be known: the capitellum (lateral condyle) appears by 1 year, the radial head by 4 years, the medial epicondyle by 5 years, the trochlea (the medial condyle) by 7 years, the olecranon by 9 years, and the lateral epicondyle by 11 years.

Lateral condylar fractures are fractures into the growth plate, and these occur in slightly older children than do supracondylar fractures. Very little trauma is needed to cause a lateral condylar fracture. The radiographic findings are often subtle and pain and swelling should alert the physician to the possibility of this injury. Visualization of the lateral condylar fracture often requires oblique views and well-arm views. The metaphyseal fragment may appear quite small and only minimally displaced, and the displaced cartilaginous fragment may not be appreciated without an arthrogram. Radiographs of minimally displaced fractures should be taken every 2 days for the first week if the fracture is being treated without in-situ pinning to ensure that no further displacement has occurred in the cast.

Displacement of more than 2 or 3 mm warrants open reduction and internal fixation to restore joint congruity and to reduce the physeal displacement in an effort to prevent growth arrest, and to promote healing. The amount of actual displacement is always far greater than it appears on radiographs. Because the blood supply to the epiphysis is through the attached muscles of the extensor group, care should be taken to preserve these attachments if surgery is necessary. Avascular necrosis may follow aggressive stripping of these muscles. Pins are removed at 3 or 4 weeks, but immobilization is continued for a total of 6 weeks.

Fractures diagnosed after 3 weeks do not warrant closed or open reduction. However, close monitoring is necessary since displaced fractures may not heal. If non-union occurs, open reduction and internal fixation are warranted. Despite residual deformity seen on radiographs of healed lateral condylar fractures, the function of the arm may be normal.

Growth arrest following injury to the growth plate and subsequent bony bridge formation can lead to a valgus deformity of the elbow. Tardy ulnar palsy may also follow late valgus deformity.

Since the secondary centre of ossification of the lateral epicondyle does not appear until approximately 11 years of age, injury to the lateral epicondyle is usually seen in an older child. The fracture may be easily confused with irregular ossification centres. Treatment of this fracture is closed reduction and cast immobilization for 1 or 2 weeks for comfort, followed by active range of motion exercises.

Unlike supracondylar or lateral condylar fractures of the humerus, medial condylar fractures are rare injuries in children. As in lateral condylar fractures, open reduction and pinning are necessary for widely displaced fractures.

Unlike most elbow injuries to the child, medial epicondylar fractures may result in elbow stiffness. Anatomical reduction is far less important than achieving a normal range of motion. Surgical treatment is usually required when a medial epicondylar fracture is associated with dislocation of the elbow. Fracture of the medial epicondyle should always be suspected if there has been an elbow dislocation.

If closed reduction of the dislocation is impossible, or if after reduction there is no flexion or extension, the fracture fragment has probably been trapped in the joint and open reduction is then necessary. During surgery one finds the origins of the flexor muscles of the forearm and the attached epicondyle spun into the joint. The fragment should be reduced and rigidly fixed to allow early motion.

The minimally displaced fracture requires splinting for comfort for several days followed by supervised active range of motion exercises several times a day to prevent stiffness. If the minimally displaced fracture is treated without reduction and with early motion, and the epicondyle is not in the anatomical location the appearance may suggest an increase in the carrying angle. However, the strength of the extremity is not compromised. Although the bump will persist, there will be no functional loss to the patient. The alternative treatment is open reduction which does not improve function and leaves a scar.

If a fracture is displaced by more than 1 cm the stability of the medial structures should be assessed by applying a valgus stress to the elbow. Instability is an indication for open reduction and internal fixation. In a teenager, a widely displaced fracture can occur following a direct blow to the elbow. Surgical treatment will restore the correct biomechanical length of the flexor muscles.

Dislocation of the humeroulnar joint is seen most commonly in adolescents and teenagers. There has usually been a fall on an outstretched hand or sometimes a direct blow to the elbow. It is mandatory to check the radiographs for an associated fracture of the elbow prior to reducing the dislocation. A dislocation without associated fracture is treated with reduction and immobilization for 3 weeks. Redislocation is usually not a problem.

