678

5.4

Introduction and general principles

1.1

Development and growth

1.2

Regulation of epiphyseal growth

679

1.3

Growth and remodeling of

the metaphyseal bone
680

1.4

Growth disturbances

679

Childrens fracturesJ.E. Alonso, T.F. Slongo

Types of fixation

686

Specific fractures

687

5.1

Fractures of the femur

680
5.1.1
5.1.2
5.1.3

681
5.2

1.5

Incidence of fracture

681

1.6

Clinical examination of the injured child 681

1.6.1 Examination of the spine
681
1.6.2 Examination of the pelvis
682
1.6.3 Examination of the extremities
682

1.7

X-ray examination and other imaging

Periarticular and articular fractures

general principles and
classification
682

2.1

Type A (Salter-Harris types I & II)

2.2

Type B (Salter-Harris types III & IV)

2.3

Type C (Salter-Harris type V)

5.3

684
684

5.4

Proximal tibia (growth plate) 690

Tibial shaft fractures
690
Distal tibialepiphyseal and
metaphyseal end and ankle 693

Fractures of the forearm

5.4.1
5.4.2
5.4.3

Treatment of fractures in children 684

3.1

Closed treatment

3.2

Open treatment

3.3

Aims of surgical treatment

685
685
685

695

Proximal humerus and humeral shaft

Distal humerus
695

695

696

Proximal forearm, radial head, and neck 696

Monteggia injuries
696
Forearm shaft
698

5.5

Multiple trauma in the injured child

Bibliography

Updates

684

690

Fractures of the humerus

5.3.1
5.3.2

682

Proximal femur
687
Femoral shaft
689
Distal Femur
690

Fractures of the tibia

5.2.1
5.2.2
5.2.3

687

700

699

698

5.4

5.4

679

Childrens fractures

Jorge E. Alonso
Revised by Theddy F. Slongo

1 Introduction and
general principles
In childhood, injuries of the musculoskeletal
system are frequent due to the inherent activities of children. One out of seven children seen
as emergencies presents with a fracture.
Therefore, the treating practitioner must
have a basic knowledge of childrens fractures,
as the child is not just a small adult. The
main differences lie in the physical properties
of the skeleton and in the phenomenon of
growth.
The strategy and aim must be to provide,
from the very beginning, treatment which is
clini-cally correct, effective and definitive, while
respecting the specific issues of pediatric injuries; repeated reduction maneuvers and
anesthesia are to be avoided. The child should
be able to return to full activity without suffering or adverse sequelae.

1.1 Development and

growth
The immature bone is very resistant to mechanical forces, but on the other hand very
sensitive in its response to injury. Provided the
essential zones of the growth plate are not
directly involved, the growing properties of the
immature skeleton have a positive influence on
fracture repair.
Two different regulatory systems exist, one
for longitudinal growth in length and the other
for diameter and thickness. The two systems,
the epiphyseal and the peri-/endosteal, follow
the rules established by Roux in 1895 [1].
While disturbances in circumferential growth
are rarely encountered, longitudinal overgrowth or premature growth arrest may be
observed after practically every injury. In
general it may be assumed that:
pediatric fractures tend to heal
rapidly and reliably,
malunions are self-corrected in most
instances, depending on age and degree of displacement.

Children are not just small

adults and treatment must
respect the specific issues of

Childrens fractures heal

rapidly and, depending on age
and angulation, most malunions correct themselves with

680

5.4

Childrens fracturesJ.E. Alonso, T.F. Slongo

1.2 Regulation of
epiphyseal growth
Zone of growth involves
longitudinal as well as circumferential growth. Any injury to
the bone initiates a positive or
negative growth stimulus.

The physis (or growth plate) is the primary

center responsible for the longitudinal
growth in most bones. We can distinguish
two zones: the epiphyseal zone with proliferation and the metaphyseal zone without any proliferation [2]. In the epiphyseal
zone the proportion of matrix surpasses that of
the cellular elements, while the contrary is the
case for the metaphyseal zone [3]. According
to Trueta and Morgan [4], the growth plate can
be divided into five zones:
bone matrix,
proliferation,
mature and hypertrophic cartilage,
mineralized cartilage,
cell degeneration and bone formation.
The physis is surrounded by the perichondrium
which is responsible for the circumferential
growth of the cartilaginous part of the epi-/
metaphyseal end of a bone (Fig. 5.4-1).
As the blood supply is essential for any prolif
erative or healing process, it appears important
to know, that epiphysis, metaphysis, and perichondrium are supplied by three different
nutrient arteries. It is generally assumed that
the growth plate acts as a buffer against axial
compression, as after an axial trauma practically
no growth disturbances are to be observed. In
contrast to this, the metaphyseal part of the
physis with its high cellular ratio shows little
resistance to shear and bending forces. Consequently, the epiphyseal growth plateby
definitionremains intact in cases of so-called
physeal lysis. The etiology of the rarely observed
growth disturbances after physeal lysis is therefore not yet fully understood.

Fig. 5.4-1: Two factors

are mainly responsible for growth: The
physis grows towards
the meta-physis and
hence pushes away
from the meta-/
diaphysis. At the
same time, the
metaphysis opens up
in a funnel-like way
and the bone ends
grow. The diaphysis
forms by endosteal
remodeling and
periosteal formation.

A further important function of the physis of

long bones concerns the remodeling of the joint
surfaces through a modified growth of the articular cartilage. Any injury to the physeal plate
has hence to be considered as an articular injury.

