Pediatrics – Fractures

Children’s bones come in diverse sizes and shapes. Their arms and legs feature long bones, while their spines consist of small bones called vertebrae. The hands and feet are made up of even smaller bones. Additionally, some bones, like the ribs and skull, have curves. All bones collectively form the skeleton, which serves not only as a structural framework but also produces blood cells, facilitates movement through joints with muscles, and protects internal organs.

Bones are living tissues that grow and adapt throughout a child’s life. The majority of bones consist of layered materials. The outer layer, known as the periosteum, acts as a life support system, providing essential nutrients and generating bone-forming cells during growth or after injuries. Beneath the periosteum is the compact bone, which is solid and hard, covering the cancellous, or spongy bone. Cancellous bone, with its porous structure, resists weight, posture changes, and growth stresses, and often contains or safeguards red bone marrow, where blood cells develop.

Fractures commonly result from falls and motor vehicle accidents. Certain sports with high impact, prolonged stress, or speed also see a higher incidence of fractures. Stress fractures, for example, often stem from repetitive activities like running, which can lead to injuries in the legs, feet, ankles, or hips. Contact sports such as football or boxing can result in high-impact injuries, while activities like skateboarding and skiing pose risks from falls or collisions.

Additionally, fractures can be caused by physical violence, such as being struck by a fist or a weapon.

While many fractures occur from accidents, some stem from diseases. Osteoporosis, a condition that causes bone density reduction, leads to fragile bones that are more prone to fractures. Type I osteoporosis typically affects women aged 51 to 75, leading to wrist and spine fractures, while Type II osteoporosis, affecting those aged 70 to 85, is associated with hip and leg fractures.

Bone tumors, which usually spread from other body parts to the bone, can also weaken bone structure, increasing fracture risk.

When a fracture occurs, a snapping or cracking sound may be heard. Symptoms can include sharp, intense pain along with numbness or tingling. The affected area may swell, bruise, or bleed, and the bone may appear bent or misaligned. In severe cases, a fracture might protrude through the skin, and movement or weight-bearing on the limb may be difficult or impossible.

A doctor can diagnose a fracture through a physical examination, coupled with a detailed discussion about the child’s injury and symptoms. Imaging tests, such as X-rays, are typically used to confirm fractures. Some stress fractures may not be visible on X-rays; in these cases, CT scans or MRI scans may be necessary for a clearer view of the bones. These imaging procedures are non-invasive and painless.

Bone scans can help identify abnormalities related to osteoporosis or tumors, as well as show fractures or infections. This scan involves a small, harmless injection of a radioactive substance, which collects in areas of bone damage.

Once a fracture is confirmed, doctors classify it to determine the best treatment plan. Fractures are categorized based on various characteristics, including:

• Complete Fracture: Bone is entirely separated into pieces.
• Incomplete Fracture: Bone is cracked but not fully broken.
• Greenstick Fracture: A common incomplete fracture in children, where the bone bends.
• Compound Fracture: Bone fragments pierce the skin.
• Simple Fracture: Bone remains beneath the skin.

Fractures are further classified by the alignment of bone fragments:

• Comminuted: Broken into multiple pieces.
• Nondisplaced: Broken but aligned.
• Displaced: Fragments are misaligned.
• Segmental: More than one fracture creates a "floating" segment.
• Angulated: Fragments are misaligned at an angle.
• Overriding: Fragments overlap.
• Impacted: One bone fragment is forced into another.

Additionally, fractures can be described based on the fracture line's orientation, particularly in long bones:

• Linear: Fracture line parallels the bone shaft.
• Transverse: Fracture line is perpendicular to the shaft.
• Oblique: Fracture line is angled at 45 degrees.

Spiral: Fracture line has a corkscrew pattern.

Treatment for fractures is determined by the type and location of the break. The primary goal is to align the fractured bones to promote healing. When a fracture occurs, it initiates a protective blood clot and callus formation, allowing new bone cells and blood vessels to grow toward each other. Once healing occurs, the callus is reabsorbed.

Doctors will use X-rays as a guide to properly set the bones. Many fractures can be stabilized with a cast, which immobilizes the area during healing. Casts are typically worn for one to two months, varying based on the fracture type and location. Removal is done with a specialized cast saw that cuts through the cast material without harming the skin.

Some fractures may not heal within the expected timeframe, leading to complications like delayed unions, nonunions, or malunions. Delayed unions occur when healing takes longer than normal, often due to excessive movement or inadequate blood supply. Nonunions are fractures that fail to heal entirely, while malunions heal incorrectly, leading to issues with alignment or length.

Treatment for these complications may involve bone stimulators, which use electricity or ultrasound to enhance healing, or surgical intervention to straighten malunions or stimulate blood flow in nonunions. Bone grafts may also be utilized to facilitate recovery.

Surgical intervention is often necessary for fractures that are unlikely to heal properly or maintain alignment with casting alone. The type of surgery depends on the fracture's location and complexity. Anesthesia options include general anesthesia or localized nerve blocks.

Surgical procedures typically involve either Open Reduction and Internal Fixation (ORIF) or Open Reduction and External Fixation (OREF). ORIF uses internal hardware, such as rods, screws, or plates, to stabilize the fracture beneath the skin. OREF involves external hardware that stabilizes the fracture from outside the skin, using surgical pins attached to a metal frame.

Pain from the fracture usually diminishes before complete healing occurs. Activity restrictions are often implemented during recovery. Following surgery or casting, physical or occupational therapy may be recommended to restore movement, strength, and flexibility that may have decreased during immobility.

Recovery times vary based on the fracture type and treatment received. Generally, fractures take around six weeks to heal, although some may require several months. Most individuals experience positive outcomes and can return to regular activities after recovery.