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(HealthNewsDigest.com) – With the upcoming start of school, children return to physical education classes, organized competitive sports, and multiple extracurricular and play activities that could result in bone fractures. About half of all children will experience a broken bone, or fracture, at some point in their childhood. Broken bones are probably the number one reason for a child being referred to an orthopaedic surgeon for treatment. During the school year, children’s fractures are usually the result of low-energy trauma, including playground falls and sports-related injuries. High-energy trauma, such as motor vehicle accidents, is less common but generally results in more severe injuries.
Fractures are more often seen in boys than in girls, and the occurrence tends to increase with age, peaking at about thirteen years of age. Most children’s fractures occur in the upper extremities, including the forearm, the hand and the elbow; less often but equally important are fractures to the leg and ankle.
In general, fractures are considered closed if the bone is broken without significant damage to the surrounding soft tissue and skin, or open if a part of the bone pierces through the skin and is exposed to the environment. Children’s bones differ from adult bones in many ways, including that their bones heal much faster than adult bones. Also, young children’s bones are softer and prone to incomplete fractures. Sometimes, only one side of the bone is broken and the other side is bent, creating what is called a “greenstick fracture.” In other cases, one side of the bone might buckle upon itself without disrupting the other side which is called a “torus” fracture.
What makes children’s bones unique is the presence of physes, or centers of growth. These highly specialized areas are responsible for the normal growth of the bones. Fractures through the centers of growth might carry long-term consequences if left untreated, or if the treatment is not appropriate. For example, an untreated or poorly treated displaced fracture through a very active center of growth, like the one present in the lower part of the femur (thigh bone) or the upper part of the tibia (leg bone), can result in significant shortening and/or angulation of the bone. In time, this can result in a limb that is deformed or with an unequal length, contributing to functional limitations.
Fractures through the centers of growth that have minimal displacement, especially in youth who are near the end of growth, are rarely associated with complications. Thus a timely, careful evaluation by an experienced pediatric orthopaedic surgeon will help determine the severity of the injury to the center of growth, the necessity for treatment, and the different options available for treatment.
The presence of pain, limitation for motion, swelling, bruising, and deformity can suggest the existence of a bone fracture. If a fracture is suspected, the injured limb should be kept as still as possible to minimize further damage to the bone and the surrounding tissues. Ideally, a provisional splint should be applied in a position that is comfortable for the child, until specialized care is obtained. With a careful physical examination, a pediatric orthopedist can usually locate the fracture site and can rule out the presence of associated injuries to the surrounding tissues, including nerves and blood vessels. Simple x-rays of the involved limb are usually all that is required to determine the type and severity of the fracture. In instances where the surface of the joint is involved in the fracture, more specialized radiological tests are required to assess the need for further treatment.
Not all children’s fractures are treated in the same way. When treating a child with a fracture, the goal is to control the pain, promote healing, avoid deformities, prevent complications and restore the normal use of the affected limb. The specific treatment for a fracture will be determined based on the type and severity of the fracture, and the age and overall health of the child.
Open fractures, where the broken bone has torn the skin leaving a bleeding wound, require immediate medical attention. Since the bone has been exposed to contaminant environmental particles, the risk of infection is increased. Therefore, surgery is usually required to thoroughly wash the bone ends and the surrounding tissues.
The treatment of closed fractures varies depending upon the location of the fracture and the amount of bone angulation. Some fractures, like most clavicle fractures, will only require the use of a protective device such an arm sling. For fractures where the bones have displaced minimally, maintaining an overall good alignment, a cast in-situ (without further manipulation) will most likely be applied.
Fractures with severe angulations usually require a manipulation aimed to restore the correct alignment. Some fractures can be manipulated without the need for surgery in a procedure known a closed reduction. If a closed reduction is successful, the fractured limb can be placed in a cast to maintain the alignment. Most closed reductions are performed at the Emergency Department under local anesthesia. A strict follow-up is usually recommended to ensure that the fracture will not re-displace inside the cast.
More serious fractures usually require surgery. But surgery does not always mean a large incision will be required. Some fractures can be treated with a closed reduction, but will require the placement of a metallic device (namely a pin or a screw) to ensure adequate stability. This surgical procedure is done at a hospital under general anesthesia.
In other cases, an open reduction may be required where the fractured bones are exposed through an incision on the skin and the surrounding tissues. Once exposed, the bones can be directly manipulated and realigned. After an open reduction, it is very common to use a metallic device (usually a pin, a nail, or a plate with screws) to maintain the alignment of the bones. Examples of fractures that require surgery include those involving the articulations, those with severe displacements that cannot be corrected with a closed reduction, and some fractures involving the centers of growth.
After a fracture is realigned with or without surgery, immobilization in a cast is usually needed. The time required to heal the fracture varies depending upon the age of the patient, and the type and location of the fracture. Most fractures will take between four and eight weeks to fully heal.
Two very common types of fractures observed in children are those involving the forearm and the elbow.
The forearm is composed by two bones: the radius and the ulna. About one half of all children’s fractures affect the forearm and they are usually the result of a fall onto an outstretched arm. Commonly, the use of skateboards, scooters, or rollerblades has been involved in the mechanism of trauma. More than half of forearm fractures involve the distal part of the radius. In young children, most types of forearm fractures can be treated with closed reduction and casting. Older children, those with severely displaced or unstable fractures, and those in which the factures are associated with a dislocation of the bones at the wrist or at the elbow, will likely require surgical correction.
Fractures of the lower part of the humerus (arm bone) account for about 60 percent of all elbow fractures in children. These fractures are usually the result of a fall onto an outstretched arm, commonly associated with falls from playground equipment, especially monkey bars. If the lower part of the humerus is broken, the child will refuse to move the limb and complain of elbow pain. The severity of the injury will be determined by the amount of displacement between the bone fragments. Fractures with minimal displacement will carry minimal risks and can be treated with manipulation and casting. However, severely displaced fractures can result in nerve damage and impaired circulation. Immediate evaluation by an orthopaedic surgeon is required in order to determine the need for prompt surgical management.
Parents, teachers and guardians need to know what to look for and when and where to seek appropriate treatment for all types of children’s fracture injuries. While broken bones do occur, children’s after school, sports and play activities should have adult supervision and youngsters should be encouraged to use properly fitted safety gear. In addition, children should have a nutritious diet, rich in calcium to build and maintain strong, healthy bones to prevent sports-related injuries.
For more information on pediatric fractures and other children’s orthopaedic conditions, contact Los Angeles Orthopaedic Hospital: visit the web site at www.orthohospital.org/medical.php.
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