1.3 Growth and remodeling

of the metaphyseal
bone
Ontologically, the diaphysis gains its rigidity by
tubular calcification in the middle of the immature shaft. Du Hamel [5] was the first to
describe the circumferential growth of the diaphysis by periosteal apposition accompanied by
endosteal resorption. The thickness and size of
the ossified tubes is in direct relation to the
mechanical stress, which seems to influence the

5.4

remodeling process. Towards the neighboring

joints, the tubular structure widens up, while
the periosteal appositions are added to the outside of the metaphysis.

1.4 Growth disturbances

As long as the physis is still open and active, we
may observe two quite different patterns of
growth disturbances: In one situation, bone
growth is stimulated; in the other, the activity
of the physis is reduced by partial or total premature closure. While the latter situation is
permanent, growth stimulation occurs only
temporarily during the repair phase of any
injury to the diaphyseal or metaphyseal bone
[6]. Therefore, special attention has to be given
to all epiphyseal injuriesincluding the epiphyseal and metaphyseal areasas well as to
the physeal lysis, as even there premature closures of the growth plate may occur.
This risk has to be communicated to the
parents and can only be minimized by a correct
initial treatment.

1.5 Incidence of fracture

Mann et al. [7] reported that of 2,650 long-bone
fractures in children, 30% involved the physis.
In other reports on physeal injuries up to 50%
occur in the distal radius. The second most
commonly injured area is the distal humerus,
of which about 50% are treated operatively [8].
The overall incidence of fractures depends very
much on the activities of a child. The increasing
participation of children in sports is accompanied by more diaphyseal fractures and injuries
of the physis. Musculoskeletal injuries are the
second most common cause, after craniocere-

bral trauma, of permanent disability in childhood.

There is a long-held and common surgical
opinion that pediatric fractures rarely have any
serious sequelae; everyday reality belies such
orthodoxy.

1.6 Clinical examination of

the injured child
Our aim must be to perform a focused clinical
examination without causing pain. This includes obtaining a short history, with the help
of the parents, and an examination of all vital
parameters according to the ATLS protocol. The
history helps to find out if the mechanism of
injury was adequate or if possibly child battering could have been involved. Unnecessary or
painful manipulations are to be avoided, although, for the radiological examination pain
medication may be required.

1.6.1 Examination of the spine

Spinal column injuries are infrequent in children and represent only about 3% of all pediatric
injuries. However, postmortem studies in children below the age of 16 years who have died
of high-energy trauma have shown that the
incidence of spinal fractures is about 12% [7].
The upper cervical spine is the most commonly
injured vertebral zone. Pain, torticollis, limitation of motion, and muscle spasm should
raise suspicion for an injury to the neck. Flexion forces seem to produce more severe spinal
cord injuries than extension forces.

681

682

5.4

Childrens fracturesJ.E. Alonso, T.F. Slongo

1.6.2 Examination of the pelvis

To evaluate injuries of the
immature skeleton an exact
knowledge of the radiological
anatomy of the growing child
is mandatory. Comparative xrays are not the solution to a
lack of knowledge.

In the traumatized child, the pelvic ring is

assessed after the spine has been evaluated.
Most pediatric pelvic fractures are stable.
Adequate x-rays should be obtained and CT
scans may be needed to complete the evaluation.
Acetabular fractures represent approximately 6% of pelvic fractures. It is of particular
importance to evaluate injury to the triradiate
cartilage, as this can produce a central growth
arrest resulting in acetabular dysplasia with
lateral subluxation of the femoral head.

1.6.3 Examination of the

extremities
In order to prevent pain, systematic manual
examinations should be minimized. An alert
child will usually indicate where it hurts, and
then, we must ask direct questions and orient
the individual about any further examination
that might be painful. Sometimes this will have
to be restricted to the absolutely essential check
of the peripheral sensomotoric functions and
the vascularity. Any suspicion of a possible
injury should be followed by an x-ray examination.
In children articular and
periarticular fractures
always involve the physis.

1.7 X-ray examination and

other imaging
X-ray evaluation of each suspected lesion must
include at least two views taken at 90 to each
other. Both projections should include both the
joint above and the joint below the suspected
fracture area. If the first x-ray clearly shows a
grossly displaced fracture a second view may

not be required, thereby preventing further

painful manipulations.
In all unclear situations rather than
taking comparative x-rays of the uninjured side, we suggest immobilizing the
injured limb and repeating the x-rays
after 610 days without the splint. As a
rule, the fracture pattern is now much easier to
identify and still allows the cor-rect treatment
to be initiated. This is especially the case in
fractures of the distal humerus.
Other diagnostic tools such as ultrasound,
CT scan or MRI should be applied in a very
focused fashion and after consultation with the
radiologist. While CT scan is most helpful in
evaluating the spine and pelvis, non-invasive
ultrasonography is gaining more and more importance for the diagnosis of intra-articular
injuries in the younger child with a large mass
of cartilage. The value of MRI is still under
debate, especially as it often requires the child
to be anesthetized.

2 Periarticular and
articular fractures
general principles and
classification1
Articular and periarticular fractures in
children are injuries that inevitably involve the physis. Both the treatment and
prognosis for physeal injuries depend on the
pattern of the injury, for example, whether the
injury involves only the physis, the physis and
the metaphysis, or the physis and the epiphysis.
The most frequently used classification of
physeal injury is that of Salter and Harris [9]
which describes five types. It fails, however, to
1

Currently, there are other groups working on a comprehensive

classification for all fractures in children.

