Orthopedic Emergencies in Pediatric Patients

Introduction

The bones in pediatric patients are more flexible than adult bones, leading to unique fractures in children. Pediatric patients suffer from orthopedic injuries that are unique and particularly seen in this population. Pediatric bones have a high metabolic turnover rate. So, closed reduction and casting is the choice of treatment for most fractures in pediatric patients.

Child specialists must be aware of these orthopedic emergencies to properly diagnose and manage these traumatic injuries.

Some of the most common orthopedic emergencies include:

• Buckle fractures.

• Greenstick fractures.

• Plastic deformation.

• Slipped capital femoral epiphysis (SCFE).

What Are Distal Radius Fractures?

Fractures in the distal one or two bones of the forearm are called distal radius fractures.

Causes -

• Free fall.

• Injury to an outstretched arm.

It is the most commonly occurring fracture in children. It usually accounts for approximately 20 percent of all child fractures. However, the frequency has increased in these years. The possible reasons could be due to activity pattern changes, reduced calcium intake in the patient's diet, or both. Snowboarding, the use of scooters that are non motorized, and soccer goalkeeping are related to higher risk. The peak incidence ranges between eight to twelve years in girls and ten to fourteen years in boys.

What Is the Classification of Distal Radius Fractures?

The classification of distal radius fractures depends on the pattern of injury that affects treatment.

• Buckle Fracture - It is also known as torus fracture. It is a type of broken bone. The bone is bent from one side, which raises a little buckle, without breaking the bone from the other side. These fractures typically appear at the metaphyseal diaphyseal junction. They usually occur as a result of crumpling of the metaphysis which is very porous. The buckle fractures are located at the distal radius, distal tibia, distal fibula and distal femur. The most common cause of injury is a fall onto an extended arm or leg. The treatment of choice is casting, immobilization, or splinting for three to four weeks, along with regular clinical follow-ups. The prognosis is good.

• Greenstick Fractures - It is a type of fracture where the bone bends and cracks, instead of breaking into fragments. They usually occur in children less than ten years of age. They usually occur due to fall on an outstretched arm, motor vehicle collisions, injuries while playing sports, or the child is hit with an object. As the pediatric bones are flexible, one end of the bone breaks while the other remains intact. It is similar to breaking a piece of green wood, hence the name. The treatment of choice for greenstick fractures involves closed reduction, immobilization, casting, or and splinting of the fracture with a supportive device. The prognosis of the pediatric patient is excellent.

• Complete Fracture - In this type of fracture, the bone breaks completely into pieces. A complete fracture of the metaphyseal plate of the distal radial bone is usually treated without surgery. This treatment of choice is especially preferred in younger patients. 75 % of the bone’s growth is responsible due to the distal growth plate of the radius bone. Therefore, the rule is to follow significant remodeling. In case, closed reduction is opted for, then it is carried out in a similar pattern as in adults by a healthcare professional.

• Physeal Fractures - In this type of fracture, the injury occurs to the growth physis or physeal plate. Distal radius, distal tibia, phalanges, and proximal humerus are the most commonly affected bones in young children. These are specifically long bones in growing children. The most commonly affected sites are the distal tibia, and femur bones. . Comparison views of the contralateral leg can help distinguish the two, though the provider should always assume it is the more serious (Type V) injury. Younger children are at a higher risk of getting injured from physeal injury because the growth potential is more in them. Males have a higher predilection than females.

What Diagnostic Tests Are Required?

• Plain Radiographs: Anteroposterior, lateral, and oblique X-rays.

• Computed Tomography Scan: To evaluate complicated fractures.

• Magnetic Resonance Imaging: Best method to identify the injury on the growth plate.

How Is the Distal Radius Fracture Managed?

• Ice pack application.

• Immobilization of fracture.

• Painkillers.

• Splinting of non-displaced fractures.

What Is Child Abuse (Non-Accidental Injuries)?

Maltreatment of children is one of the most common orthopedic emergencies. Usually, infants and handicapped children are at a higher risk of child abuse. The signs and symptoms do not match the description of the injury. The child is not able to sustain such injuries developmentally. The most common injuries are soft-tissue injuries, which include bruises, and ecchymosis. The injuries are typically seen on the face, cheeks, or back.

The fractures that can occur due to abuse include

• Posterior rib fractures.

• Metaphyseal fractures.

• Scapular fractures.

• Sternal fractures.

The treatment of each fracture should be done accordingly by the doctor. The abuse should be reported immediately to the concerned child authority.

What Is Slipped Capital Femoral Epiphysis (SCFE)?

This type of injury occurs specifically in obese children who have not attained puberty. Pain is less severe, but sometimes the pain may worsen in an acute case. It is mostly present bilaterally. These types of fractures are very common but can be easily missed. The consequences of a misdiagnosis are very serious. The frequency is about 10 in every 100,000 children. Most boys between the ages of 10 to 15 are mostly affected. The risk factors include children with hypothyroidism, pituitary tumors (abnormal growths in the pituitary gland), bone changes due to chronic kidney disease, and Down syndrome. Mostly affected children complain of hip pain. The treatment includes early surgical intervention. This helps to prevent further complications like avascular necrosis and osteoarthritis. Usually, fixation using a single cannulated screw through the head of the femur bone is done.

Conclusion

Orthopedic emergencies in children are very common. The bones of pediatric patients remodel at a rapid rate than adults. This makes closed reduction the main treatment of choice for many fractures. The same fractures require operative repair in adults. Bones are more flexible in children. This leads to unique fracture patterns in children, like buckle and greenstick fractures, that are not found in adult patients. Care should be taken to immediately report the pediatric patient to the hospital for prompt treatment in order to avoid further complications.