FRACTURES IN CHILDREN Fractures in growing bones are subject to influences which do not apply to adult bones. 1.

ln very young children, the bone ends are largely cartilaginous and therefore do not show up in x-ray images. Fractures at these sites are difficult to diagnose; it helps to x-ray both limbs and compare the appearances on the two sides. 2. Childrens bones are less brittle, and more liable to plastic deformation, than those of adults. Hence the frequency of incomplete fractures - torus fractures (buckling of the cortex) and greenstick fractures, injuries which are very rare in adults. 3. The periosteum is thicker than in adult bones; this may explain why fracture displacement is more controlled. Cellular activity is also more marked, which is why childrens fractures heal so much more rapidly than those of adults. The younger the child, the quicker is the rate of union. Femoral shaft fractures in infants will heal within 3 weeks and in young children in 4-6 weeks, compared to 14 weeks or longer in adults. 4. Non-union is very unusual. 5. Bone growth involves modelling and remodelling, processes which determine the structure and overall form of the bone. This makes for a considerable capacity to reshape fracture deformities (other than rotational deformities) over time. 6. Injuries of the physis have no equivalent in adults. Damage to the growth plate can have serious consequences however rapidly and securely the fracture might heal. INJURIES OF THE PHYSIS More than 10 per cent of childhood fractures involve injury to the physis (or growth plate). Because this is a relatively weak part of the bone, injuries that cause ligament strains in adults are liable to disrupt the physis in children. The fracture usually runs transversely through the hypertrophic (calcified) layer of the growth plate, often veering off towards the shaft to include a triangular piece of the metaphysis. This has little effect on longitudinal growth, which takes place in the germinal and proliferating layers of the physis. However, if the fracture traverses the cellular (reproductive layers of the plate, it may result in premature ossification of the injured part and cessation of growth or deformity of the bone end. Classification The most widely used classification of physeal injuries is that of Salter and Harris, which distinguishes five basic types of injury. Type I A transverse fracture through the hypertrophic or calcified zone of the plate. Even if the fracture is quite alarmingly displaced, the growing zone of the physis is usually not injured and growth disturbance is uncommon.

Type2 This is similar to type 1, but towards the edge the fracture deviates away from the physis and splits off a triangular piece of metaphyseal bone. Growth is usually not affected. Type 3 A fracture running partly along the physis and then veering off through the epiphysis into the joint. Inevitably it damages the reproductive zone of the physis and may result in growth disturbance. Type 4 As with type 3, the fracture splits the epiphysis, but it continues through the physis into the metaphysis. These fractures are particularly liable to displacement and a consequent misfit between the separated parts of the physis, resulting in asymmetrical growth. Type 5 A longitudinal compression injury of the physis. There is no visible fracture, but the growth plate is crushed and this may result in growth arrest. Clinical features Physeal fractures usually result from falls or traction injuries; they occur mostly in road accidents and during sport or playground activities and are more common in boys than in girls. Deformity is usually minimal, but any injury in a child followed by pain and tenderness near the joint should arouse suspicion, and xray examination is essential. X-rays The physis itself is radiolucent and the epiphysis may be incompletely ossified; this makes it hard to tell whether the bone end is damaged or deformed. The younger the child, the smaller the visible part of the epiphysis and thus the more difficult it is to make the diagnosis; comparison with the normal side is a great help. Tell-tale features are widening of the physeal `gap, incongruity of the joint or tilting of the epiphyseal axis. If there is marked displacement, the diagnosis is obvious, but even type 4 fractures may at first be so little displaced that they are hard to see; if there is the faintest suspicion of a physeal fracture, a second x-ray examination after 4 or 5 days is essential. Type 5 injuries are usually diagnosed only in retrospect. Treatment Undisplaced fractures These may be treated by splinting the part in a cast or a close-fitting plaster slab for 2-4 weeks (depending on the site of injury and the age of the child). However, with type 3

and 4 fractures, a check x-ray after 4 days and again at about 10 days is mandatory in order not to miss late displacement. Displaced fractures Displaced fractures must be reduced as soon as possible. With types 1 and 2, this can usually be done closed; the part is then splinted securely for 3-6 weeks. Type 3 and 4 fractures demand perfect anatomical reduction. An attempt can be made to achieve this by gentle manipulation under general anesthesia; if this is successful, the limb is held in a cast for 4-8 weeks (the longer periods for type 4 injuries). Here again, check x-rays at about 4 and 10 days are essential to ensure that the position has been retained. If a type 3 or 4 fracture cannot be reduced accurately by closed manipulation, immediate open reduction and internal fixation is called for. The limb is then splinted for 4-6 weeks, but it takes that long again before the child is ready to resume unrestricted activities. Complications Premature fusion Type l and 2 injuries, if properly reduced, usually have an excellent prognosis and bone growth is not adversely affected. Exceptions to this rule are injuries involving the distal femoral and proximal ribial physes; both are undulating in shape, so a transverse fracture may pass through several zones in the physis and result in a focal point of fusion. Type 3, 4 and 5 injuries are more likely to cause premature fusion of part of the growth plate, resulting in cessation of growth or asymmetrical growth and deformity of the bone end. The size and position of the bony bridge across the physis can be assessed by CT or MRI (Fig. 23.9g). If it is relatively small (less than half the width of the physis), it can be excised and replaced by a fat graft, with some prospect of preventing or diminishing the growth disturbance. However, if the bone bridge is more extensive, the operation is contraindicated as it can end up doing more harm than good. Deformity Established deformity, whether from asymmetrical growth or from malunion of a displaced fracture (eg. a valgus elbow due to proximal displacement or non-union of a lateral humeral condylar fracture), should be treated by corrective osteotomy. If further growth is abnormal, the osteotomy may have to be repeated.

SPONTANEOUS FRACTURES IN CHILDREN Fractures following minimal trauma may be due to unusual genetic disorders (e.g. osteogenesis imperfecta, which is described in Chapter 8). It is obvious; however, that infants cannot say what happened to them and one should keep in mind the possibility

that they may be victims of deliberate injury (the battered baby syndrome). Suspicious features are an unconvincing history, multiple fractures in different stages of healing and bruise elsewhere on the body. X-rays may show florid callus formation, mimicking the appearances of osteomyelitis or scurvy (Fig. 23.10).