General principles of fracture management: Fracture patterns and description in children
- David J Mathison, MD, MBA
David J Mathison, MD, MBA
- Medical Director, Pediatric Transport Team
- Attending Physician, Pediatric Emergency Medicine
- Assistant Professor of Pediatrics & Emergency Medicine
- George Washington University School of Health Sciences
- Dewesh Agrawal, MD
Dewesh Agrawal, MD
- Associate Professor of Pediatrics and Emergency Medicine
- Children's National Medical Center
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic discusses the unique properties of pediatric fractures and illustrates different classification systems that exist to identify and describe them. Management of specific fractures is discussed separately and can be found by searching for the anatomic region of interest.
Common fracture patterns (eg, transverse, oblique, spiral) seen in both children and adults are discussed in detail separately. (See "General principles of fracture management: Bone healing and fracture description", section on 'Orientation: Transverse, oblique, and spiral'.)
Musculoskeletal injuries comprise approximately 12 percent of the 10 million annual visits to United States pediatric emergency departments . Skeletal fractures account for a significant proportion of these injuries and cause considerable cost and morbidity to children. Despite aggressive campaigns for injury prevention, the overall rate of fractures has been increasing [2-5].
Fractures in children exhibit unique patterns. Because of the distinctive properties of the growing bone, special attention is required to differentiate normal variants and, for the physeal fracture, to guarantee adequate healing while avoiding growth disturbance. (See 'Physeal fracture description' below.)
FRACTURE DESCRIPTION IN CHILDREN
Describing a fracture entails a thorough explanation of both the clinical scenario and the radiographic findings (table 1).
- Chamberlain JM, Patel KM, Pollack MM, et al. Recalibration of the pediatric risk of admission score using a multi-institutional sample. Ann Emerg Med 2004; 43:461.
- Khosla S, Melton LJ 3rd, Dekutoski MB, et al. Incidence of childhood distal forearm fractures over 30 years: a population-based study. JAMA 2003; 290:1479.
- Landin LA. Fracture patterns in children. Analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950-1979. Acta Orthop Scand Suppl 1983; 202:1.
- Jónsson B, Bengnér U, Redlund-Johnell I, Johnell O. Forearm fractures in Malmö, Sweden. Changes in the incidence occurring during the 1950s, 1980s and 1990s. Acta Orthop Scand 1999; 70:129.
- Jones IE, Williams SM, Dow N, Goulding A. How many children remain fracture-free during growth? a longitudinal study of children and adolescents participating in the Dunedin Multidisciplinary Health and Development Study. Osteoporos Int 2002; 13:990.
- Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am 2006; 53:41.
- Della-Giustina K, Della-Giustina DA. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 1999; 17:895.
- Frost HM, Schönau E. The "muscle-bone unit" in children and adolescents: a 2000 overview. J Pediatr Endocrinol Metab 2000; 13:571.
- Specker BL, Brazerol W, Tsang RC, et al. Bone mineral content in children 1 to 6 years of age. Detectable sex differences after 4 years of age. Am J Dis Child 1987; 141:343.
- Tencer AF, Johnson KD. The biomechanics of bone fracture. In: Biomechanics in Orthopedic Trauma: Bone Fracture and Fixation, 1st, Informa Health Care, 1994. p.35.
- Hipp JA, Hayes WC. Biomechanics of fractures. In: Skeletal Trauma: Basisc Science, Management, and Reconstruction, 3rd, Browner. (Ed), Saunders, Philadelphia 2000. p.92.
- Solan MC, Rees R, Daly K. Current management of torus fractures of the distal radius. Injury 2002; 33:503.
- Mabrey JD, Fitch RD. Plastic deformation in pediatric fractures: mechanism and treatment. J Pediatr Orthop 1989; 9:310.
- Gruber R, von Laer LR. [The etiology of the refracture of the forearm in childhood (author's transl)]. Aktuelle Traumatol 1979; 9:251.
- Schwarz N, Pienaar S, Schwarz AF, et al. Refracture of the forearm in children. J Bone Joint Surg Br 1996; 78:740.
- Park HW, Yang IH, Joo SY, et al. Refractures of the upper extremity in children. Yonsei Med J 2007; 48:255.
- El-Zawawy HB, Silva MJ, Sandell LJ, Wright RW. Ligamentous versus physeal failure in murine medial collateral ligament biomechanical testing. J Biomech 2005; 38:703.
- Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop 1990; 10:713.
- Wilkins KE, Aroojis AJ. Incidence of fractures in children. In: Rockwood & Wilkins' Fractures in Children, 6th, Beaty JH, Kasser JR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.12.