Subluxation of the radial head or ‘nursemaid's elbow’ is caused by longitudinal force applied to a young child's arm. It may reduce spontaneously, leaving a normal range of motion, but the child may refuse to use the extremity for several days. Radiographs are rarely diagnostic. If the history and physical examination is consistent with subluxation, reduction can be achieved by flexing and supinating the arm while applying pressure over the lateral aspect of the elbow. Although one may hear the radial head reduce, the child will continue to guard the extremity for several days. Subluxation may recur if the annular ligament and capsule have become stretched. If the injury occurs more than twice, the arm should be immobilized for 3 weeks to allow the annular ligament and capsule to tighten.

Dislocation of the radial head may occur as an isolated injury. It should be differentiated from congenital or an old untreated dislocation of the radial head by noting adaptive changes in the capitellum and radius that are seen in the case of long-standing dislocation.

If the diagnosis of an acute traumatic dislocation is made promptly, closed reduction is usually successful. If the diagnosis is missed for several weeks, open reduction becomes necessary. The annular ligament should be repaired or reconstructed and motion should not be started for a week. At that time, gently active supination and flexion - extension motion may be started. A hinged brace which protects against pronation and full extension should be worn for several weeks.

Fractures of the radial neck and head are growth plate injuries. They may be seen in association with dislocation of the elbow or may occur as an isolated injury. Malunion can cause a loss of pronation and supination, and forceful attempts at reduction may cause avascular necrosis and subsequent overgrowth by the medial side of the elbow.

Because angulation of up to 30⁰ will remodel in a young child, anatomical alignment is not necessary. However, if the fracture is widely displaced and reduction is necessary, a general anaesthetic is usually needed. If closed reduction is to be attempted, the associated haemarthrosis should first be aspirated under sterile conditions. If the elbow can be brought through a normal range of motion, reduction is adequate. The elbow should be immobilized for 1 week and range of motion exercises are then started.

Open reduction is indicated if closed reduction fails, if there is significant loss of pronation and supination caused by the proximal fragment being caught in the joint, or if there is angulation of more than 40⁰. Stability should be assessed intraoperatively and internal fixation may be unnecessary. If the reduction is unstable, smooth Kirschner wires are used to hold the reduction. The wires are inserted retrogradely from the metaphysis into the epiphysis but do not enter the joint. These wires are removed after 2 weeks, and active motion is begun.

Fractures of the radius and ulna are far more common than fractures of the elbow or humerus. The diagnosis is not difficult, but the wrist and elbow must be examined for other injuries. Dislocation of the radial head and concomitant fracture of the ulna is not uncommon. While the treatment for fractures of both the radius and ulna is open reduction and internal fixation in adults, these fractures can usually be managed conservatively in children.

The difficulty in treating fractures of both the radius and ulna is achieving and maintaining satisfactory alignment. The propensity for loss of reduction, especially of the midshaft of the forearm, even in a well-moulded cast is high. While anatomical reduction in the varus - valgus and sagittal planes is unnecessary, if such reduction is achieved, then slight loss of reduction over the next few weeks as soft tissues swelling abates is easily tolerated. Some 5 to 10⁰ of varus - valgus angulation and 10 to 15⁰ of anterior - posterior angulation is acceptable. Rotational alignment which is assessed by knowing the proper relationship of distal and proximal landmarks of both bones, is essential if normal pronation and supination is to be restored. The forearm should be immobilized in neutral for midshaft fractures, in supination for proximal fractures, and in pronation for distal fractures. A long arm cast is used to immobilize the limb. Since it is common to lose reduction within the first 7 to 10 days, close monitoring is mandatory so that the fracture can be re-reduced.

Complete fracture of one bone and partial or greenstick fracture of the other requires completion of the partial fracture. Plastic deformation of one bone and fracture of the other requires reduction of both. Distal fractures of the radius and ulna may be difficult to reduce. An irreducible fracture may have interposition of soft tissue, such as periosteum or extensor tendon. If the fractures are irreducible and are widely displaced, open reduction and pinning is indicated. If alignment is satisfactory, but the fracture fragments cannot be distracted and the ends hooked on, bayonet apposition can be accepted. There is a tendency for over-riding of the fracture fragments.

After closed reduction in the emergency room, a long arm well-moulded cast should be applied and the child admitted for observation and elevation. If there is any indication of impairment of circulation, the cast should be split widely or removed completely, even if reduction is lost. Repeat reduction may be accomplished under a general anaesthetic once the swelling diminishes.

