In comparison, a greenstick fracture, also unique to the pediatric population, is one in which the cortex shows plastic deformity on the side of the force or impact but is interrupted on the opposite side due to the tension of the impact itself. Greenstick fractures are frequently angulated and may require reduction for anatomic alignment, but long-term complications are typically minimal. These fracture patterns are distinguished from complete fractures (as seen in adults), which are quite unstable and generally require surgical intervention.
Of note, the location of pediatric forearm fractures varies with age as well. Diaphyseal fractures are more common in prepubescent children, whereas the highest incidence of physeal injuries occurs during large growth spurts, particularly throughout adolescence.7
Management
The remodeling potential of pediatric bones also makes management unique. Pediatric orthopedic literature has well-studied acceptable angles and degrees of appropriate displacement based largely on the age of the patient and proximity to a growth plate. Knowledge of these is imperative for definitive care of such fractures but is beyond the scope of this review.
Traditional treatment of pediatric forearm fractures includes immobilization of various types and duration to minimize pain and deformity while producing the best possible outcome. Several recent studies have aimed to determine best practice for the different fracture types with the goal of producing best alignment and return to function while decreasing cost, discomfort, and number of physician visits. Another concern among healthcare providers is the risk of refracture, which in buckle fractures is estimated at approximately 2% with a median time of 8 to 16 weeks after the initial injury.7
A 2010 review by Kennedy et al8 sought to determine if the refracture rate was affected by the technique used to immobilize torus fractures. The five studies used in this review had no reports of refracture in the 443 patients included in analysis, though only one of the studies (Plint et al) followed patients for more than 6 weeks.8,9 In this study, 75 patients were randomized to either a plaster removable splint or full below-elbow cast for 3 weeks; thereafter, they were followed for 6 months, during which time none experienced refracture.9
Another outcome from the same study assessed the ability of the patient to use the affected arm in the recovery period. While those in removable splints scored better during and immediately after cast removal, no differences were present after 1 week. Not surprisingly, families preferred the soft bandages or a removable splint for treatment.
Case 3
A 13-year-old boy presented to the ED with right ankle pain and difficulty bearing weight. He stated that he was playing basketball when he “rolled” his right ankle coming down from a rebound.
Ankle Fractures
Ankle fractures are among the most common acute injuries of the lower extremity in children, accounting for approximately 5% of pediatric fractures and 15% of physeal injuries.10 Ankle fractures also account for up to 40% of all injuries to the skeletally immature athlete.10,11 More specifically, distal fibular physeal fractures are the most common types of pediatric ankle fracture; however, they are associated with a relatively low risk for long-term complications. In contrast, distal tibial physeal fractures are associated with a higher risk for long-term complications.12,13
Presentation and Evaluation
Typically, patients presenting with ankle fractures are too sore to bear weight, and swelling and ecchymosis can be identified anterior to the ankle. In addition, there may be diffuse tenderness throughout the ankle and point tenderness may be induced on the anterolateral aspect of the distal tibia.14 A complete evaluation of the entire lower extremity should be conducted before assuming that the injury is confined to the ankle, especially in children younger than age 5 years and/or who are nonverbal.10 When evaluating an ankle fracture, in general, orthopedic consultation should be obtained for children with neurovascular compromise, open fractures, and/or Salter-Harris III, IV, and V fractures.
The juvenile Tillaux fracture represents a Salter-Harris III physeal injury that involves the anterolateral portion of the tibia. It usually occurs in children between ages 12 and 14 years as they approach skeletal maturity and who have a partially fused tibial physis. The common mechanism of injury is inversion of the ankle with the foot pointed away from the midline (supination with external rotation). This leads to avulsion of the lateral tibial epiphysis that is attached to the anterior inferior tibiofibular ligament. The uninvolved medial portion of the epiphysis is closed.10
Radiographic Imaging
Three radiographic views should be obtained in the evaluation of pediatric ankle injuries as Tillaux fractures or other subtle injuries could be easily missed if only two views are obtained. Interpretation of the radiographs must be correlated with the physical examination.10 The fracture line is usually best seen on a mortise view (Figure 2). Computed tomography (CT) is warranted in cases in which displacement greater than 2 mm is suspected because it better defines fracture displacement and can aid in surgical planning.14 Because of its sensitivity in detecting fractures displaced more than 2 mm, CT is now the preferred imaging modality in the assessment of juvenile Tillaux fractures.15