None of us are immune from injuries, especially children who spend most of their time in active movement. What are the signs that suggest a fracture in a baby? What first aid should be provided? How will the treatment proceed and how soon will the baby be able to fully play?
Statistics on childhood injuries indicate that bone fractures in children occur due to minor trauma and trivial circumstances - at home, on the street, on the sports field, for example, when falling from a great height, while running or walking, etc. Fractures of arm bones in children are 2 times more common than leg bones. The most common sites for fractures are the elbow and forearm bones. Fortunately, severe multiple injuries in children are not common and account for 2.5% - 10% of all injuries to the musculoskeletal system.
Features of bone fractures in children
A child's bones contain more organic matter (the protein ossein) than those of adults. The shell covering the outside of the bone (periosteum) is thick and well supplied with blood. Children also have areas of bone tissue growth (Fig). All these factors determine the specificity of childhood fractures.
- Often bone fractures in children occur as a “green branch”. Outwardly, it looks as if the bone was broken and bent. In this case, the displacement of bone fragments is insignificant, the bone breaks only on one side, and on the other side a thick periosteum holds the bone fragments.
- The fracture line often runs along the bone tissue growth zone, which is located near the joints. Damage to the growth plate can lead to its premature closure and subsequently to the formation of curvature, shortening, or a combination of these defects during the child’s growth. The earlier the growth plate is damaged, the more severe the consequences it leads to.
- Children are more likely than adults to experience fractures of the bone projections to which the muscles are attached. Essentially, these fractures are separations of ligaments and muscles with bone fragments from the bone.
- Bone tissue in children grows together faster than in adults, which is due to good blood supply to the periosteum and accelerated processes of callus formation.
- In children of the younger and middle age groups, self-correction of residual displacements of bone fragments after a fracture is possible, which is associated with bone growth and muscle functioning. In this case, some displacements undergo self-correction, while others do not. Knowledge of these patterns is important for deciding the issue of surgical treatment of fractures.
Local features of traumatic bone injuries
Today we will look at the most common injuries to the skeleton of the chest, shoulder girdle and limbs.
Rib fractures
Occurs as a result of chest injury due to direct or indirect exposure to excessive force. The middle, most convex and protruding ribs (from the 5th to the 8th) are most often damaged. Paradoxically, multiple injuries are more common than isolated ones.
Fractures of the bony parts of the ribs cannot always be immediately identified using classical radiography; in this case, the most informative would be the use of spiral computed tomography.
Rib fractures can also cause additional damage to the surrounding soft tissue: bone fragments can injure: pleura, lung tissue, diaphragm, and even the liver and spleen. In turn, damage to the pleura can lead to an additional complication: the development of pneumo or hydrothorax, possibly both.
Also, rib fractures can be combined with fractures of the clavicle, scapula, and humerus.
Sternum
It breaks extremely rarely, most often due to direct force. Usually breaks in the body area (slightly below the upper section).
In the next article we will look in detail at the most common fractures of the clavicle, scapula, humerus, and limbs in general.
Types of fractures in children
Depending on the condition of the bone tissue, traumatic and pathological fractures are distinguished. Traumatic fractures arise from the impact of a short-term, significant amount of mechanical force on an unchanged bone. Pathological fractures occur as a result of certain painful processes in the bone that disrupt its structure, strength, integrity and continuity. A minor mechanical impact is sufficient to cause pathological fractures. Often pathological fractures are called spontaneous.
Depending on the condition of the skin, fractures are divided into closed and open. With closed fractures, the integrity of the skin is not compromised, bone fragments and the entire fracture area remain isolated from the external environment. All closed fractures are considered to be aseptic, uninfected (uninfected). With open fractures, there is a violation of the integrity of the skin. The size and nature of damage to the skin varies from a pinpoint wound to a huge defect of soft tissues with their destruction, crushing and contamination. A special type of open fracture is gunshot fracture. All open fractures are primarily infected, i.e. having microbial contamination!
Depending on the degree of separation of bone fragments, fractures are distinguished between non-displaced and displaced. Displaced fractures can be complete when the connection between bone fragments is broken and there is their complete separation. Incomplete fractures, when the connection between the fragments is not broken along the entire length, the integrity of the bone is largely preserved or the bone fragments are held by the periosteum.