Radiographs must be repeated within a week of the initial reduction. In a young child, the fragments will become sticky after 10 days and further attempts at closed reduction will be futile.

Open injuries are associated with more extensive soft tissue damage and a greater propensity for loss of reduction in the first 2 weeks following reduction. Meticulous debridement and closed reduction in the operating room are the mainstay of treatment. The need for a second reduction under a general anaesthetic should be anticipated.

A rare complication of a fracture of both bones is the formation of a synostosis. This occurs more commonly at the proximal two-thirds of the forearm and following high-energy trauma. There is significant loss of pronation and supination. Resection of the synostosis and interposition with an inert substance, such as fat or silicon, carries a guarded prognosis. Resection should not be attempted until the synostosis matures.

Fractures of the distal radius can involve just the metaphysis and/or the growth plate. Fractures of metaphysis require reduction and long arm casting. These fractures can slip back into the initial malalignment even with anatomical reduction. Careful three-point moulding of the cast helps maintain alignment. Repeat radiographs should be obtained several days after reduction. Even after 4 weeks of immobilization and radiographic evidence of callus formation, most children have tenderness at the fracture site. If there has been no loss of reduction, a short arm cast is then applied for 2 more weeks. Distal radius fractures heal promptly and near anatomical reduction should be obtained and maintained.

Fractures of the distal radial growth plate behave differently from fractures of the distal radial metaphysis not involving the growth plate. While these fractures heal more quickly than metaphyseal plate fractures, forceful repeated attempts to reduce the fracture carries the risk of damage to the growth plate. Only one attempt should be made to reduce a completely displaced growth plate fracture without anaesthesia. Integrity of the median nerve should be documented prior to reduction as these injuries may cause a median nerve neuropraxia. The cast should be split to prevent circulatory embarrassment. Passive movement of the extensor tendons over the fracture site causes pain that can be confused with compartment syndrome. Therefore, pain at rest and paraesthesias, and paralysis are better clinical indications of compartment syndrome.

Anatomical reduction, especially in the sagittal plane, is unnecessary for a growth plate fracture. Repeated attempts should not be made to reduce the fracture. Late attempts at reduction should similarly not be attempted. Premature closure of the growth plate and subsequent overgrowth of the ulna is rare. Loss of reduction is rare (Fig. 18) 2544,2545.

While tears of tendons and muscles are rare in children, avulsion fractures at the origin of tendons are seen in the pelvis. The sartorius muscle may avulse the anterior superior iliac spine, the rectus origin may avulse the anterior inferior iliac spine, and the origin of the hamstring muscles may avulse the ischial tuberosity. These injuries are usually associated with an athletic event. They are treated conservatively with rest and crutches. If the injury is not seen for several weeks, abundant callus formation at the site of the avulsion may be mistaken for a bone tumour or infection.

More serious injuries to the pelvis can occur after violent trauma: significant injury to the underlying viscera may also be present. A careful physical examination, including neurological examination of the sacral roots and radiographic views to image the complex shape of the pelvis should be done. Pubic diastasis may be associated with injuries to the bladder and perineum. External fixation with skeletal pins can be used to close the symphysis. These injuries are associated with significant morbidity.

Isolated pubic and ischial fractures can be managed conservatively with bed rest and crutch walking after several days. Double breaks in the pelvic ring and superior displacement of the hemipelvis can cause significant leg length discrepancy and may require open reduction and internal fixation. Concomitant injuries to the underlying viscera or massive haemorrhage require external fixation. The treatment of pelvic fracture is, therefore, dictated by the stability of the pelvis and/ or the underlying visceral trauma or haemorrhage which requires tamponade by volume reduction of the disrupted pelvis.

Similarly, widely displaced acetabular fractures may require open reduction and internal fixation. Central fractures of the acetabulum and dislocation of the femoral head can cause cessation of growth of the triradiate cartilage and avascular necrosis of the femoral head. CT scans can show joint incongruity and identity free fragments in the joint.

Dislocation of the hip is usually associated with high-energy trauma and occurs most often in teenagers. Prereduction assessment of sciatic nerve function and CT imaging to look for fragments of cartilage or bone in the joint should precede closed reduction. Prompt reduction should then be carried out and open reduction should be used when fragments are found on CT scan.