5.4

Fig. 5.4-2: Mller AO Classification of articular and

periarticular fractures in children with involvement of the
physeal plate; three main groups:

a
A1

A2

B1

B2

B3

B4

c
C1

a) The fracture passes through the junction of the zones

of hypertrophy and provisional ossification. The fracture
line does not involve the growth zones. Growth disturbance is unlikely (except at the proximal femur and
proximal radius), even with incomplete reduction.
Deformity in the plane of motion is likely to remodel as
long as growth continues.
A1: (Salter-Harris type I) This is a pure shearing injury of
the physeal plate and usually results from a rotational
force.
A2: (Salter-Harris type II) This is partly a shear injury of
the physis and partly a metaphyseal fracture (ThurstonHolland fragment). 70% of physeal injuries are type A2.
b) The fracture line traverses the epiphysis and some, or
all, of the layers of the physis. If reduction is not anatomically perfect, growth disturbance is highly likely.
B1: (Salter-Harris type III) Partial physeal separation with
an intra-articular epiphyseal fracture. Open reduction
with screw fixation is strongly indicated. The screw must
not penetrate the physeal plate.
B2: (Salter-Harris type IV) The fracture plane passes from
the joint surface through all layers of the physis and
through the metaphysis. As in type B1, screw fixation is
strongly indicated, using one screw in the epiphysis and
one in the metaphysis, with neither crossing the growth
plate.
B3: (termed by Rang the type VI) Avulsion fracture of
an insertion of a ligament, taking with it a portion of the
perichondrial ring (zone of Ranvier). Accurate reduction
and fixation are required, but growth disturbance can still
follow.
B4: is an open abrasive injury of the periphery of the
growth platethis too often causes physeal bridging.
c) (Salter-Harris type V) There is compression of the
articular surface and impaction of epiphyseal bone into
metaphyseal bone, with consequent disorganization of
part of the physeal cartilage. Partial growth arrest is to be
expected and reconstructive procedures, such as those of
Langenskild and Oesterman [11], are necessary later.
C1: Different degrees of impaction.

683

684

5.4

Childrens fracturesJ.E. Alonso, T.F. Slongo

recognize the injuries to the zone of Ranvier at

the periphery of the physis, both the ligamentous avulsion type and those caused by open
abrasive trauma: Rang later proposed that these
be included retrospectively in the Salter-Harris
classification as type VI.
Mller has proposed a classification based
upon three major divisions according to whether the physis is damaged by shearing, by fracture perpendicular to the physeal plane, or by
crushing.
Both these classifications are summarized in
Fig. 5.4-2.
A new classification for childrens fractures
has been proposed especially for prospective
clinical studies [10]. This takes into account the
possibility that displacements may be corrected
as growth progresses.

2.1 Type A
(Salter-Harris types I & II)
The fracture line does not involve the germinal
zone of the physeal plate. If a proper reduction
is carried out, no growth disturbance is to be
anticipated, although exceptions exist.

At the distal femur, ligamentous avulsion of

an osteochondral block spanning the edge of
the physis may occur: growth arrest is likely
unless perfect reduction is achieved. Open abrasive injury of the periphery of the physis,
resulting in destruction of the zone of Ranvier,
usually results in local growth arrest.

2.3 Type C
(Salter-Harris type V)
Compression of the physeal cartilage with impaction of epiphyseal bone into the metaphysis
results in severe damage to the growth area and
partial or complete closure of the epiphyseal
plate, with consequent growth disturbance, is
to be anticipated.
Ogden has proposed a most detailed and
comprehensive classification, but in some ways
this is not necessarily prospective, inasmuch as
the assignment of some injuries to certain
groups requires observation of the behavior of
the physis over a period of time after injury.
For this reason, and because of its complexity, it has not been widely received as a
working classification, but perhaps more as a
research tool.

2.2 Type B
(Salter-Harris types III & IV)
The fracture line crosses the epiphysis and the
germinal zone of the physeal plate. An absolutely accurate, watertight reduction must be
achieved, otherwise partial closure, with resultant eccentric growth disturbance, is to be anticipated. In addition, these injuries involve the
articular surface and malunion can produce
later joint degeneration.

3 Treatment of fractures
in children
The goal of each fracture treatment must be:
effective and fast treatment of pain,
reconstruction of anatomy and function,
early mobilization and regain of the
childs activities,
avoidance of late lesions.

5.4

3.1 Closed treatment

The majority of fractures in children and
adolescents will be treated by closed reduction and casting or traction. The only
way to splint and hold reduction is by applying
a well-molded cast. This can be a well-padded
circular cast to be closed secondarily or
an equally padded dorsovolar or U-L splint. A
cast should only be applied when the fracture
has been satisfactorily reduced. Since children
cannot be relied on to tell the doctor about pain,
sensory alterations, circulatory disturbances, or
other signs of impending complications, regular
and competent clinical observation is required.
The circulation and neurological status
distal to the fracture must be checked
frequently and thoroughly.

3.2 Open treatment

Today, due to bad results of closed treatment,
all fractures that cannot be reduced or retained
in a satisfactory position should be approached
operativelyirrespective of the patients age.
This should especially be the case in unstable
forearm fractures.
The following algorithm should be applied:

Definitive primary fracture treatment

+/- reduction
+
Type of fracture

cast
correction of cast

reducible?
retainable?

operative
-

stabilization
(ESIN/external fixator/K-wire)

No secondary reduction

Table 5.4-1

In addition, the following indications for an

open/surgical treatment are today accepted:
open fractures,
polytrauma
children with head and brain injuries,
femoral neck fractures,
femoral shaft fractures in adolescents,
unstable forearm fractures
certain physeal injuries
(dislocation > 2 mm),
fractures associated with burns.

