Introduction

• The anatomy and biomechanics of pediatric bone differ from that of adult bone, leading to
unique pediatric fracture patterns, healing mechanisms, and management.
• pediatric bone is significantly less dense, more porous and penetrated throughout by
capillary channels, lower modulus of elasticity, lower bending strength, and lower mineral
content.
• The low bending strength induces more strain in pediatric bone
• low modulus of elasticity allows for greater energy absorption before failure.
Anatomy of Pediatric Bone
Pediatric long bones have three main regions: epiphysis, physis and metaphysis.
• Epiphysis: each end of a long bone with associated joint cartilage.
• Physis (growth plate): cartilage cells that create solid bone with growth.
• Metaphysis: wide area below the physis, closest to the diaphysis/shaft.
Another key component of bone is the periosteum, which is a thick, nutrient layer that wraps
circumferentially around bones. It serves a major role in healing the outer layer of bone.
 Pediatric Fracture Patterns
As a child’s ligaments are stronger than those of an adult, forces which would tend to cause a sprain in an older individual
will be transmitted to the bone and cause a fracture in a child

1-Plastic Deformation:
• A force produces microscopic failure on the tensile/convex side of bone which does not propagate to the concave side.
The bone is angulated beyond its elastic limit, but the energy is insufficient to produce a fracture.
• No fracture line is visible radiographically.
• Unique to children
• Most commonly seen in the ulna, occasionally in the fibula.
• Bend in the ulna of < 20° in a 4 year old child should correct with growth

2-Buckle fracture:
• Compression failure of bone that usually occurs at the junction of the metaphysis and the diaphysis
• Commonly seen in distal radius.
• Inherently stable
• Heal in 3-4 weeks with simple immobilization

3-Greenstick fracture:
• Bone is bent and the tensile/convex side of the bone fails.
• Fracture line does not propagate to the concave side of the bone, therefore showing evidence of plastic deformation.
4-Complete fracture:
Fracture completely propagates through the bone.
Classified as spiral, transverse, or oblique, depending on the direction of the
fracture line.
• Spiral fractures:
• Created by a rotational force.
• Low-velocity injuries
• An intact periosteal hinge enables the orthopedic surgeon to reduce the fracture by
reversing the rotational injury.
• Oblique fractures:
• Occur diagonally across the diaphyseal bone at 30° to the axis of the bone.
• Fracture reduction is attempted by immobilizing the extremity while applying traction.
• Transverse fractures:
• Easily reduced by using the intact periosteum from the concave side of the fracture
force.
5-Physeal fractures:
Fractures to the growth plate can be caused by
• i) crushing
• ii) vascular compromise of the physis or
• iii) bone growth bridging from the metaphysis to the bony portion of the epiphysis.

• Damage to growth plate may result in progressive angular deformity, limb-length discrepancy or joint incongruity.
• The distal radial physis is the most frequently injured physis.
• Most physeal injuries heal within 3 weeks. This rapid healing provides a limited window for reduction of
deformity.
• Physeal injuries are classified by the Salter-Harris (SH) classification system, based on the radiographic
appearance of the fracture.
 Differences between Pediatric and Adult Fracture Healing
1-Factors affecting amount of remodeling:
• Age: younger children have greater remodeling potential.
• Location: fractures adjacent to a physis undergo greatest amount of remodeling.
• Degree of deformity

2-Overgrowth:
• Caused by physeal stimulation from the hyperemia associated with fracture healing.
• Prominent in long bones (ex. femur).
• Growth acceleration is usually present for 6 months to 1 year following injury
• > 10 years of age, overgrowth is less of a problem

3-Progressive Deformity:
• Injuries to the physis can be complicated by progressive deformities with growth.
• The most common cause is complete or partial closure of growth plates.
• Deformities can include angular deformity, shortening of bone, or both.
• The magnitude of deformity depends on the physis involved and the amount of growth remaining.

4-Rapid Healing:
• Pediatric fractures heal more quickly than adult fractures due to children’s growth potential and a thicker, more active periosteum.
• → the periosteum contributes the largest part of new bone formation around a fracture.
• As children reach their growth potential, in adolescence and early adulthood, the rate of healing slows to that of an adult.
• There is one downside to rapid healing, however; refractures.
 Physical examination
• Young child may not be able to describe bony pain or the circumstances of injury.
• toddlers and non-verbal children may simply present with the refusal to weight bear or move the injured area, irritability,
or due to a caregiver’s observation of a new deformity
• Physical examination should include assessment of the joint in question
• Always examine a joint above and below the symptomatic one.
Inspection:
• Patient movement
• Discrepancy in limb length
Palpation:
• Assessment of local temperature, warmth, tenderness
• Existence of swelling or mass
• Tightness, spasticity, contracture
• Bone or joint deformity
• Evaluate anatomic axis of limb
Range of Motion:
• Assess and record the active and passive range of motion of the joint
Neurovascular assessment of the injured area:
• Inspect the color of the limb
• Palpate for pulses, and to elicit appropriate sensation to touch, temperature
• If possible, elicit strength in neighboring muscle groups
• Finally, plain radiographs are the first step in evaluating most musculoskeletal disorders. When indicated, advanced imaging may
 Principles of Fracture Management
• ‘Reduce – Hold – Rehabilitate’.

1-Reduction involves restoring the anatomical alignment of a fracture or dislocation of the

deformed limb.
• The main principle in any reduction, regardless of the method employed, is to correct
the deforming forces that resulted in the injury.
• Reduction is typically performed closed to stop bleeding, reverse pressure on surrounding soft
tissues, blood vessels and nerves

2-Hold:
• ‘Hold’ is the generic term used to describe immobilising a fracture.
• There most common ways to immobilise a fracture are via simple splints or plaster casts.
• Surgical procedure involving splints, plates, screws are done depending upon the condition
• For severe fractures, a procedure called an open reduction internal fixation (ORIF) may be
required in which open surgery is performed to correct the bone position. Pinning and screws
can help secure the bone fragments in place.
3-Rehabilitate:
This refers to the need for most patients to undergo an intensive period of
physiotherapy following fracture management.
Physical therapy may be started to help regain normal mobility and range. The therapy will
focus on restoring the following functions:

• Range of motion: After a period of immobilization, the ability to move a joint may be
limited. Flexibility exercises can help stretch tightened muscles and joints, while joint
mobilization (a hands-on technique used to passively move joints) can help restore the
range of motion.
• Strength: Strengthening exercises, like plyometric strengthening exercises
• Gait: Gait training may be necessary to help improve child's walking ability in lower limb
fracture
• Balance and proprioception exercises may be prescribed. Foot orthotics may also be
recommended if the foot position or gait is imbalanced.
• Scar tissue management: After surgery, scar tissue near the incision can sometimes cause
pain and a restriction of motion. A physical therapist can perform scar tissue massage and
mobilization to improve the mobility of a scar