Depending on the direction of the fracture line, longitudinal, transverse, oblique, helical, stellate, T-shaped, V-shaped fractures with bone cracking are distinguished.
Depending on the type of bone, fractures of flat, spongy and tubular bones are distinguished. Flat bones include the bones of the skull, scapula, and iliac bones (forming the pelvis). Most often, with fractures of flat bones, significant displacement of bone fragments does not occur. Spongy bones include the vertebrae, calcaneus, talus and other bones. Fractures of cancellous bones are characterized by compression (compression) of bone tissue and lead to compression of the bone (reduction in its height). Tubular bones include the bones that form the basis of the limbs. Fractures of tubular bones are characterized by pronounced displacement. Depending on the location, fractures of tubular bones can be diaphyseal (fracture of the middle part of the bone - the diaphysis), epiphyseal (fracture of one of the ends of the bone - the epiphysis, usually covered with articular cartilage), metaphyseal (fracture of the part of the bone - the metaphysis, located between the diaphysis and the epiphysis) .
Depending on the number of damaged areas (segments)1 of the limbs or other body systems, isolated (bone fractures of one segment), multiple (bone fractures of two or more segments), combined (bone fractures in combination with traumatic brain injury, injury to the abdominal organs) are distinguished. or chest). 1 Limb segment - anatomical and morphological unit of a limb (for example, shoulder, elbow, lower leg, thigh).
Patients and methods
In the period from 2000 to 2021, in the Department of Pediatric Bone Pathology and Adolescent Orthopedics of the Federal State Budgetary Institution “National Medical Research Center for Orthopedics named after. N.N. Priorov" 82 patients (51 female, 30 male) aged from 5 to 18 years were operated on with pathological fractures of long bones due to aneurysmal cyst in 19 patients, solitary cyst in 24, non-osteogenic fibroma in 7, fibrous dysplasia in 20, osteofibrous dysplasia in 2, giant cell tumor in 3, Ollier disease in 6, hemangiomas in 1. The distribution of patients by nosological forms, taking into account localization, is presented in the table.
Distribution of patients by nosological forms of the pathological process, taking into account its localization Bone cyst Fibrous dysplasia Non-osteogenic fibroma Ollier's disease Osteofibrous dysplasia Giant cell tumor Hemangioma Total
Osteosynthesis with a plate was carried out in 29 cases, an external fixation device was used in 1 patient, in 51 patients the fracture was stabilized using intracanal allografts after removal of pathological tissue.
A comprehensive examination of patients included a number of diagnostic measures: clinical examination; radiation methods (radiography, computed tomography, magnetic resonance imaging); morphological methods (cytological, histological).
When examining patients with suspected pathological fracture, special attention was paid to the appearance of complaints, the manifestation of the first symptoms of the disease, their connection with injury, the nature, intensity, and irradiation of pain. The general physical condition, resting posture, function, presence of deformity, and shortening of the injured limb were assessed.
Pathological fractures, unlike traumatic ones, are low-energy, occur when exposed to minor traumatic forces or physiological loads, and are usually accompanied by less pain.
Pathological fractures with bone cysts mainly occurred from impacts uncharacteristic of a fracture, such as swinging a hand, throwing an object, or hitting a ball. In pathological fractures associated with bone cysts, in the vast majority of cases (36 patients), the pain syndrome was mild, local pain on palpation and dysfunction of the affected limb were noted. Severe pain was observed in 7 patients in the presence of significant displacement of bone fragments.
In non-osteogenic fibroma, pathological fractures occurred as a result of trauma (a fall with emphasis on the affected limb) and, as a rule, passed through the area of the greatest bone damage. Most often (in 6 patients), the fracture occurred in the lower third of the tibia. Pathological fractures in 4 cases were accompanied by severe pain, soft tissue swelling, impaired limb function and displacement of fragments.
In all 20 patients, fractures due to fibrous dysplasia, regardless of the form of the disease and the location of the pathological process, occurred with severe pain, severe limitation of movements in the adjacent joint, swelling of the soft tissues and impaired limb function.
A typical symptom of osteofibrous dysplasia was a saber-shaped deformation of the segment associated with eccentric swelling of the affected bone. The pain syndrome was explained by the presence of microfractures of the damaged segment.