3.3 Aims of surgical

treatment
As in the adult, open fractures are surgical
emergencies and must be treated aggressively to prevent infection and possible
permanent disability. Tscherne and Gotzen
[12] divided the management of open fractures
into four priorities:
1) preservation of life,
2) preservation of limb,
3) avoidance of infection,
4) preservation of function.
There are various soft-tissue classifications
applicable to open fractures; please refer to
chapter 1.4 and chapter 5.2 as well as section 2
in this chapter.
In severe fractures the first decision is to
determine whether the limb is salvageable.
Grade IIIC open injuries are associated with a
high amputation rate and limb salvage is often
impractical in the adult. In children, however, all efforts should be made to salvage
limbs, unless all of the major nerves to the
extremity are irreparably damaged.
A thorough and aggressive dbridement,
comprising excision of all damaged and devita-

685

The majority of fractures in

children and adolescents will
be treated by closed reduction
and casting or traction.

Regular clinical checking of

circulation, pain, and neurological status is mandatory
after cast application.

Open fractures in children are,

as in adults, surgical emergencies.

In children limb salvage

should always be attempted.

686

5.4

In children as in adults, the

goal of operative fracture
treatment must be to obtain
full functional recovery with a
minimal effort and as little
implant material as possible.
The most sensitive growth
zones must be carefully
respected.

Only K-wires, and not screws,

may transverse the growth
plates.

Childrens fracturesJ.E. Alonso, T.F. Slongo

lized tissue (muscle, skin, bone, etc.) is mandatory. The wound should be irrigated copiously
with Ringer lactate or Hartmanns solution both
before and after dbridement. Pulse lavage systems should be used with care as they have
been shown to be capable of driving contamination deep into healthy tissue recesses.
Pressure lavage cannot be a substitute for meticulous surgical excision of the damaged and
contaminated tissue. Normal saline should be
avoided as it can be cytotoxic, especially to
tissues of compromised viability.

4 Types of fixation
The aim of operative fracture fixation in
children must be to obtain a good outcome while using as little implant material
as possible. The strong desire of every
child to move around constantly must also
Fig. 5.4-3: In inserting the
pins for the external fixator
(so-called selldrill Schanz
screws) it is important to
remember that the growth
plate is about 4 mm thick.
In order not to overheat
the growth plate, the
Schanz screws should be
inserted by hand about
12 cm from the growth
plate in the metaphyseal
area. In the epiphyseal
area fine wires and Schanz
screws can be inserted by
hand without damaging
the growth plate.

be taken into account aiming to allow an

early return to full activity. A postoperative
splint can be applied (e.g., in supracondylar
fractures) without the danger of algodystrophy
or limited joint mobility.
When choosing the fixation device, we must
distinguish between diaphyseal and epiphyseal
fractures. For the former, we today prefer the
elastic nail to stably splint the medullary canal,
while for the epiphyseal area a number of different implantsmostly wires and screwscan
be applied.
3.5 mm cortex screws, 4.0 mm cancellous
bone screws (exceptionally 6.5 mm in the
proximal femur), and cannulated screws, as
well as K-wires, are used in the treatment of
periarticular and articular fractures. Nowadays,
plates are hardly ever applied in immature
bone; however, the small external fixator is
becoming more popular especially for open and
metaphyseal fractures, for example, supracondylar humeral fracture [ 13 ]. The physeal
plate may, if necessary, be crossed by Kwires rather than lag screws. Percutaneously
inserted K-wires should, whenever feasible, be
inserted by hand and cross the growth plate at
a right angle. Repeated drilling must be avoided
to minimize damage to the physis. At risk also
are the soft tissues (infection) and delicate
structures such as nerves. Generally, the Kwires can be removed after 23 weeks.
In articular fractures, the fragments should
be approximated anatomically and fixed in a
watertight fashion by interfragmentary compression screws parallel to the growth plate
(type B) [14]. Such screws should always be
removed, which may be considered as a drawback. The correction of any malalignment due
to early closure of the physis must be timed well
and discussed with the patient and the parents
[15].

5.4

For the treatment of diaphyseal fractures

two methods are mainly used today: The technique of intramedullary splinting with the
elastic titanium nail (TEN) can be applied to
practically all diaphyseal fractures in children
between the ages of 34 years and puberty,
depending, however, on the size, development,
and age of the patient. The external fixator is
used in 1012% of casesmostly older
children with very complex and unstable
femur frac-tures; great care must be exercised
not to damage the growth plate (Fig. 5.4-3).
Plates are reserved for exceptional indicationspreferably using minimally invasive techniquesas well as for secondary corrections. In
a 10-years statistic, the percentage of plate
application went from 60% to 5% [16].
Any implant removal should only be done
after fracture healing with visible callus is radiologically ascertained as refractures do occur also
in children.

687

Fig. 5.4-4:
a) Intracapsular fractures of the neck
in children result in an increase in intracapsular joint pressure (joint tamponade)
endangering any remaining blood supply
to the proximal femoral epiphysis and
physis. Emergency arthrotomy and open
reduction are indicated.
b) Transcervical femoral fracture in a child.
Two cancellous bone screws with 16 mm
thread lengths (either 6.5 mm or 7.3 mm
cannulated) are used. Make sure that the
threads have passed fully across the
fracture and that the screws do not
penetrate the physis.