On rare occasions, trivial trauma causes dislocation of the hip in a young child. Prompt reduction should be followed by Buck's traction to allow the resulting haemarthrosis to resolve. Partial weight bearing in a child who is old enough to use crutches or non-weight bearing in the younger child is then employed for several weeks. Underlying ligamentous laxity, such as that associated with Down's syndrome, renders the hip susceptible to dislocation following minor trauma or even activities of daily living.

Except when pathological bone is present, fractures to the proximal femur usually result from severe trauma. These fractures may involve the area proximal to the growth plate, the growth plate itself, or the metaphyseal bone distal to the plate. The main risks are resultant varus deformity of the neck-shaft angle and avascular necrosis of the head of the femur. Fractures of the proximal femur may occur through pathological bone, such as through a simple bone cyst. Traction, closed reduction, and possibly pinning of the fracture is required. Severe trauma can cause complete separation of the femoral head through its growth plate resulting in avascular necrosis. This occurs even if anatomical open reduction has been performed immediately following the injury. Fractures of the femoral neck are also at risk for subsequent avascular necrosis. These fractures require reduction and pinning. In general, the more proximal the fracture, the higher likelihood of injury to the blood supply to the femoral head.

If growth from the capital femoral physis ceases, but growth from the greater trochanter continues, relative overgrowth of the greater trochanter occurs and a varus morphology of the proximal femur will develop. This causes poor hip abduction strength because of the mechanical disadvantage of the high riding trochanter. Overgrowth may also cause loss of abduction as the trochanter begins to abut the lateral aspect of the acetabulum. Depending on the age of the child, a leg length discrepancy may follow a injury to the proximal femoral physis, because this growth plate contributes 30 per cent of the femur's longitudinal growth. In a young child, this can be a devastating injury, causing leg length discrepancy of up to 7 cm.

Fractures of the femoral shaft may result from low-energy or high-energy trauma. A fall from a low height or a vigorous twist to the leg against a firmly planted foot cause typical low-energy femur fractures in a young child. A direct blow to the femur by a car is an example of high-energy trauma which may be also associated with injuries to the head and thorax. All major organ systems must be assessed in victims of high-velocity injuries.

In a child who is not yet of walking age, a femur fracture suggests child abuse. Children who have special problems, such as muscular dystrophy and who no longer walk, or children who have myelomeningocele and have limited walking ability, may sustain femoral shaft fractures from trivial trauma. Good alignment must be maintained, even in those unable to walk, to prevent angular deformities and further progression of the deformities when weightbearing is resumed.

The mainstay of treatment of femoral shaft fractures in children are traction and spica casting. The duration of hospital traction and the type of traction depends upon the age and weight of the child and the availability of hospital resources. The consequences of malalignment include progressive deformity and limb length discrepancy.

Children who weigh less than 13.5 kg (30 lb) and who are less than 2 years old can be treated with overhead traction of both legs. Complications of circulatory embarrassment and skin breakdown can be avoided. The knees should not be placed in hyperextension, and elastic wraps must not be allowed to slide down and act as tourniquets. In children less than 3 years, no overlap or shortening at the fracture should be tolerated. Bayonet apposition of the fragments is acceptable, but the varus - valgus alignment should be anatomical. Varus - valgus alignment can be corrected in a few days to a week when the child is placed in a spica cast. A well-padded spica cast should be applied with the hips and knees slightly flexed. Both legs and both feet are included in the cast to prevent skin breakdown. Families should be instructed in cast care, and a visiting nurse should assist unreliable families. The hips and knees should be flexed to maintain reduction. The child should be handled carefully after cast removal in 1 month. No formal physical therapy is necessary, but in a child older than 3 years, a walker should be provided for several weeks. Refracture is not a common problem in this age group.

Unlike very young children who should have the femur fracture set out to normal length, children between the ages of 3 and 10 face a problem with overgrowth of the fractured limb. The reason for overgrowth is unclear but it probably results from an increase in vascularity during the healing phase. It is necessary to anticipate some overgrowth of the injured femur and to set the fracture 1 or 1.5 cm short.