Pathological fractures in giant cell tumors were also characterized by severe pain, limitation of movements in the nearby joint, and swelling in the projection of the lesion.
In 2 patients with pathological fractures due to Ollier's disease and hemangioma, intense pain syndrome was noted with significant displacement of bone fragments.
The main role in diagnosis belonged to radiation research methods.
X-ray examination allows us to identify the location and nature of the fracture. X-ray examination began after clinical examination and clarification of the area of study. The scope of the examination was determined based on complaints, clinical picture and permissible radiation doses (for children) (Fig. 1).
Rice. 1. Patient K., 9 years old. Diagnosis: pathological fracture of the left humerus secondary to a bone cyst. Radiographs of the left humerus in a plaster cast (a), 6 weeks after removal of the plaster cast (b): consolidation of the fracture and signs of bone cyst repair are noted.
Computed tomography was used to obtain a three-dimensional image of the lesion, as well as to identify the true location of bone fragments. Layer-by-layer scanning and high resolution with the possibility of multispiral image reconstruction make it possible to reliably determine the size and location of the pathological focus, which is especially important for intra- and periarticular pathological fractures.
Magnetic resonance imaging was used in cases where it was necessary to determine the exact location of the neurovascular bundle in the fracture zone and the interaction of its structures with bone fragments.
Morphological verification of the diagnosis was mandatory in all cases.
How to suspect a fracture in a child?
It is not difficult to suspect a fracture in a child. Most often the child is excited and crying. The main symptoms of bone fractures in children are severe pain, swelling, swelling, deformation of the damaged limb segment, and inability to function (for example, the inability to move an arm or step on a leg). A bruise (hematoma) may develop on the skin in the area where the fracture is projected.
A special group of fractures in children are compression fractures of the spine, which occur as a result of an atypical injury, usually when falling onto the back from a small height. The insidiousness of these fractures lies in the fact that diagnosing them in children is difficult even when hospitalized in the trauma departments of children's hospitals. Pain in the back is minor and completely disappears in the first 5 to 7 days. X-ray examination does not always allow making the correct diagnosis. Difficulties in diagnosing this group of fractures are due to the fact that the main radiological sign of vertebral damage as a result of trauma is its wedge-shaped shape, which in children is a normal feature of a growing vertebra. Currently, in the diagnosis of vertebral compression fractures in children, modern methods of radiodiagnosis - computer2 and magnetic resonance imaging3 - are becoming increasingly important. 2 Computed tomography (CT) (from the Greek tomos - segment, layer + Greek grapho - write, depict) is a research method in which images of a certain layer (section) of the human body are obtained using X-rays. Information is processed by computer. Thus, the smallest changes that are not visible on a regular x-ray are recorded. 3 Magnetic resonance imaging (MRI) is one of the most informative diagnostic methods (not associated with x-rays), which allows obtaining layer-by-layer images of organs in various planes and constructing a three-dimensional reconstruction of the area under study. It is based on the ability of some atomic nuclei, when placed in a magnetic field, to absorb energy in the radio frequency range and emit it after the cessation of exposure to the radio frequency pulse.
Fractures of the pelvic bones are considered severe injuries and are manifested by severe pain, inability to stand on one’s feet, swelling and deformation in the pelvic area, and sometimes crepitus (crunching, creaking) of bone fragments is observed when moving the legs.
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Symptoms
In children, unlike adults, the spine is not fully formed; accordingly, the tissues and vertebrae are more elastic. Therefore, symptoms may be minor, which sometimes complicates diagnosis.
After a child's injury, it is imperative to see a doctor if any of these symptoms occur:
- Pain in the area of injury. Typically, severe pain occurs in the first minutes after the injury, then the pain gradually decreases but may intensify with movement;
- Hematoma or bruising is one of the main symptoms of a fracture;
- Restriction of movement occurs when the transverse processes of the vertebrae are injured. Also, with a fracture, pain may appear that radiates to the legs when trying to move.
- General malaise - dizziness, nausea and weakness. These symptoms indicate serious damage involving nerve structures
- Abdominal pain. This symptom occurs if the damaged vertebra is located in the lumbar spine;
- Limited head mobility, observed with trauma to the thoracic and cervical spine;
- Feeling of pressure in the back. The presence of this symptom indicates damage to the spinal cord or nerve roots.