5 Specific fractures
5.1 Fractures of the femur
5.1.1 Proximal femur
Fractures of the femoral neck comprise an
abso-lute indication for open reduction
and stable internal fixation as an
emergency (Fig. 5.4-4). Immediately after the
fracture, some of the retinacular vessels are
usually still intact. Dis-placement of the fracture
leads to kinking of these precious vessels, which
predisposes to their occlusion and thrombosis.
Additionally, the hemarthrosis may lead to a
joint tampo-nade, which further threatens the
epiphyseal vascularity. Stable internal fixation
is achieved by inserting up to three 3.5 or 4.5
mm cortex screws, threaded K-wires, or 6.5 or
7.0 mm cannulated cancellous bone screws
taking care not to cross the physis with the
thread.
The hip capsule is exposed in the interval
between the lesser glutei and tensor fasciae

Femoral neck fractures

require emergency joint
decompression and ORIF.

There is no scientific proof,

that anatomical reduction
of shaft fractures results in
overgrowth [17].

688

5.4

Childrens fracturesJ.E. Alonso, T.F. Slongo

Fig. 5.4-5: a) Fully displaced, unstable, spiral, wedged subtrochanteric femoral

fracture (32-B1.3) in a young adolescent. b) Treatment with elastic-stable
intramedullary nailing (ESIN): closed reduction on orthopedic table and
stabilization with well prebent elastic titanium nail 3.5 (TEN). c) 8 weeks
postoperative, full weight bearing after 6 weeks. d) X-ray at 6 months, after
implant removal.

Fig. 5.4-6:
a) Displaced femoral fracture
of the middle third (32-A3.2),
classic indication for ESIN.
b) Postoperative x-ray after
closed reduction and
retrograde standard splinting.
c) 6-week follow-up with
solid callus formation, full
weight bearing allowed.
d) X-ray at 6 months,
immediately after implant
removal.

5.4

latae muscles and then opened by a T-shaped

capsulotomy. The fracture is exposed with the
aid of three small retractors. One is inserted
over the anterior pelvic rim, the second very
gently above the femoral neck and the third
below it. Great care must be exercised in passing
the retractors around the femoral neck, so as
not to damage the retinacular vessels bound to
the bone beneath the periosteum. Once reduced, the fracture is fixed temporarily with Kwires and the reduction checked, particularly at
the level of the calcar, by flexing and rotating
the hip. After definitive fixation, the capsular
incision is never fully closed, in order to avoid
the danger of recurrent joint tamponade. The
use of cannulated cancellous bone screws greatly facilitates this type of fixation. If possible,
implants in the proximal femur in children
should be made of titanium, which will cause
less MRI distortion than steel if avascular necrosis is to be investigated.
Any type of nailing of these fractures is
absolutely contraindicated. The cancellous
bone is very hard, and in nailing, there is a great
danger of driving the fragments apart and

689

thereby tearing the retinacular vessels, which

would lead to avascular necrosis of the head.

5.1.2 Femoral shaft

With the introduction of flexible nails by the
Nancy group, the treatment of femoral shaft
fractures in children has been completely
changed during the last 10 years [16]. Today,
the majority of patients between the age of
34 years and puberty are best treated by
the TEN (titanium elastic nail) method. Most
suitable are transverse short oblique type A and
spiral type B fractures (Fig. 5.4-5 and Fig. 5.4-6).
With some experience, more complex type C
fractures may also be approached by this
method, although the external fixator may be
the alternative [18]. Its application is practically
independent of the patients age, though an
age-dependent implant should always be
considered [19].
Plate osteosynthesis should today be reserved for some exceptional situations (i.e.,
older children and secondary treatment).
Fig. 5.4-7: Lag screw fixation in
the distal femur with 4.5 or 7.3
mm cannulated screws.
a) Type A2 (Salter-Harris type II)
fracture of the distal femur. If
unstable, or irreducible, such
fractures should be fixed,
ensuring that the growth plate is
not violated. Intraoperative
image intensifier control should
be used.
b) Type B3 avulsion fracture can
be fixed by open reduction and
internal fixation with one or two
4.0 mm cannulated lag screws if
bony fragments are large
enough for screw placement.

Nailing of femoral neck

fractures is absolutely
contraindicated because
of the very dense cancellous
bone.

690

5.4

Childrens fracturesJ.E. Alonso, T.F. Slongo

Classical intramedullary nailing without or

with reaming should no longer be performed
in the growing child or adolescent as nail introduction can cause permanent damage to the
growth plate of the femoral neck or head.

5.1.3 Distal Femur

Repeated reduction
maneuvers may explain the
high incidence of growth
distur-bances at the distal

Most closed tibial shaft

fractures in children are
the domain of nonoperative treatment.

Fractures of the distal femur are mostly SalterHarris type II (A2). The reduction and fixation
may be difficult, which often demands an open
procedure. Defintive fixation can be obtained
by crossed threaded K-wires, which may go
across the physis or cancellous bone screws
introduced parallel to the physis. The use of
cannulated screws may facilitate this procedure
(Fig 5.4-7a). Repeated attempts at closed
reduction damage the growth plate. This
may explain the high incidence of growth
disturbances at the distal femur, untypical
for Salter-Harris type II fractures.
Unrecognized osseous ligament avulsion
fractures may also be the cause of growth abnormalities. It is therefore most important to
reduce any avulsed fragment by anatomical and
watertight approximation with interfragmentary compression (Fig 5.4-7b).

5.2 Fractures of the tibia

5.2.1 Proximal tibia (growth plate)

Premature growth arrest at

the tibial tuberosity can
cause serious, progressive
genu recurvatum deformity.

Fractures of the tuberosity are due to direct

trauma and are quite rare. These injuries are
easily overlooked, especially in the young
child, which may lead to a progressive
recurvatum deformity. Visible fractures must
therefore be fixed by lag screws (Fig. 5.4-8a); in
very small children a tension band wire may
suffice (Fig.5.4-8b).