In children weighing more than 13.5 and less than 22.5 kg (30 - 50 lb), skin traction to both legs and straight leg traction can be used if the initial fracture is minimally displaced. In this case, early spical casting is done with close follow-up to allow the cast to be wedged if malalignment occurs. In children heavier than 22.5 kg (50 lb), a distal femoral pin is applied and the hip and knee are flexed to 90⁰. Proximal tibial pins should be avoided because of potential damage to the anterior portion of the proximal tibial physis. Posterior subluxation of the tibia on the femur can also be associated with so-called 90/90 traction. When adequate callus forms at about 3 weeks a spica cast can be applied. Some 1 to 1.5 cm of over-riding is desirable in anticipation of femoral overgrowth.

Muscle relaxants and analgesics should be offered for the first several days to relieve painful muscle spasms. After several days, the muscles fatigue and traction weight may have to be removed to prevent overdistraction of the fracture fragments. Varus - valgus angulation can be corrected with traction adjustments or at the time of cast application while the callus is still soft. However, it is difficult to change the amount of distraction of the fragments once new bone has begun to form. The fracture should be monitored closely during the first week to obtain the appropriate length. Neurovascular injury is uncommon in closed injuries, but circulation and painless motion of the toes should be monitored.

Length of time in traction varies with the age of child. Children less than 5 or 6 years old require about 2 weeks of traction, followed by another 4 to 6 weeks of spica casting. Children from 6 to 10 years old require 3 weeks of traction prior to casting. The hips and knees should be flexed when the cast is applied to prevent angulation and shortening. The child is seen again in 1 week at which time the radiographs are repeated and the cast is checked for comfort. Loss of reduction can be corrected by wedging the cast. The total time in the cast in a child 6 to 10 years old is 6 to 8 weeks. Protected weightbearing after adequate return of joint mobility and quadriceps strength should be maintained for another 4 to 6 weeks, depending on the age and weight of the child and the maturation of the fracture callus.

When less than 2 years of skeletal growth is predicted, intramedullary nailing is a viable alternative to skeletal traction. It allows for rapid mobilization of the patient. If the preference of the treating physician and family is traction, ‘adult’ type of traction, such as split Russell's or a Thomas splint with a Pearson attachment may be appropriate for the older child. High energy trauma with extensive comminution and/or soft tissue damage results in a fracture which will require longer treatment in traction. Premature casting risks loss of reduction in the cast.

Fractures through the distal third of the femur not involving the growth plate are uncommon. Difficulties are encountered in placing a traction pin distal to the fracture site without violating the femoral growth plate. If the child is close to skeletal maturity, a tibial pin can be safely used. The use of internal fixation by an intramedullary rod or an external fixator is dictated by special circumstances. A child who can not tolerate skeletal traction because of a head injury, seizures, pulmonary problems, or severe open fractures requires operative intervention. Elective intramedullary rodding is reserved for children with less than 3 years of skeletal growth left.

Choosing the correct traction and maintaining attention to alignment and over-riding will result in very satisfactory results of treatment of a major long bone injury.

Fractures to the distal femoral growth plate are most common in the adolescent. A direct blow to the side of the knee or thigh is usually the cause. While the injury is usually a Salter II or III fracture without penetration to the joint, it has a high potential for local growth arrest and subsequent angular deformity or leg length discrepancy. Stress radiographs may reveal an occult injury that is suspected by history and physical examination but not seen on standard radiographs. Closed reduction and pinning with smooth Kirschner wires should be performed. If closed reduction fails, open reduction to remove a soft tissue block, such as a torn piece of periosteum is appropriate. Widely displaced fractures or unicondylar or intracondylar fractures require open reduction and internal fixation.

Dislocation of the patella is common in adolescents. It is usually the result of a valgus force applied to the knee causing a lateral dislocation. Spontaneous reduction may occur. The medial aspect of the retinaculum tears, and there is an associated haemarthrosis. Treatment includes aspiration of the haemarthrosis and immobilization of the joint. If there is moderate to severe swelling, an elastic wrap and knee immobilizer and crutches are used. Once the swelling has diminished, a well-moulded cylinder cast is applied, with the knee in slight flexion to prevent it from sliding. The cast may be removed in 4 weeks, and quadriceps strengthening should be begun. No sports activities should be resumed until the thigh circumferences have been equalized. A removable knee immobilizer should not be used for definitive treatment because of the likelihood of non-compliance in an adolescent.

