Fractures: General Information

Overview

The simple definition of a fracture is a partial or complete break in the bone. Fractures and breaks are the same thing. Fractures can be classified in many different ways depending on the type and position of the break in the bone. Most fractures in children can be treated with closed reduction and casting.

What are the symptoms of a fracture?

The following are the most common symptoms of a fracture. It is important to remember, however, that every child may experience symptoms differently. Symptoms of a fracture may include:

• Pain in the injured area
• Swelling in the injured area
• Obvious deformity in the injured area
• Difficulty or refusal to use or move injured limb
• Bruising, redness, warmth of injured area

Diagnosis

A fractured bone is diagnosed by the history of the injury (what happened?), the physical examination (what does it look like?) and by radiographs (x-rays). X-rays are a diagnostic test that we use to see your bones and determine if there is an injury or fracture.

What causes a fracture?

Fractures occur when there is more force applied to the bone than the bone can absorb. Bones are weakest when they are twisted. Common causes of fractures include falls and trauma. Fractures in children are different than adult fractures in many important ways. First, children have growth plates (also called physes) located at the ends of every long bone. The physes are responsible for the longitudinal growth of a bone. Fractures can pass through the growth plate which adds a separate set of concerns.

Pediatric fractures vs. adult fractures

Fractures in children are significantly different then they are in adults. A thick vascular lining called the periosteum covers children’s bones. This periosteum is much thinner in an adult. In the child, the thicker periosteum can impart some stability to a fracture. With open growth plates and the thick periosteum, children are generally able to heal their fractures much more rapidly than adults.

Having open growth plates (physes) does have some advantages when treating fractures. Bones that are growing have the ability to “remodel” or correct back to their original shape when fractured. Remodeling of a bone refers to the attempt to straighten itself out over time. Generally, the closer the fracture is to a growth plate, the more it can remodel. Because of the growth plates and ability to remodel, we accept some fracture alignments in children that we cannot accept in adults.

Injury to the growth plate can be minor or severe. A fracture occurring through the growth plate may not be seen on plain x-rays. The growth plate is not calcified and is therefore seen as a black line on x-rays (fracture line impossible to see: black on black). A physeal fracture (Salter Harris) is sometimes presumed based on the presence of tenderness at the growth plate alone. Damage to the physis can disrupt future growth at that site. The more severe the injury, the more likely some growth disturbance will arise after the fracture has healed. We will monitor all patients with physeal fractures for any growth arrest/disturbance.

What does the growth plate look like on x-ray?

Treatment

In general, the majority of pediatric fractures can be satisfactorily treated in a cast. Sometimes the fracture is initially placed in a splint prior to the cast to allow for swelling. The cast is placed to hold the fracture in alignment and protect the extremity while the initial healing occurs. Casts immobilize the joint above and the joint below the injured bone. For example, a child with a forearm (radius/ulna) fracture will need to have a long arm cast initially to immobilize the wrist and elbow joints.

The outside, or hard part of the cast, is usually fiberglass (can come in a variety of colors, patterns, and designs). Some fractures will need to be immobilized with plaster of Paris.

Children are able to tolerate immobilization in a cast much better than adults. Stiffness (decreased range of motion) is unusual in children after the cast is removed. Following cast immobilization, physical therapy is rarely needed because children tend to resume normal activity gradually on their own.

The overall goal of treatment is to control the pain, promote healing, prevent complications, and restore the normal use of the fractured area. Any open fracture (broken bone exits through the skin) should be treated urgently in the operating room.

Treatment may include:

Closed Reduction/Casting: Child is often given conscious sedation for relaxation and pain control, and the surgeon will put the bones back into alignment. There is no incision in a closed reduction. After the bones are in acceptable alignment, the surgeon will put on the appropriate cast/splint.

Medication: Pain medications are often needed with fractures. Tylenol with codeine elixir and/or Ibuprofen (Motrin) can be used in the first few days after a fracture/reduction. If there was an open fracture, then antibiotics will be needed to prevent infection.

• Surgery: Some fractures will require surgical intervention. Fractures likely to require surgery include:
• Fractures displacing a growth plate/physis
• Fractures extending into a joint
• Pathologic fractures (through abnormal bone/tumors)
• Open fractures (any skin break)
• Elbow fractures (supracondylar, lateral condyle fractures)
• Hip, Pelvis and Femur (thigh) fractures

Surgery may necessitate the placement of pins, screws or plates to maintain alignment as the fracture heals. The surgery may involve closed reduction and pinning (no incision), or an open reduction with internal fixation (open incision). Percutaneous pins are removed in the office once the fracture has healed, and internal hardware may need to be removed at a later date in the operating room.

Cast Care Instructions

• Keep the cast clean and dry
• Check for cracks and breaks in the cast
• Do NOT scratch the skin under the cast by inserting objects inside the skin (this can cause skin infections/skin breakdown)
• A hairdryer can be used on COOL (NOT warm or HOT) setting to blow air under the cast to help with dry, itchy skin
• Do NOT put any powders or lotion inside the cast
• Prevent any small toys, coins, or other objects from being put inside the cast
• Elevate the cast above the level of the heart to decrease swelling
• Encourage wiggling of fingers and/or toes to promote circulation

Cast removal

Your child’s cast will be removed with a small cast saw in our offices. The cast saw is very loud, similar to a loud vacuum cleaner. It can be startling and frightening for some kids.

The blade of the cast saw itself will not touch the skin, and even if you touch the moving blade it cannot cut skin. Marie, the cast technician, will demonstrate this. It only cuts the cast material through slightly more that half its thickness. Marie will then gently pry off the cast.

If you think your child will be frightened of the cast saw, it can help to talk to your child about the cast saw before you come in for the appointment. A pair of headphones may also help. Casts are removed quickly, and kids are thrilled to have their casts off at the end of the appointment. Marie can also tape the cast back and give it to your child to take home.

When to call the office

Call the doctor’s office if your child experiences:

• Fever greater than 101.0 F
• Increased pain and/or swelling of the extremity
• Cast feels "too tight" or is causing pain
• Complaints of numbness or tingling
• Drainage or foul odor from the cast
• Cool or cold fingers or toes
• Broken or wet cast

If any of these symptoms occur, please contact our office at 617-726-8523 if during regular business hours (8am-4:30 pm) or call the hospital at 617-726-2000 and ask for the orthopaedic resident on call after hours and on the weekend. You can also bring your child to the emergency department for evaluation if urgent issues arise.