Displaced fractures of the intercondylar eminence should equally be reduced and adequately fixed. This can usually not be achieved
arthoscopically as it is hardly possible to bring
a large fragment back underneath the anterior
horn of the meniscus. To fix the fragment, lag
screws may be used from an intra-articular or
metaphyseal approach or cerclages with resorbable suture material introduced through
two parallel drill holes. We prefer the fixation
technique with the special osteochondral hooks
(by Jakob) by which the cruciate ligament can
be tensioned; the implant can then be removed
without arthrotomy (Fig. 5.4-8c/d). Postoperatively, the knee should be immobilized with a
splint in neutral position for 45 weeks (axial
weight bearing allowed) [20], a method which
could also be considered as treatment for a
minimally displaced fragment.

5.2.2 Tibial shaft fractures

Fractures of the tibial shaft are the most frequent injuries of the lower extremity. These
fractures are still a domain of non-operative treatment. In view of the outcome, we
must, however, distinguish between fractures
of the lower leg (both bones) and isolated fractures of the tibial shaft. The latter are usually
short oblique or transverse located in the middle/lower third of the bone. Due to the intact
fibula a varus angulation is common to all these
fractures. This deformity appears to correct itself
over time in most instances. Isolated tibial shaft
fractures are therefore in general immobilized
in an above-knee cast, while angulation may be
corrected by wedging of the cast at about 8 days
after the injury [21, 22].
In contrast to the adult, changing in midterm from a long to a below-knee cast is seldom done in children, as by that time the childs

5.4

691

Fig. 5.4-8:
a) Avulsion of the tibial tubercle in the adolescent
requiring anatomical reduction and lag screw fixation.
b) In the younger child a wiring technique is indicated.
c) Avulsion of the intercondylar eminence: anterograde
stabilization of the fragment with osteochondral hook
(after Jakob). This procedure should be either open or
arthroscopically controlled.
d) A large avulsed fragment may be held by an
alternative technique. An absorbable thread is placed
into the anterior cruciate insertion, passed out through
the base of the avulsed fragment, then through a small
hand-drilled tunnel across the physis, to exit the
anterior tibial cortex, where it can be tightened and tied
over a small cortex screw anchor.

cast or splint can in general be discarded completely; algodystrophy due to immobilization is

hardly a problem in this age group.
In stable fractures of both fibula and tibia
that do not require major reduction, a plasterof-paris cast is again a safe and reliable way of
treatment. Lower leg fractures are more unstable, and progressive shortening may occur
which is not as easily corrected as axial
malalignment. Any displaced, unstable lower

leg fracture has to be reduced under general

anesthesia. In case reduction or retention fails,
or if the fracture is very unstable, we advocate
definitive operative fixation with the elastic
nails (TEN) [18] or the external fixator. In more
complex fractures and in obese children, plating
remains a well-established and proven alternative. Classical intramedullary nailing should,
however, not be performed for the same reason
as in femoral shaft fractures [23].

692

5.4

Childrens fracturesJ.E. Alonso, T.F. Slongo

A2

B1

B2

B2

Fig. 5.4-9: Ankle injuries.

a) Salter-Harris type II (A2) injury can be stabilized with one to two cannulated cancellous bone screws across the
metaphyseal fracture.
b) Salter-Harris type III (B1) fracture of the medial malleolus after anatomical reduction and fixation with a 4.0 mm
cancellous bone screw totally within the epiphysis.
c) Salter-Harris type IV (B2) of the tubercle of Tillaux fixed using intraepiphyseal lag screw. Type IV injuries are typically
fixed, after open reduction, with a lag screw across the metaphyseal fracture and another in the epiphysis.
d) Type IV (B2) injury fixed using two screws, one each above and below the growth plate, for watertight adaptation.
e) The triplane fracture has a complex configuration and various forms. The lag screws, metaphyseal or epiphyseal,
must be correctly placed, respecting the fracture planes. Additional stabilization of the fibula is usually not neces-sary in
children.

In case of a manifest or impending compartment syndrome, fractures of the lower leg must
be operatively stabilized after fasciotomy or for
easier monitoring.
Distal metaphyseal valgus fractures are rare
and may or may not be associated with a fibular

fracture. These injuries have a tendency to a

progressive valgus deformity and delay of
medial consolidation. Malalignment must
therefore be corrected early on by casting or by
applying a medial external fixator compressing
the fracture gap.

5.4

693

Fig. 5.4-10:
Proximal humeral physeal
separation with deforming
forces inducing adduction
and extension.
Considerable deformity can
be accepted, but in older
children with soft-tissue
interposition (biceps
tendon) open reduction and
transcutaneous K-wire
fixation may be required.

While non-operative treatment as a rule is

to be preferred, the following indications
ask for an operative approach:
grossly unstable or not retainable
fractures,
progressive varus or valgus angulation,
open fractures,
severe closed soft-tissue injuries, inclusive degloving,
compartment syndrome,
tibial fractures in the polytraumatized child.

5.2.3 Distal tibial epiphyseal

and metaphyseal end and
ankle
Growth-plate disturbance/growth arrest can
occur after any distal fracture of the tibia. This
applies also for the pure physeal lysis (SalterHarris type I) as well as for the Salter-Harris
type II injuries.