First aid
First aid for fractures of the limbs consists of immobilizing the damaged segment using improvised means (planks, sticks and other similar objects), which are secured with a bandage, scarf, scarf, piece of fabric, etc. In this case, it is necessary to immobilize not only the damaged area, but also two adjacent joints. For example: for fractures of the forearm bones, it is necessary to fix the damaged segment of the limb and the wrist and elbow joints; for fractures of the shin bones, the damaged segment of the limb along with the knee and ankle joints. To relieve pain, the victim can be given a painkiller based on paracetamol or ibuprofen. You should try to calm the child down, first of all, with your calm behavior. Then call an ambulance (it can be called even before first aid begins) or go independently to the nearest children's hospital (emergency department) or trauma center. Since with open fractures there is a violation of the integrity of the skin, the wound is infected and bleeding may begin from blood vessels damaged by bone fragments, before immobilizing the limb, it is necessary to try to stop the bleeding, treat the wound (if conditions allow) and apply a sterile bandage.
The damaged area of skin is freed from clothing (the hands of the person providing assistance should be washed or treated with an alcohol solution). In case of arterial bleeding (bright red blood flows out in a pulsating stream), it is necessary to press the bleeding vessel above the bleeding site - where there are no large muscle masses, where the artery does not lie very deep and can be pressed against the bone, for example, for the brachial artery - in the elbow bend . In case of venous bleeding (dark-colored blood flows continuously and evenly, does not pulsate), it is necessary to press the bleeding vein below the bleeding site and fix the injured limb in an elevated position.
If the bleeding does not stop, cover the wound with a large piece of gauze, a clean diaper, a towel, or a sanitary pad (clamp the wound until a doctor arrives).
If there is no bleeding with an open fracture, then dirt, scraps of clothing, and soil should be removed from the surface of the skin. The wound can be washed under running water or poured with hydrogen peroxide (the resulting foam should be removed from the edges of the wound with a sterile gauze pad). Next, apply a sterile dry bandage to the wound. An open fracture is an indication for vaccination against tetanus4 (if it has not been administered previously or the period has passed since the last revaccination), which must be done in an emergency room or hospital. 4 Tetanus is a deadly infectious disease caused by the bacterium Clostridium tetani. Its spores can enter the body through a wound contaminated with soil. Tetanus is characterized by progressive damage to the nervous system, convulsions, and paralysis.
First aid for a fall from a height consists of immobilizing the spine and pelvis, which are often damaged. The victim must be laid on a hard, flat surface - a shield, boards, hard stretcher, etc. If a fracture of the pelvic bones is suspected, a bolster is placed in the popliteal areas of the legs. All this leads to muscle relaxation and prevents secondary displacement of bone fragments.
If a child’s arm is injured and he can move independently, he must go to a children’s trauma center, which, as a rule, is located at every children’s clinic and hospital.
If a child has an injured leg, spine or pelvic bones, he cannot move independently. In these cases, it is advisable to call an ambulance, which will take the injured child to the emergency department of a children's hospital.
Hospitalization to the hospital is carried out in cases of displaced bone fractures requiring reposition (comparison of fragments) or surgery, as well as with fractures of the spine and pelvis.
Diagnosis of bone fractures in children is carried out in emergency rooms or emergency departments of children's hospitals by traumatologists or surgeons. Of great importance for the correct diagnosis is an examination by a doctor, interviewing parents, witnesses or the child about the circumstances of the injury. An X-ray examination is required. Computed or magnetic resonance imaging is also often performed (especially if a spinal fracture is suspected). In case of combined injury, ultrasound examinations (ultrasound), blood tests, urine tests, etc. are performed to diagnose the condition of internal organs.
