by Michael Sukay, MD
Health in Sports Report Issue # 3
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There are many differences between the skeletons of children and adults, and each difference is crucial in treating pediatric fractures. Children's bones bend more prior to fracture. Because fracture healing is more rapid, shorter periods of immobilization are required for children. Regardless of the length of immobilization, stiffness across joints is less of an issue in children than adults.
Of critical concern is the fracture that involves the physis, or the source of growth. The physis is thought to be the weakest area in a child's bone and must be preserved for normal growth to occur.
A review of 2,650 long-bone fractures in children found that 30 percent involved the physes. In a review of 2,500 consecutive physeal injuries, 43.8 percent involved the distal radius. A distal radius fracture occurs when the larger forearm bone on the thumb side is broken near the wrist. Some physeal injuries are sport-specific, including "Little Leaguer's elbow" and "gymnast's wrist."
Most patients with physeal injury report a specific incident. Pain and localized tenderness are the most common symptoms. Swelling and effusion vary, depending on the severity and location of the injury. Children may not be the best historians, so clinicians must be alert as these injuries can present in various ways.
Radiographic evaluation begins with two views taken at 90-degree planes to each other. Slight widening of the physis may be the only sign noted. Stress views are helpful about the knee and elbow. Vigilance is mandatory, as physeal injuries may be difficult to detect on plain radiographs. Identical views may be helpful to detect separation of the physis.
Treatment of physeal fractures is based on the severity of the injury, its anatomic location and the age of the patient. Different physes have different growth potentials; this discrepancy is greatest in the humerus, the long arm bone that extends from the shoulder to the elbow. The distal humeral physis contributes only about 20 percent of the longitudinal growth, so angular deformity is less tolerated. Age is an important consideration for a young patient.
There are important principles in the treatment of physeal injuries. Closed reduction should be as gentle as possible to avoid further insult to the physis. Adequate sedation is essential. Traction should be used to prevent further injury. Smooth pins, as opposed to threaded, should be used and the physis avoided if possible. Neurovascular status must be carefully monitored before and after treatment. Complete growth arrest is infrequent and its significance depends on the age of the patient.