How Are Fractures Different in Children?
A fracture is a partial or complete break in the bone. A fracture in a child can be very different from a fracture in the same location in an adult. If the fracture involves the ends of the bone, the growth plate may be involved.
The growth plate is a very active region of the bone and is the location of continued growth of that individual bone. Occasionally, there can be a disturbance of the normal growth, resulting in a bone shortening or angulation (bending at an angle).
Although fractures often involve the growth plate, it is rarely a problem. The doctor will say if the fracture involves the growth plate and if there is a potential growth plate problem, which depends on the type and site of the injury.
How are Fractures Diagnosed?
X-rays will often show if a fracture involves the growth plate. Sometimes the first X-rays will not show a fracture even when one is present. This can cause confusion for parents and patients. But if the area over the growth plate or bone is tender, the doctor will treat for a growth plate injury or an occult fracture. Sprains are extremely rare in young children.
There are five different patterns of growth plate injuries, and each may have a different prognosis. X-rays can determine what pattern the child has. X-rays are also used to follow the healing of the fracture and to detect any growth abnormalities as they occur. This may require follow-up X-rays for up to two years after the original fracture.
Treatment
Most often the fracture is treated with casting, splinting or immobilization of some type. If the fracture is displaced, the doctor may need to realign the bone through manipulation of the fracture. This is often done under sedation in the Emergency Department. Some injuries require surgery, and pins, plates or screws may have to be placed. The doctor will advise which option is best.
Types of Fractures
Growth Plate Fractures
Growth plate fractures occur through the growth plate. If the bone broke in this area but did not move or displace, the X-rays may appear normal and a fracture line cannot be seen. If the child is tender, has swelling or bruising, and a history of an injury to this part of the body, they most likely will be placed in a cast or splint for about four weeks.
X-rays may or may not be needed once the cast is removed. At this time, signs of healing may be evident, confirming the suspicion of a fracture. It is much better to place a child in a cast / splint for protection than to assume it is "just a sprain."
Closed Treatment of a Distal Fibular Fracture (Ankle)
This fracture occurs on the outside bone of the ankle. The injury may occur when twisting, turning or rolling the ankle. There is pain, swelling and often bruising around the ankle that may extend to the foot. Bearing weight may be painful. If the fracture is through the growth plate, X-rays often look normal, unless the fracture is displaced.
If the fracture is stable, the child is usually placed in a walking cast or boot for about three to four weeks, or until the injury has healed. Weight on the foot may be tolerated, with pain as the guide. An X-ray is sometimes taken at follow-up, but it usually looks normal. Once the cast is removed, the patient may need to limit activity for one to two more weeks before returning to sports. Instructions for home exercise may improve range of motion and strength before returning to normal activity.
Closed Treatment of Metatarsal Fractures (Foot)
The metatarsals are the bones in the forefoot just behind the toes. Most fractures are due to one specific acute injury. Stress fractures, although rare in children, can occur from repetitive overuse or stress, as seen in athletes, runners or people taking up new activities that involve being on their feet a lot.
For fractures of the metatarsals, the foot is immobilized in a cast, boot or hard-soled shoe. These fractures often require four weeks or more to heal. Depending on which metatarsal is broken, a child may need crutches for walking, but most metatarsal fractures are treated with full weight bearing permitted.
Closed Treatment of Tibial Shaft Fractures (Lower Leg)
The tibia is the large shin bone located below the knee. This bone can be broken by an injury that takes significant force, such as in football, but it can also be broken in a toddler by a simple fall. It is one of the slowest bones to heal and can take one to four months to heal.
If the fracture is displaced, manipulation is usually done with sedation or pain medication. The child is then placed in a long leg cast. It is important for the cast to be above the knee to keep the tibia from moving since it forms part of the knee joint. Usually, the patient uses crutches or a wheelchair for the first several weeks and must keep weight off the leg. Tibia fractures in toddlers are typically stable. Children are allowed to bear weight immediately if pain allows. Once the fracture starts to heal and new bone is present, the patient is allowed to bear weight. Frequently, the cast is changed to a below-knee cast, allowing the knee to move and giving the patient more mobility.
If the initial fracture is displaced, X-rays are taken frequently to assure the alignment has been maintained in the cast. Angles can be measured on the X-rays to confirm satisfactory alignment of the fracture. Often the position is not perfect, but future growth will usually correct any offset.
Closed Treatment of Metacarpal Fractures (Hand)
The metacarpals are the bones that form the palm of the hand, located just before the fingers. Most fractures of the metacarpals involve bones that lead to the small finger (fifth finger). These breaks are commonly known as "boxer's fractures" since the most common cause of injury is striking someone or something with a closed fist. If significantly displaced, manipulation may be necessary.
A large degree of angulation, or displacement, can be accepted without compromising the function of the hand. Casting may be needed for four to six weeks.
Buckle Fractures
Buckle fractures are incomplete fractures that compress (buckle or dent) one or both sides of the bone. These fractures usually occur near the end of the bone. They are among the quickest to heal and are usually treated with a brace for three to four weeks.
Greenstick Fractures
Greenstick fractures involve a complete break on one side of a child's bone and a bending of bone (stays partially together or intact) on the other side. This is similar to snapping the branch of a young tree, in which it cracks on one side but it stays partially intact on the other side. The length of treatment time depends on the location of the fracture.
Remodeling
Unlike adults, children can show tremendous remodeling (bone will straighten as they grow) of their fractures. Overlapped and moderately crooked bones in a child may not need manipulation if the child has good remodeling potential. Bones are rarely held in perfect position in a cast, but the results are usually excellent due to remodeling. The younger the child is, the more remodeling potential they have.
Overall Care
Information about specific care will be given by the provider.
Cast Care
- Do not get the cast wet, unless it is a waterproof cast. Waterproof casts may be a good option for many children with simple fractures. The child may swim and shower in a waterproof cast.
- Do not pull out the cast padding.
- Do not stick objects under the cast edge.
- Do not walk on a cast without the doctor's permission.
- A hair dryer on a cool setting may be used to relieve itching, cotton cast only.
After-Care
- Children will likely experience joint pain and stiffness for a few days after cast removal.
- Detailed discharge instructions for the specific injury will be provided.
Physical Therapy
Many simple fractures in children do not require physical therapy. If a child had a severe fracture or wants to return to sports, exercises or physical therapy may be necessary.
Diet and Activity
Activity restrictions, if any, will be provided by the orthopaedic nurse or doctor. Most patients will need to wait one to two weeks after casting before they can return to sports and gym class. Ask the provider or nurse for a note to be excused from these activities during this time.
Sports
Most athletes with minor hand and wrist fractures may play sports with a padded cast or splint, if league rules allow. The athlete may need a note approving sports participation. The cast or splint will need to be covered with bubble wrap during play.
Return to Sports Criteria
- Full range of motion of all joints of affected limb
- Greater than 85% strength in the affected limb compared to opposite side
- Good agility (jumping, hopping) for lower extremities
- No limp if lower extremity injury
When to Call Your Child's Doctor
Call your child's doctor after fracture treatment if:
- Pain gets worse after casting and is not relieved with rest, elevation, and ibuprofen or Tylenol
- Your child has swollen, pale, or blue fingers or toes
- Your child has any changes in feeling in their toes or fingers, such as numbness and tingling or being cold to the touch; fingers and toes should remain warm and pink
Raising the arm or leg on a pillow above heart level should relieve swelling or blueness of the fingers or toes. If there is no improvement within 30 minutes, call the doctor.
