Do not assume that patients have fractures without obtaining comparison views of thecontralateral body part
Do not assume that patients have fractures without obtaining comparison views of thecontralateral body part: Excerpt from Avoiding Common Pediatric Errors
Author:
Madan Dharmar, MD
What to Do - Gather Appropriate Data
Fractures account for nearly 15% of all pediatric injuries. The anatomical,
physiologic, and biomechanical differences in the bones make fractures in
children different from adult fractures. Hence, children have some unique
types of fractures that can be problematic to diagnose, and at the same time,
their bones typically heal faster, so it is important that pediatric fractures be
managed in a timely manner.
The difference in children's bones are:
1. The bones are more porous and, hence, can absorb more energy before
they are fractured or deformed. They have greater plasticity.
2. The bones have a thicker periosteum, which can help in stabilizing the
fracture and can also result in fasterhealing. Insome instances, this makes
it difficult to diagnose a fracture.
3. Inchildren,thelongboneshavegrowthplatesorphysis,whicharepresent
between the epiphysis and the metaphysis of the bone.
4. The bones have more cartilage than adult's bone, which changes as children grow older. The bones are composed of perosseous cartilage, physes,
and an osteogenic periosteum.
5. Variation in the appearance of ossification centers in the growing bone
can make it difficult to diagnose fractures in children.
6. Childrenalsohealdifferentlyduetotheirhighpropensityforremodeling.
Thefactorsthatcouldaffectremodelingaretheageofthechild,proximity
to a joint, and relation of residual deformity to the plane of the joint axis
of movement.
Types of fracture in children:
1. Complete fracture: This is the most common type of fracture, where
the bone is broken on both the sides. Comminuted fractures are rare in
children.
2. Buckle or torus fracture: They commonly occur in the metaphysic
of the long bones. This fracture occurs when the bone buckles due to a
longitudinal force applied along the long axis of the bone (e.g., a fall onto
an outstretched hand).
3. Bowing of bone: Occurs when the bone is angulated beyond its limits of
plastic deformation, resulting in bending of the bone, but is not fractured.
4. Greenstick fracture: When the bone is angulated beyond its limits of
plastic deformation, resulting in a fracture, but the force is insufficient to
cause a complete fracture.
5. Growth plate (physeal) fractures: Growth plates are unique to children; they are present in growing long bones. A growth plate is a cartilaginous disc present between metaphysic (widened area of the shaft) and
the epiphysis (end of the bone). The Salter-Harris classification is most
commonly used to classify growth plate fractures. The five classification
of growth plate fractures are:
a. Type 1: Fracture through the physis separating the epiphysis from the
metaphysis.
b. Type 2: Fracture through the physis extending through metaphysis.
c. Type 3: Fracture through physis extending through epiphysis.
d. Type 4: Fracture through epiphysis and metaphysis crossing the
physis.
e. Type 5: Compression fracture through the physis not extending to
epiphysis or metaphysis.
Growth plate fractures need immediate management, as they could
result in progressive angular deformity, progressive limb length discrepancy, and joint incongruity.
Assessment of fractures in children. Evaluation of the fracture involves a
detailed history to determine the mechanisms of injury, examination of the
affected region, and imaging studies. When a child presents with deformity,
swelling, or localized bony tenderness following trauma, a fracture must
be suspected. If a younger child does not move a limb or refuses to bear
weight on a limb, a fracture must be suspected. The suspected region must
be examined for deformity, swelling, point tenderness, skin wound around
the injured region (open fracture), peripheral pulse, and signs of neurologic
impairment distal to the injury. The child must also be examined for signs
of compartment syndrome such as tense compartment, excessive pain, and
pain on movement of fingers or toes.
X-rays are used to determine the type of fracture and decide on a treatment plan. X-ray of the suspected injured region, including the joints on
either side of the injured region, must be obtained. X-rays should include
both anteroposteriorandlateral views for diagnosis offracture. Growthplate
are seen in x-rays as either spaces or sometimes they are difficult to see, and
as children are in different stages of development, the presence of primary
and secondary ossification center can make a diagnosis from an initial x-ray
difficult. Hence in many circumstances, when a fracture is suspected based
on the mechanisms of injury and/or based on examination, it is important to
take a comparison x-ray of the uninjured side to make a diagnosis of fracture.
This is particularly true if a fracture involving the growth plate is suspected.
In growth plate fractures, magnetic resonance imaging can provide useful
information on the appearance of the growth plate. Other diagnostic tests,
such as computed tomography scan or ultrasound, can also be used.
Suggested Readings
Beaty JH, Kasser JR. Rockwood and Wilkins' Fractures in Children. 6th ed. Philadelphia: Lip
pincott Williams & Wilkins; 2006.
Bernier J. Fractures. Pediatr Rev. 1999;20(5):179.
Macewen GD, Kasser JR, Heinrich SD. Pediatric Fractures: A Practical Approach to Assessment
and Treatment. Baltimore: Williams & Wilkins; 1993.
Wenger DR, Pring ME, Rang M. Rang's Children's Fractures. 3rd ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.
Young SJ, Barnett PL, Oakley EA. II. Fractures and minor head injuries: minor injuries in
children II.Med J Aust. 2005;182(12):644–648.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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