Learn about the differences between fractures in your young and adult patients and how to care for them

Injuries to the skeletal system in a young patient are different from those in an adult due to a combination of factors. These include the rapid growth and remodeling of bone in response to the changing biomechanical stresses and the relatively more pliable skeleton in a young patient compared to that of the more rigid skeleton of an adult.

Young patients may develop a variety of skeletal injuries, though these are uncommon in the first year of life. Two peaks of injuries occur between the ages of 1 and 2 and then between 13 and 18 in both boys and girls.¹

A number of characteristic fractures occur in young patients. The fractures are commonly referred to as bowing fractures and buckling fractures, both types of incomplete fractures.

Bowing fractures occur when the fracture occurs on the convex surface of the bone and is common in the radius, ulna, and fibula. It is also common to have a simultaneous fracture of the adjacent bone. An example of a bowing fracture is that of a green-stick fracture. A buckle fracture occurs due to an impaction-type injury, resulting in buckling of the bone on the concave surface and occurs at the metaphysis. An example of a buckle fracture is a torus fracture.

Growth-plate injuries. An additional group of fractures affecting the young are those of the Salter-Harris classification. This group of fractures affect the growth plate/physis, and therefore are very important to evaluate using plain film and special imaging, due to the potential effect on the development of the affected bone.^2,3

The classic Salter-Harris group consists of five main subtypes of fracture although variations on classification exist. Type 1 occurs when there is an injury solely at the level of the growth plate, usually in the hypertrophic region, examples include slipped capital femoral epiphysis or slipped radial epiphysis. This type of injury tends to occur in neonates and infants with smooth growth plates.

Type 2 occurs when there is a growth-plate injury and involvement of the metaphysis. This is the most common type of Salter-Harris injury. This injury occurs most commonly in young children after the first big growth spurt (3 to 7 years old).

Type 3 occurs when there is a growth-plate injury and involvement of the epiphysis. This injury tends to occur at the time of growth-plate closure and is very important due to the involvement of the epiphysis. Type 3 injuries commonly result in complications due to the involvement of the epiphysis and articular surface.

Type 4 occurs when a growth-plate injury is accompanied by metaphyseal and epiphyseal involvement.

Type 5 occurs when there is a compressive force applied to the growth plate. This type of injury is important since it is commonly not recognized at the time of injury but several months later when interruption of the growth of the bone is noted. Complications of growth-plate injuries include growth arrest, the development of early degenerative joint disease and osteomyelitis.⁴

Diagnosis. After a clinical examination a variety of imaging techniques are available to determine the diagnosis. A common routine is to perform plain film radiographs (preferably using digital imaging) to determine the site of the osseous injury.

Bone scintigraphy may be used to determine more subtle injuries but in a skeletally maturing patient assessment for fractures can be very challenging due to the increased uptake of technitium at sites of active growth, the metaphysis, also a common site to sustain fractures.

Special imaging can be used and although computed tomography (CT) is used to determine the osseous injury, magnetic resonance imaging (MRI) can be used to assess the involvement of the bone marrow and for defining subtle injuries without the need for ionizing radiation.⁵

Figure 1. Posterior-anterior view of the forearm of a 10-year old girl. Lateral displacement of the distal fragment is noted with no evidence of rotation or angulation.

Case History
A 10-year-old girl presented to the chiropractic clinic with a history of a direct blow to the forearm followed by immediate pain and swelling. She was unable to move her arm or wrist and her mother had noticed deformity of her forearm. A brief physical examination was performed to ensure the neurological and vascular integrity of the upper limb. The patient was referred immediately for radiographs. Figure 1 is the posterior anterior view of the forearm from the series that was performed.

Radiographic findings. The new complete transverse slightly impacted closed fracture involves the metadiaphyseal junction of the distal radius. Lateral displacement of the distal fragment is noted with no evidence of rotation or angulation. No additional bony injury is noted on the radiograph provided although a further recommendation of an elbow examination is necessary to exclude bony trauma. The remaining alignment, bone density, and articular spaces are within normal limits. The skeletal maturation process is within normal limits. Soft tissue is noted around the fracture site. In this case the clinical approach was to immobilize the forearm for 6 weeks in a cast.

Management of forearm fractures. Stabilization of the forearm is important to reduce the likelihood of sharp fracture fragments causing neurovascular damage. A full clinical examination needs to be performed to ensure that no additional injuries have been sustained. Imaging should be performed using plain film and if necessary special imaging.^6,7 Due to the vast range of fracture types and consequent treatments, immobilization with a plaster cast, reduction with anaesthetic, or surgical pinning may be required. Referral to a pediatric orthopedist is important. The injury should then be followed during the following weeks to ensure that adequate reparation is occurring and to ensure that complications are not developing. Such complications include compartment syndrome, complex regional pain syndrome (Sudek’s atrophy/algoneurodystrophy) or osteomyelitis.

When the plaster cast is removed gentle mobilization and rehabilitation should be given, which includes the use of chiropractic treatment.⁸ To provide chiropractic treatment for postfracture patients, it is important to determine that the fracture has healed completely using imaging modalities. The initial phase of treatment should include gentle passive and the active exercises, followed with gentle mobilization.

It is also important to establish the cause of the fracture to be sure that the patient has no underlying disorder for example osteogenesis imperfecta. In such a case, the chiropractic approach should change dramatically due to the associated severe osteopenia.

Michelle A. Wessely, DC, DACBR, FCC (UK/Radiology), is the head of radiology and clinical director at Institut Franco-European de Chiropratique, Paris. She completed her fellowship in musculoskeletal radiology at the Department of Osteoradiology, Veterans Affairs Healthcare Center, San Diego, under Donald Resnick, MD, professor of radiology. Wessely travels throughout Europe lecturing to chiropractors on imaging and imaging-related subjects. She can be reached at: mwessely@ifec.net;   michelle_wessely@yahoo.com;   (033) (0)1 45 15 89 10.

References
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2. Close BJ, Strouse PJ. MR of physeal fractures of the adolescent knee. Pediatr Radiol. 2000;30(11):756–762.
3. Carey J, Spence L, Blickman H, Eustace. MRI of pediatric growth plate injury: correlation with plain film radiographs and clinical outcome. Skeletal Radiol. 1998;27 (5):250-255.
4. Craig JG, Cramer KE, Cody DD, Hearshen DO, Ceulemans RY, van Holsbeeck MT, et al. Premature partial closure and other deformities of the growth plate: MR imaging and three-dimensional modeling. Radiology. 1999;210(3):835–843.
5. Lohman M, Kivisaari A, Kallio P, Puntila J, Vehmas T, Kivisaari L. Acute paediatric ankle trauma: MRI versus plain radiography. Skeletal Radiol. 2001;30(9):504–511.
6. Anderson LD, Meyer FN, Lippincott JB. Fractures of the shafts of the radius and ulna. In: Rockwood and Green’s Fractures in Adults. 3rd ed. Lippincott-Raven Publishers; 1991:679–737.
7. Metz VM, Gilula LA. Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am. 1993;24(2): 217–228.
8. Kaufman Rl, Bird J. Manipulative management of post-Colles’ fracture weakness and diminished active range of motion. J Manipulative Physiol Ther. 1999;22(2): 105–107.