The treatment of these injuries is primarily

non-operative by cast in all undisplaced or
minimally displaced fractures. In case of major
displacement, a closed reduction under anesthesia may be attempted. However, the patient
as well as the parents must be informed that if
this fails an operative fixation will be performed
in the same session. For fixation of the fragments, K-wires, or 3.5 or 4.0 mm screws may
be used (Fig.5.4-9ac).
During transition from adolesence to skeletal maturity the physeal plates are slowly fusing
which may lead to very unusual fracture patterns. At the distal tibia, two very typical
injures may be observed at this time: the
twoplane (purely physeal) and the triplane (including a metaphyseal part) fractures. The fracture line may thereby reach into
the joint or the medial malleolus. Any fracture
gap of more than 2.0 mm should be operated
upon in order to obtain an anatomical reconstruction [24]. 3.0 or 4.0 mm cannulated
screws are most appropriate for stable fixation
(Fig. 5.4-9d/e).

Exceptional indications for

surgical stabilization in tibial
fractures are: grossly unstable
or not retainable fractures,
progressive varus or valgus
angulation, open fractures,
severe closed soft-tissue
injuries (inclusive degloving),
compartment syndrome, tibial
fractures in the polytraumatized child.

Epi-/metaphseal fractures of
the distal tibia and the fibula
especially the two- and triplane
typesmay require ORIF to
restore anatomy and function.

694

5.4

Fig. 5.4-11:
a) Percutaneous K-wire fixation
of supracondylar fracture of the
humerus after closed reduction.
Wires are removed after 23
weeks. Be aware of the ulnar
nerve during percutaneous wire
placement.

Childrens fracturesJ.E. Alonso, T.F. Slongo

70 -75

b) After reduction and

fixation, Baumanns angle
should be equal to that of
the uninjured side (usually
in the range 7075).
Baumanns angle is the
angle between the lateral
condylar physis and the
long axis of the humerus
shaft. More than 75 usually
denotes varus malposition.
Correct rotational alignment
is best judged on a lateral
view.

c) Lateral condylar fracture of

the distal humerus. If the
metaphyseal fragment is large
enough, a metaphyseal lag
screw can be inserted via a
posterolateral approach. In the
younger child, K-wires can be
used and should be inserted
exactly as illustrated.

d) Apophyseal injury to the

medial epicondyle of the
distal humerus. K-wires or
(less frequently) a figure-ofeight wire loop are used in
younger children, but in the
near mature child a screw
should be used. Great care
is needed to ensure a
smooth surface over which
the ulnar nerve will lie.

5.4

In any case of doubt about the indication, a

CT scan will be helpful for the exact diagnosis
as well as for the correct planning.

5.3 Fractures of the

humerus
5.3.1 Proximal humerus and
humeral shaft
Malalignment or functional deficit after fractures of the proximal humerus are rare, as there
is a great potential for correction (up to 60
under the age of 12) as well as an exceptional
range of motion of the shoulder joint for compensation. These fractures are therefore
treated in general non-operatively. Over
the age of 12 years, reduction should be attempted and in any unstable situation K-wire
pinning is again the treatment of choice (Fig.
5.4-10). An alternative would be the TEN, using
a nail for reduction. Rarely will we observe an
interposition of the biceps tendon, which will
require open disengagement and K-wire fixation.

5.3.2 Distal humerus

In childhood, injuries to the elbow occur extremely often. We should distinguish between
extra-articular (supracondylar) and intra-articular (condylar) fractures.
For the inexperienced eye, the diagnosis
may be difficult due to the many apophyses and
especially in the case of minimal displacement.
A reliable indirect hint for an intra-articular
injury is the fat pad sign or hemarthrosis.
Comparative x-ray should be avoided as they
do not compensate for a lack of anatomical

knowledge. In supracondylar fractures, the

presence or absence of malrotation will be decisive for the choice of treatment (Fig. 5.4-11a)
[2527].
Fractures without malrotation can usually
be reduced and fixed without anesthesia in a
collar and cuff splint, while most fractures
with malrotation should be reduced closed, but
under anesthesia, and possibly be fixed with
percutaneous K-wires. Be aware of the ulnar
nerve on the medial side. For any open reduction, we therefore prefer the lateral or radial
approach, which is also safer for the insertion
of K-wires and and best to prevent cubitus
varus (Fig.5.4-11b) [17]. On the other hand,
an initial neurovacular disturbance is rarely an indication for primary surgery.
Fractures of the lateral condyle are always
Salter-Harris type IV lesions and may be difficult
to diagnose. Grossly displaced fractures must be
fixed with K-wires or a lag screw (Fig.5.4-11c).
The stability of the joint must be checked after
any fixation as medial instability may persist. At
the elbow, any undiagnosed condylar fracture
inevitably results in a non-union and cubitus
valgus deformity, often associated with an irritation of the ulnar nerve. Radial ligamentous
instability causes overgrowth of the capitulum
with a secondary varus. Injuries to the medial
side (Salter-Harris type II) are rare, but should
also be treated accordingly.
The combined fracture of both humeral condyles is very exceptional in childhood and never
shows an intermediate fragment. This fracture
must be reduced anatomically and is best fixed
with 4.0 mm cannulated cancellous bone
screws. Unstable and irreducable fractures have
to be opened in a conventional way and fixed
by K-wires or screws. An exact adaptation of
the growth plate is, as always, very essential.

695

Most fractures of the

proximal humerus and of
the humeral shaft can be
treated non-operatively.

An initial neurovascular
disturbance is rarely an
indication for primary surgery.
An initial neurovascular
disturbance is rarely an
indication for primary surgery.

Perfect alignment of the

physeal plate is absolutely
essential and may require
operative stabilization.