Dislocation of the patella following trivial trauma is more common in adolescent females who have a relatively wide pelvis relative to the centre of the knee joint. Adolescents of either sex with high-riding patellae are also predisposed to dislocation. Children with Down's syndrome are liable to dislocation because of their underlying ligamentous laxity. Initial management does not differ from the treatment of the traumatic dislocation, but there may be no haemarthrosis and reduction is often spontaneous. Physical therapy is of limited value in these children and surgical reconstruction of the patellar alignment may be necessary if there are repetitive dislocations.

Patellar fractures occur in older children and adolescents and are caused by a direct blow to the knee. A cylinder cast is used for a minimally displaced fracture. If there is a displacement of 3 mm or more, especially in an adolescent, internal fixation with a tension band construction is indicated. The hardware should be removed after healing.

Repetitive stress or acute patella dislocation may cause a fragment of cartilage and attached subchondral bone to break away from the articular surface. The most common location for this injury is the lateral aspect of the medial femoral condyle. Tomograms are often necessary to delineate the fracture fragment. If the fragment has broken free in the joint, it may cause locking, and arthroscopic removal of the fragment may be required. Small defects are treated with cylinder casting and crutches for 4 to 6 weeks. Acute fractures which involve large areas of the weightbearing portion of the femur should be treated with open reduction and internal fixation. Chronic large defects may require bone grafting from the metaphyseal side to prevent further collapse of the subchondral bone.

Although tears of the anterior cruciate ligament are common sports injuries in adults, tears through the midsubstance of the ligament are uncommon in children. Avulsion fractures of the tibial spine and the associated intercondylar area of the proximal tibia are more common. Standard radiographs often underestimate the size and amount of displacement of the fracture; tomograms or CT scans give a more accurate picture of the injury. Small or minimally displaced fractures may be reduced by aspiration of the accompanying haemarthrosis, followed by extending the knee to reduce the fracture. However, most of these fractures require open reduction and internal fixation with absorbable sutures. Radiographs often fail to represent accurately the amount of joint incongruity that is seen at the time of operation. After surgery, a cylinder cast is used for several weeks. Supervised rehabilitation and protection of the repair with a hinged brace is needed when the cast is removed.

Fractures of the proximal tibial growth plate are rare but potentially serious. The popliteal artery is vulnerable to disruption in this injury because of its proximity to the fracture. Careful vascular evaluation including arteriogram is mandatory to prevent loss of limb or myonecrosis. Closed reduction and pinning or open reduction and internal fixation are needed due to the inherent instability of these fractures. As in distal femoral growth plate injuries, partial growth arrest and subsequent leg length discrepancy or angular deformity may follow.

Fractures of the proximal tibia that do not involve the growth plate are usually the result of a direct blow, commonly by a car bumper. Many of these fractures are minimally displaced and appear innocuous, but there is great potential for progressive valgus deformity. Subsequent valgus deformity may be caused by interposition of periosteum or hypervascularity at the fracture site. Comparative views of the well leg, precise reduction to physiological valgus, and long-term monitoring are required. Because spontaneous correction of the valgus deformity may also occur, the timing of corrective osteotomy should include a waiting period of several years.

Repetitive traction on the tibial tubercle physis (called an apophysis) may cause fragmentation to occur. This type of stress fracture is commonly seen in children between the ages of 10 and 12. The tubercle enlarges and becomes exquisitely tender to palpation. If left untreated, the avulsed fragments never heal to the main body of the tubercle; chronic pain may ensue. The most effective treatment is to use a cylinder cast to immobilize the knee and reduce the activity level. After 6 weeks the cast is removed and active range of motion exercises are begun. No sports are allowed until all motion and equal girth in the injured limb is equal to that of the opposite side. If both legs are affected, immobilization of just one limb allows the other to rest sufficiently, and the symptoms abate.

If the injury is not treated and chronic pain ensues, the ossicles may be removed to relieve pain. However, the bony prominence of the tubercle is unchanged by the surgery.

Fractures of the tibial and fibular shafts range in severity from a non-displaced spiral fracture in the toddler to high-velocity open fractures caused by a motor vehicle. A mild twisting injury in a toddler may cause the child to limp and complain. These non-displaced fractures require a well-padded long leg cast with the knee flexed to prevent walking. These fractures are clinically healed in 2 weeks due to the intact periosteum and rapid repair in the young child. However, the fracture line may still be visible on radiographs.

Closed reduction and application of a long leg cast is the usual treatment for tibia - fibula fractures. Flexing the knee allows control of rotation. Less than 5⁰ of varus - valgus and less than 10⁰ of anterior posterior angulation constitutes an acceptable reduction.