- Leung AG, Peterson HA. Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop 2000; 20:7.
- Peterson HA, Madhok R, Benson JT, et al. Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988. J Pediatr Orthop 1994; 14:423.
- Benjamin, HJ, Hang, BT. Common acute upper extremity injuries in sports. Clin Pediatr Emerg Med 2007; 8:15.
- Iannotti JP. Growth plate physiology and pathology. Orthop Clin North Am 1990; 21:1.
- Murray DW, Wilson-MacDonald J, Morscher E, et al. Bone growth and remodelling after fracture. J Bone Joint Surg Br 1996; 78:42.
- Ortiz EJ, Isler MH, Navia JE, Canosa R. Pathologic fractures in children. Clin Orthop Relat Res 2005; :116.
- Marini JC. Osteogenesis imperfecta: comprehensive management. Adv Pediatr 1988; 35:391.
- Tischer W. [Forearm fractures in childhood (author's transl)]. Zentralbl Chir 1982; 107:138.
- Bould M, Bannister GC. Refractures of the radius and ulna in children. Injury 1999; 30:583.
- Filipe G, Dupont JY, Carlioz H. [Recurrent fractures of both bones of the forearm in children]. Chir Pediatr 1979; 20:421.
- Noonan KJ, Jones JW. Recurrent supracondylar humerus fracture following prior malunion. Iowa Orthop J 2001; 21:8.
- Baitner AC, Perry A, Lalonde FD, et al. The healing forearm fracture: a matched comparison of forearm refractures. J Pediatr Orthop 2007; 27:743.
- Chadwick CJ, Bentley G. The classification and prognosis of epiphyseal injuries. Injury 1987; 18:157.
- Grantham SA, Kiernan HA Jr. Displaced olecranon fracture in children. J Trauma 1975; 15:197.
- Letts M, Locht R, Wiens J. Monteggia fracture-dislocations in children. J Bone Joint Surg Br 1985; 67:724.
- Canale ST. Fractures and dislocations in children. In: Operative Orthopedics, Campbell. (Ed), Mosby, Philadelphia 2003. p.1512.
- Arkader A, Warner WC Jr, Horn BD, et al. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop 2007; 27:703.
- Sponseller PD, Stanitski CL. Distal femoral epiphyseal fractures. In: Rockwood and Wilkins: Fractures in Children, 5th, Beaty JH, Kasser JR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2001. p.982.
- Czitrom AA, Salter RB, Willis RB. Fractures Involving the Distal Epiphyseal plate of the femur. Int Orthop 1981; 4:269.
- Tandberg D, Sherbring M. A mnemonic for the Salter-Harris classification. Am J Emerg Med 1999; 17:321.
- Rang M. The Growth Plate and Its Disorders, Williams & Wilkins, Baltimore 1969.
- Weber BG. Fibrous interposition causing valgus deformity after fracture of the upper tibial metaphysis in children. J Bone Joint Surg Br 1977; 59:290.
- Ogden JA. Injury to the Growth Mechanisms. In: Skeletal Injury in the Child, 3rd, Springer-Verlag, New York 2000. p.147.
- Canale TS. Physeal injuries: Mechanism of injuries: Classification. In: Skeletal Trauma in Children, 3rd, Green NE, Swiotkowski MF. (Eds), Saunders, Philadelphia 2003. p.528.
- Rathjen KE, Birch JG. Physeal injuries and growth disturbances. In: Rockwood & Wilkins' Fractures in Children, 6th, Beaty JH, Kasser JR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.111.
- Peterson HA. Physeal fractures: Part 3. Classification. J Pediatr Orthop 1994; 14:439.
- Slongo TF, Audigé L, AO Pediatric Classification Group. Fracture and dislocation classification compendium for children: the AO pediatric comprehensive classification of long bone fractures (PCCF). J Orthop Trauma 2007; 21:S135.
- FRACTURE DESCRIPTION IN CHILDREN
- PLAIN RADIOGRAPH VIEWS
- FRACTURE PATTERNS
- Buckle (torus)
- Plastic deformation
- Physeal (growth plate)
- Apophyseal avulsion
- SPECIAL CIRCUMSTANCES
- Stress fractures
- Child abuse
- Pathologic fracture
- Repeat fracture
- PHYSEAL FRACTURE DESCRIPTION
- Salter I (Ogden IA-B)
- Salter II (Ogden IIA-D)
- Salter III (Ogden IIIA-D)
- Salter IV (Ogden IVA-C)
- Salter V (Ogden V)
- Ogden Type VI
- Ogden Type VII
- Peterson fractures
- AO pediatric classification