Fractures in Children

Pediatric Bone: Unique Features - Growing Pains & Gains

• Physis (Growth Plate): Weakest structural link, vital for longitudinal bone growth; prone to injury.
• Periosteum: Exceptionally thick, highly osteogenic, and strong; contributes to rapid healing, callus formation, and stability.
• Bone Structure: Increased elasticity and porosity compared to adult bone; lower bending strength, making it susceptible to unique fracture patterns.
• Healing: Rapid and robust due to increased vascularity and the highly active periosteum.
• Remodeling Potential: Significant, especially in younger children.
  • Decreases with age.
  • Greater for fractures near the physis.
  • More effective for deformities in the plane of joint motion (e.g., sagittal plane).
• Common Incomplete Fractures:
  • Greenstick: Fracture on tension side, plastic deformation (bend) on compression side.
  • Torus/Buckle: Compression failure of cortex, causing a bulge.
  • Plastic Bowing: Bone bends without a visible cortical break.

⭐ The periosteum in children is significantly thicker and stronger than in adults, contributing to fracture stability and rapid callus formation.

Physeal Injuries (Salter-Harris) - Growth Plate Perils

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Common Fractures: Site-Specific - Top Break Spots

• Supracondylar Humerus: Commonest pediatric elbow #. Extension type (95%).
  • Gartland: I (undisplaced), II (angulated, post. cortex intact), III (displaced).
  • Risks: ⚠️ AIN/Median N., Brachial A. Radial N. (posteromedial displacement).
  • Complications: Cubitus varus, Volkmann's. Baumann's angle (70-78°).
  • 

• Clavicle: Middle third (~80%) common.

  • Treatment: Usually non-op (sling 3-4 wks).
  • Operative: Open #, NV compromise, skin tenting, >2cm shortening.
  • 

• Forearm (Distal Radius):

  • Buckle (Torus): Stable; cast ~3 wks.
  • Greenstick: Reduce if angulated >10-15°.
  • Complete: CR +/- K-wire. Both-bone # often ORIF if displaced.
  • 

• Tibia Shaft:

  • Toddler's #: Undisplaced spiral # (distal tibia), <3 yrs.
  • ⚠️ High risk of Compartment Syndrome, esp. with fibula #.

⭐ Posteromedial displacement in supracondylar humerus fractures often injures radial nerve; posterolateral injures median nerve & brachial artery.

Special Cases: NAI & Others - Red Flags & Odd Breaks

• Non-Accidental Injury (NAI):

  • Red Flags: Inconsistent history, delay seeking care, multiple fractures (different healing stages).
  • Suspicious Patterns: 📌 Metaphyseal corner, posterior ribs, sternal, scapular, spinous process. Also complex skull #, vertebral body #.

  ⭐ > Metaphyseal corner fractures (classical metaphyseal lesions) are considered pathognomonic for non-accidental injury in infants.

• NAI vs. Accidental Injury Features:

  Feature	Non-Accidental Injury (NAI)	Accidental Injury
  History	Vague, inconsistent, changing	Clear, consistent with injury
  Delay in seeking care	Common	Uncommon
  Fracture Pattern	Metaphyseal, posterior ribs, sternal, multiple	Spiral (long bones), buckle, greenstick

• Other Special Cases:

  • Toddler's Fracture: Undisplaced spiral/oblique tibia; child 9mo-3yr; refuses weight-bearing.
  • Pathological Fractures: Weak bone (Osteogenesis Imperfecta, cysts); minimal trauma.
  • Stress Fractures: Young athletes; repetitive microtrauma (tibia); pain with activity.

High‑Yield Points - ⚡ Biggest Takeaways

• Salter-Harris classifications are key for physeal injuries.
• Greenstick and torus (buckle) fractures are unique to children.
• Supracondylar humerus fractures: risk median nerve & brachial artery injury.
• Children exhibit significant remodeling potential, especially near active physes.
• Suspect NAI with spiral fractures in non-ambulatory infants or multiple fractures at different healing stages.
• Clavicle fractures are common; usually conservative treatment.
• Recognize Monteggia (ulna fracture, radial head dislocation) & Galeazzi (radius fracture, DRUJ dislocation).