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Treatment
Due to the fairly rapid healing of bones in children, especially under the age of 7 years, the leading method of treating fractures is conservative. Fractures without displacement of bone fragments are treated by applying a plaster splint (a version of a plaster cast that does not cover the entire circumference of the limb, but only part of it). As a rule, non-displaced bone fractures are treated on an outpatient basis and do not require hospitalization. Outpatient treatment is carried out under the supervision of a traumatologist. The frequency of visiting a doctor during the normal course of the fracture healing period is 1 time every 5 - 7 days. The criterion for a correctly applied plaster cast is the subsidence of pain, the absence of impaired sensitivity and movement in the fingers or toes. “Alarming” symptoms that the bandage is compressing the limb are pain, severe swelling, impaired sensitivity and movement in the fingers or toes. If these symptoms appear, you must immediately consult a traumatologist. Treatment of fractures by applying a plaster cast is a simple, safe and effective method, but, unfortunately, not all fractures can be treated only in this way.
In case of displaced fractures, in case of severe comminuted or intra-articular fractures, an operation is performed under general anesthesia - closed reduction of bone fragments, followed by the application of a plaster cast. The duration of the surgical procedure is several minutes. However, anesthesia does not allow the child to go home immediately. The victim should be left in the hospital for several days under the supervision of a doctor.
For unstable fractures, transosseous fixation with metal pins is often used to prevent secondary displacement of bone fragments, i.e. bone fragments are fixed with knitting needles and additionally with a plaster cast. As a rule, the doctor determines the method of reposition and fixation before performing the manipulation. When fixing the fracture area with knitting needles, subsequent care and ligation of the places where the knitting needles exit the limb are necessary. This method ensures reliable fixation of the fracture and after 3 - 5 days the child can be discharged for outpatient treatment.
In pediatric traumatology, the method of permanent skeletal traction is widely used, which is most often used for fractures of the lower extremities and consists of passing a pin through the heel bone or the tibial tuberosity (tibia bone) and traction of the limb with a load until the fracture heals. This method is simple and effective, but requires hospital treatment and constant monitoring by a doctor until the fracture heals completely.
Causes and types of displacement of bone fragments
When a bone is fractured, the displacement of fragments is caused by:
1) the primary effect of the force of the mechanical factor - the greater the force, the greater the displacement of the fragments;
2) antalgic muscle contraction - the body’s protective reaction to pain, causing muscle contraction;
3) the mass of the peripheral segment (earth gravity). The displacement depends on the place of attachment of individual muscles or their groups in the central and peripheral fragments, and their functional purpose.
So, the following types of displacement of fragments are distinguished:
1) in width;
2) in length;
3) along the axis;
4) rotation of the peripheral segment.
Recovery period
The timing of fracture healing in children depends on the patient’s age, location and nature of the fracture. On average, fractures of the upper limb heal within 1 to 1.5 months, fractures of the lower limb - from 1.5 to 2.5 months from the moment of injury, fractures of the pelvic bones - from 2 to 3 months. Treatment and rehabilitation of spinal compression fractures depend on the age of the child and can last up to 1 year.
The active recovery period begins after removal of plaster immobilization or other types of fixation. Its goal is to develop movements in adjacent joints, strengthen muscles, restore the supporting ability of an injured limb, etc. The means of rehabilitation treatment include physical therapy (physical therapy), massage, physiotherapy, and a swimming pool. Physiotherapy and massage are carried out in courses of 10 - 12 sessions and help improve microcirculation of blood and lymph in the damaged area, restore muscle function and joint movements.
A balanced diet is of particular importance for fracture healing in children. In this regard, it is advisable to include vitamin-mineral complexes containing all groups of vitamins and calcium in the treatment regimen.
For severe open fractures complicated by circulatory disorders, treatment with oxygen under high pressure in a pressure chamber is recommended - the method of hyperbaric oxygenation (used to prevent infection and helps activate metabolic processes in the body).
Rehabilitation treatment begins in a hospital setting and then continues on an outpatient basis. In case of severe injuries accompanied by severe dysfunction of the damaged segment, treatment is carried out in rehabilitation centers, as well as sanatorium-resort treatment.
Complications of fractures
With complex fractures, severe dysfunction of the injured limb and pain syndrome are possible. Open fractures are often accompanied by poor circulation. The consequences of undiagnosed compression fractures of the spine in children lead to the development of juvenile osteochondrosis - a dystrophic (associated with tissue malnutrition) disease of the spine, which affects the intervertebral discs, which is accompanied by their deformation, changes in height, and dissection. Also, such fractures can lead to spinal deformities, poor posture and persistent pain. Fractures of the pelvic bones may be accompanied by damage to hollow organs, such as the bladder.