Other than the simple toddlers' fractures, these injuries warrant overnight observation for compartment syndrome. If the fracture is still adequately reduced after 1 week, 6 weeks total in a long leg cast followed by a short leg walking cast for 1 month is necessary (Fig. 21) 2550.

Ankle radiographs of fractures close to the distal growth plate are required to enable accurate assessment of the deformity. In young children there is more tolerance for angulation, especially near the growth plates.

Open injuries require immediate irrigation and debridement. If a compartment syndrome ensues, fasciotomies and internal or external fixation may be necessary. In severe open injuries where contamination is great, an external fixator allows wound care while alignment is maintained. The fixator is normally left in place for several weeks until partial healing of the fracture has occurred and the risk of deformity is minimal.

Severe open injuries treated with internal or external fixation carry the risk of overgrowth of the tibia and/or progressive valgus angulation of the leg.

Failure of the growth plate is much more common in children than is ligamentous injury. This situation differs from that in adults, who commonly suffer sprains or tears to ankle ligaments from inversion or eversion stresses. The distal fibular growth plate is often fractured in children without obvious radiographic changes. Subtle widening of the plate and accompanying soft tissue swelling may be seen. However, no radiographic signs of injury may be present.

The distal tibial growth plate fracture which traverses the joint and exits through the metaphysis (Salter IV fracture) has a propensity for partial growth arrest. Joint incongruity of more than 2 mm should be treated with open reduction and internal fixation of the epiphyseal fragment without violating the growth plate. Non-displaced fractures through the epiphysis should also be pinned to prevent displacement and a frame shift of the osteogenic cartilage layers.

Children near skeletal maturity are subject to fractures with complex geometric patterns, the so-called triplane fractures. A fracture may be propagated horizontally across the plate and exit vertically through the metaphysis. Another fracture pattern, the Tillaux fracture, is seen when the medial portion of the distal tibial growth plate has started to close. The lateral portion of the tibia fractures through the growth plate, leaving the medial portion intact. CT scans or tomograms are necessary to provide preoperative planning for these complex fracture patterns. When a child has reached the end of skeletal growth, fractures are treated as for adults. Methods used include transphyseal threaded wires or screws. The goal is to restore joint congruity.

Assessment of fractures of the foot requires comparative views of the uninjured foot and reference to a skeletal atlas depicting secondary centres of ossification. Fractures of the hindfoot, the calcaneus, and the talus are far less common in children than in adults. High-energy trauma is usually responsible for these fractures, and assessment requires knowledge of the vascular supply to the talus: avascular necrosis is a severe complication of talar fractures. Severely displaced intra-articular fractures of the calcaneus and talus require open reduction and internal fixation.

When looking for stress fractures of the calcaneus, radiographs should be assessed for subtle disruption of the normal trabecular patterns. As in adults, severely displaced fractures of the calcaneus are usually the result of a fall from a significant height, and patients have other associated morbidity including lumbar and sacral spine injuries. In addition to anteroposterior, lateral, oblique, and axial views, CT scans can help visualize the comminution and involvement of the subtalar joint. A severely displaced fracture carries a high risk of post-traumatic arthritis.

Osteochondral fractures of the talus can cause symptoms associated with a loose body. Acute fractures may heal following immobilization, but this is unlikely for old chronic fractures. Tomograms of CT scans are necessary to delineate the lesion. A small defect can be treated with short leg cast immobilization for 3 months, but a large symptomatic defect may require subchondral bone grafting.

Fractures of the first metatarsal may involve the growth plate. The growth plate is proximal in the first ray, unlike its distal position of the lesser toe metatarsals. Multiple metatarsal fractures are usually the result of a crush injury. The foot should be monitored for possible compartment syndrome, which is treated by release of the interosseous fascia. Failure to recognize and treat a compartment syndrome of the foot carries the risk of subsequent claw toe deformities.

A short leg, non-weight bearing cast is used for several weeks following adequate reduction of uncomplicated metatarsal fractures. Avulsion fractures of the base of the fifth metatarsal should be treated with casting.

Fractures of the phalanges can usually be managed with taping of the toe to its neighbour. Fractures of the great toe may require a short leg cast for several with a long toe plate for comfort. Crutches are not needed after several days.

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