696

5.4

With the TEN, even totally

displaced radial head injuries
can be reduced and fixed
closed, thereby considerably
minimizing the risk of AVN.

Childrens fracturesJ.E. Alonso, T.F. Slongo

Avulsion injuries of the ulnar apophysis are

usually the result of an elbow dislocation,
which may spontaneously have reduced again.
If this was the case, it may be difficult to
correctly diagnose the lesion,although a small
fragment may have been interposed during
reduction. This injury must be approached surgically to reduce the fragment and to provide
stability. A non-union may lead to painful irritation of the ulnar nerve as well as to a sense
of elbow instability.

5.4 Fractures of the forearm

5.4.1 Proximal forearm, radial
head, and neck

In Monteggia fractures,
anatomical reduction and
fixation of the ulna is a
prerequisite for the correct
reduction of the radial head.

Fractures of the proximal end of the radius are

about as frequent as those of the radial condyle
of the humerus. One third have a pure physeal
lysis such as Salter-Harris type I, and two third
are injuries of Salter-Harris type II. Actual radial
head fractures are very rare and must be reduced openly. They often result in considerable
growth disturbances.
The diagnosis is usually not difficult to make
except in very small children, where the radial
head is not yet ossified. In such cases we have
to look for the already mentioned indirect signs.
The main problem of all radial head injuries
concerns the vascular supply, which comes
across the periosteal vessels of the radial neck.
Any lesion to these delicate structures inevitably leads to growth disturbances, which may
result in an impairment of pronation and supination. The more dislocated the radial head the
higher the risk of late sequelae, which must be
taken into account in the treatment plan.

Below the age of 810 years angulations up

to 4050 may be tolerated, provided there is
not too much lateral displacement or any subluxation. In children over 10 years angulations
up to 1020 are still acceptable.
With the introduction of closed reduction
and fixation by elastic nails according to the
technique of Mtaizeau [28], open procedures
for reduction and fixation have become almost
obsolete and should no longer be performed.
Even a totally displaced radial head can be
reduced closed using a K-wire as joy-stick,
holding the head fragment in place with
a titanium elastic nail (TEN) introduced
from the distal end of the bone (Fig. 5.4-12).
With this gentle closed method the
already impaired circulation is not damaged any further. Since using this
method in over 40 cases of Judet type III
and IV fractures, we have not had any
instance of secondary avascular necrosis of
the radial head. In the aftercare, there is no
need for additional splintage, thus allowing
controlled pronation and supination exercises
to start immediately.

5.4.2 Monteggia injuries

The classical Monteggia fracture shows a
combination of an isolated fracture of the
proximal ulna with a dislocation of the
radial head. In the small child the ulnar
fracture may be quite proximalappearing like a fractured olecranon, which may
hide the dislocated the radial head. The
aim of the treatment must be the exact reduction of the radial head. In case of a stable
greenstick fracture of the ulna, closed reduction
and immobilization in a cast (in supination)
may be adequate. X-ray control after 8 days is
however required. In an unstable situation, the

5.4

Fig. 5.4-12: Mtaizeau et al. [22] recommend gentle

partial reduction with a percutaneous probe, followed by
completion of the reduction using the rotation of a
cranked tip of an elastic titanium nail (TEN), as illustrated.

Fig. 5.4-13: Closed reduction and stabilization with TEN of the unstable
ulna and the displaced radial head. Today, Monteggia fractures should
only exceptionally be treated by plating.

697

698

5.4

Childrens fracturesJ.E. Alonso, T.F. Slongo

ulna must be reconstructed anatomically, which

automatically reduces the radial head. This can
usually be accomplished by elastic nailing,
although rarely a small plate may be used (Fig.
5.4-13).

5.4.3 Forearm shaft

The unstable, not retainable
fracture of the forearm should
be fixed operatively (TEN),
regardless of the childs age.

Independent of the age group, all unstable

or potentially unstable both-bone fractures of the forearm shaft should be
approached surgically, as the functional
results after conservative treatment are
often poor [18]. This somewhat aggressive
attitude is justifiable with the use of the titanium elastic nails allowing for a minimally

Fig. 5.4-14: Displaced, unstable both-bone forearm

fractures are fixed surgically regardless of the age of
a child. Closed reduction and stabilization by ESIN
is preferred. Aftertreatment is usually functional
without a cast, although an antalgic splint can be
indicated. Today, ORIF is a special indication only.

invasive technique. This method has replaced

conventional plating which should be reserved
for the older (rather big) adolescent with very
unstable fractures, which could also be treated
with an external fixator (Fig. 5.4-14).

5.5 Multiple trauma in the

injured child
The combination of high-speed recreational/
sporting goods (i.e., roller blades, skateboards,
special bikes, and scooters) and their use by
children on public roads, has caused a steady
increase in the number of accidents and the
severity of injuries (ave. ISS), while the fracture

5.4

patterns and soft-tissue injuries become more

and more complex.
The algorithms of the initial treatment
should follow the ATLS guidelines and are
very similar to those of the adult (see
chapter 5.3), where early or immediate
stabilization of all major long-bone fractures, the unstable pelvis, and the spine
has a high priority. As treatment of choice
we also prefer external fixation. Special
consideration has to be given to the fact, that
in children, a major blood lossfor ex-ample,
due to one or more closed fractureswill be
compensated for quite a long time, only to be
followed by a sudden circulatory collapse that
may be difficult to manage. It is therefore important that, after successful resuscitation, the
severely injured child is transferred as rapidly
as possible to a specialized center.

4.

5.

6.

7.

8.

9.

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7 Updates
Updates and additional references for this chapter
are available online at:
[Link]

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