First, let's start with the anatomy. The most noticeable difference between adult
and children's bones is that children's bones have growth plates ("physeal plates")
, which are located at the ends of the long bones and are responsible for the longitudinal growth of a bone. There is a specific classification for fractures, which pass through the growth plate.
Injury to the growth plate can be minor or severe. Often an injury to the growth plate may not be seen on a x-ray, because the cartilage making up the growth plate is not calcified and therefore seems to be a clear space. A minor injury may be diagnosed on the basis of tenderness (tenderness means a specific spot that hurts when pressed by a nasty probing finger) at the growth plate alone. The more severe the injury, the more likely some growth disturbance will arise after the fracture has healed. This is termed a growth plate arrest, which will usually be detected within nine months of the injury if it happens at all.
Having growth plates has some advantages. Fractures in bones that are growing will correct their own shape ("remodel"). Remodeling simply means that a growing bone, which is deformed, will attempt to straighten itself out over time. The closer the fracture is to a growth plate, the more it can remodel. For this reason, we accept some fracture alignments in children that we cannot accept in adults. We always strive to align a fracture perfectly, but we have a little more leeway in the child.
The periosteum of a child's bone is thick. It allows for fast fracture healing because it is very vascular and active. It also can impart some stability to a fracture, which improves healing in a cast. An orthopedist often takes advantage of the periosteum being intact to reduce fractures (reduce the displacement and/or angulation) with greater ease.
Since a child's bones can bend a lot before breaking, different fracture patterns can be seen in children. A toros (toros = knuckle or bump, ie: not the bull torus)
fracture is a term used for a distal radius fracture in which the back cortex is disrupted from a compression injury, while the front cortex is stretched but does
not break. A bump is typically seen. This is a stable injury, treated with a cast for a short time. A buckle fracture is a synonymous term to the
Generally speaking, a majority of pediatric fractures are satisfactorily treated in a cast. Often the fracture is first placed in a splint before the cast. The splint will allow for swelling, which may occur, in the first few days following the injury. When the swelling is decreased, a carefully shaped cast is placed to hold the fracture in alignment.
Some Need Surgery :
fractures extending into a joint,
Osteo-chondritis dessicans (a fragmentation of bone with cartilage) is a condition in which the large cartilage area at the joint which later which later transforms to the substance called bone, does so irregularly. Instead of an expanding uniform transition of cartilage, small islands of bone appear. They seem disconnected. In fact they are connected, but within the larger cartilage structure, like grapes floating in Jello.
However, shearing stress can occasionally split the softer cartilage and pull off such an island of bone - as a flap (shown) or as a loose body. The x-ray might not be able to tell whether the bone hunk is actually a free or partially attached piece.
If the surrounding cartilage is not split, then eventually the bone piece will link up with the rest of the bone as cartilage continues to transform. This is especially true if the growth plates are open. But if the piece is free or split open, then a problem exists which needs a surgeon to deal with it. In the past, arthrograms (fluid contrast injected into the joint) could see the tracer material seeping deep to the joint surface indicating a fragmentation of the cartilage. MRI MIGHT be able to discriminate. It depends on the size of the chunk and of the joint. Any articular joint may have this happen. The most common ones to come to intervention are the knee, elbow, ankle and occasionally - the hip