Fractures in children can occur due to accidents, child abuse or due to some pathologies. Motor vehicle accidents and falls from a height account for major mechanisms of accidental trauma causing fractures in children.
Some fractures are known to occur more in specific age groups. For example, fractures of the femur are most common in children ages 0 to 3 years of age. Similarly, fractures of supracondylar area in humerus are more common in second decade and peak is around 7 years of age.
Physeal fractures are more common near skeletal maturity.
Distal Forearm, phalanges, proximal humerus peak around 14 years of age. Clavicle, Femur, foot bones, forearm bones have peak incidence of fractures around 5 years and 15 years whereas ankle, carpal metacarpal rise linear with age. Diaphyseal fractures showed irregular pattern.
In children, upper limb is injured much more commonly than the lower limb. Distal radius is most common fracture in uppper limb followed by elbow.
Physeal injuries constitute 14.5% – 27.6% of pediatric injuries. Open fractures constitute about 3% of the injuries are open fractures
Multiple fractures in children are uncommon.
Epidemiology of Fractures in Children
- 42% of the boys and 27% of the girls sustain at least one fracture from 0 to 16 years of age.
- Each year 1.6% to 2.1% of all the children sustain a fracture.
- About 18% of children out of all children with injury, would have a fracture.
- Fractures show a linear increase with age , peaking at 12 years and then decrease until age of 16 years
Type of Trauma
Nonaccidental trauma [Child abuse] is the leading cause of fractures during the first year of life. In later years accident is.
Boys are affected almost 3 times more than girls for a single fracture. However, in some areas there is little difference in the incidence of fractures between boys and girls.
Role of Behavior
Boys had a higher number of injuries in pedestrian/auto injuries but the trend is changing as more and more girls are showing increased participation in physical activities.
Left upper extremity demonstrates a slight but significant predominance in most of the reports.
Fractures are more common during the summer. This is due to the fact that length of the day increases and physical activity is more.
But this does not apply to small children and infants, whose activities do not depend on the season. There appears to be no significant seasonal influence.
Increase in Minor Trauma
Increased participation in sports has resulted in increase in some types of fractures in children, for example – fracture of shaft of femur. Moreover, there is increased awareness and better availability of medical facilities, minor injuries are reported more than before.
The number of fractures due to non-accidental causes has risen consistently in the past and the increase has been reported as high as 150 times.
Treatment of Fractures in Children
Initial Management of Injured Child
First priority in an injured child management of the life-threatening,injuries if present.
As in trauma management, care of airway, breathing and circulation takes precedence followed by cervical spine stabilization.
Fluid replacement is done to compensate the loss from hemorrhage, initially with intravenous crystalloid solution.
In very young children where rapid intravenous access may be difficult, intraosseous fluid infusion through tibia may be considered using an intraosseous route.
Death is common if hypovolemic shock is not rapidly reversed but excessive fluid replacement also may lead to interstitial pulmonary edema. A urinary catheter is essential during the resuscitation to monitor urine output and to gauge adequate organ perfusion.
After the initial resuscitation and stabilization, the child is assessed from head to toe and injuries in the head, face, cervical spine, chest, abdomen, pelvis, spine and extremities.
The scoring system assess mortality risk at the time of initial treatment, as well as allowing some degree of prediction of future disability.
For head injury, Pediatric Glasgow Coma Scale is used.
If an extremity is injured, note should be made if the injury is closed or open. Any active bleeding should be stopped by pressure bandage.
After the initial resuscitation and physical examination, xrays are done. Any limb with a significant injury should be examined on x-ray. In presence of head injury or suspected neck injury, a lateral cervical spine x-ray is obtained.
Computed tomography is essential in a child with multiple injuries.
Ultrasound is very helpful in abdominal injuries. It is very accurate means for detecting hemoperitoneum following injury. But ultrasound reporting is dependent on operator and in comparison CT is superior for diagnosing visceral injury in children.
Magnetic Resonance Imaging
Primary use of the Magnetic resonance imaging is for the detection of injury to the brain or the spine and the spinal cord. In SCIWORA syndrome, MRI demonstrates the site and extent of spinal cord injury and in defining the level of injury to the disks or vertebral apophysis.
MRI also is very useful in evaluating knee injuries that cannot be visualized on routine x-rays.
Life threatening injuries are priority. Splinting of the fractures will generally suffice as the initial management.
After the child is stabilized, the management of orthopedic injuries is done depending on the type of injury.
Classically, fractures in children were treated with non operative treatment. With evolution of orthopedics and improvement in surgical techniques, availability of C-arm image intensifier more and more fractures see increased operative management.
One of the major advances in orthopedics is surgical techniques that allow to fix the fractures with percutaneous methods. Children tolerate all types of casts well for short periods of time, which allows a minimally stabilized fracture to be immobilized with a cast until there is sufficient internal callous.
Perfect expectation of modern parents often direct the treating physician toward operative intervention.
Actual treatment of the fracture depends on site of fracture, age and body habitus of the child, expectation of the parents and concomitant injuries. Treatment of individual fractures is discussed separately.