PHT 482 MUSCULOSKELETAL DISEASES AND DISORDERS

Child bone fracture

A child bone fracture or a pediatric fracture is a medical condition in which a

bone of a child (a person younger than the age of 18) is cracked or broken. About
15% of all injuries in children are fracture injuries. Bone fractures in children are
different from adult bone fractures because a child's bones are still growing. Also,
more consideration needs to be taken when a child fractures a bone since it will
affect the child in his or her growth.

On an everyday basis bones will support many kinds of forces naturally applied to
them, but when the forces are too strong the bones will break. For example, when
an adolescent jumps off of a trampoline and lands on his/her feet the bones and
connective tissue in the adolescent's feet will usually absorb the force, flex, then
return to their original shape. However, if the adolescent lands and the force is too
strong, the bones and the connective tissue will not be able to support the force and

will fracture.

Types of fractures

The bones of a child are more likely to bend than to break completely because they
are softer and the periosteum is stronger and thicker. The fractures that are most
common in children are the incomplete fractures; these fractures are the greenstick
and torus or buckle fractures.

Greenstick fracture

This fracture involves a bend on one side of the bone and a partial fracture on the
other side. The name is by analogy with green (i.e., fresh) wood which similarly
breaks on the outside when bent. The Sub-nanostructure of cortical bone may
provide one possible explanation for the greenstick fractures in children. On the
contrary to adults bone tissue, the low ratio between the mature and the immature
enzymatic cross-links in children bone tissue is a potential explanation of the
presence of greenstick fractures in children.

Torus or buckle fracture

This fracture occurs at the metaphyseal locations and resemble the torus or base of
a pillar in architectural terms. Acute angulation of the cortex is noted, as opposed
to the usual curved surface. It is caused by impaction. They are usually the result of
a force acting on the longitudinal axis of the bone: they are typically a consequence
of a fall on an outstretched arm, so they mainly involve the distal radial
metaphysis. The word torus is derived from the Latin word 'torus,' meaning
swelling or protuberance.

Bow fracture

The bone becomes curved along its longitudinal axis.

Hairline fracture

An incomplete fracture (a thin crack in the bone that doesn't go all the way through
the bone.)

Single fracture

The bone is fractured only in one place.

Segmental fracture

Fracture in two or more places in the same bone.

Comminuted fracture

The bone fractures in more than two places or is crushed into pieces.

Corner or bucket-handle fracture

A corner fracture or bucket-handle fracture is fragmentation of the distal end of

one or both femurs, with the loose piece appearing at the bone margins as an
osseous density paralleling the metaphysis. The term bucket-handle fracture is
used where the loose bone is rather wide at the distal end, making it end in a
crescent shape. These types of fractures are characteristic of child abuse-related
injuries.

Closed fracture

A fracture that doesn't penetrate the skin.

Open (compound) fracture

A fracture resulting in the ends of a bone penetrating the skin (these pose an
increased risk of infection).

Non-displaced fracture

A fracture where the bone cracks completely and the pieces line up.

Displaced fracture

A fracture where the bone cracks completely in two or more pieces, and the pieces
move out of alignment (this type of fracture might require surgery to make sure the
pieces are aligned before casting).

Symptoms and signs

Even though symptoms vary widely after experiencing a bone fracture, the most
common fracture symptoms include:

 pain in the fractured area

 swelling in the fractured area
 obvious deformity in the fractured area
 not being able to use or move the fractured area in a normal manner
 bruising, warmth, or redness in the fractured area

Cause

Children with a higher risk of a fracture

Low bone mineral content

Children with generalized disorders such as renal diseases, cystic fibrosis, diabetes
mellitus, growth hormone deficiency, and osteogenesis imperfecta disorders are at
risk. Neuromuscular disorders: children with cerebral palsy, spina bifida, and
arthrogryposis, have a higher risk of a fracture because of the combination of joint
stiffness and poor mineralization.

Fracture personality

Children in general are at greater risk because of their high activity levels. Children
that have risk-prone behaviors are at even greater risk.

Child abuse

Over 2.5 million child abuse and neglect cases are reported every year, and thirty-
five out of every hundred cases are physical abuse cases. Bone fractures are
sometimes part of the physical abuse of children; knowing the symptoms of bone
fractures in physical abuse and recognizing the actual risks in physical abuse will
help forward the prevention of future abuse and injuries. Astoundingly, these abuse
fractures, if not dealt with correctly, have a potential to lead to the death of the
child. Fracture patterns in abuse fractures that are very common with abuse are
fractures in the growing part of a long bone (between the shaft and the separated
part of the bone), fractures of the humeral shaft (long bone between the shoulder
and elbow), ribs, scapula, outer end of the clavicle, and vertebra. Multiple fractures
of varying age, bilateral fractures, and complex skull fractures are also linked to
abuse. Fractures of varying ages occur in about thirteen percent of all cases.

Pathophysiology

Differences between child and adult bones

There are differences in the bone structure of a child and an adult. These
differences are important for the correct evaluation and treatment of the fractures.
A child's bones heal faster than an adult's because a thicker, stronger, and more
active dense fibrous membrane (periosteum) covers the surface of their bones. The
periosteum has blood vessels that supply oxygen and nutrition to the bone cells.
The stronger and thicker periosteum in children causes a better supply of oxygen
and nutrients to the bones, and this helps in the remodeling of the fractured bones
by supplying. The periosteum in children causes a more rapid union of fractured
bones and an increased potential for remodeling. A child's fractures not only heal
more quickly, but are significantly reduced due to the thickness and strength of a
child's periosteum. But this thickness also has its drawbacks; when there is a small
displacement in the periosteum the thickness and strength of it will make the
fracture in the periosteum difficult to diagnose.

Growth plate

Growth plates are the areas in bones where the bones grow. In children the growth
plates are open, which helps to manage a child's fractures.

Age and sex related fractures

Bone fracture types differ depending on the age and sex of the child. The changes
in the bones over time cause variance in the pattern and number of bone fracture
injuries. The probability of bone fractures in children increases with age. For a
small child, injuries will most likely be minimal because the child doesn't have the
speed or mass to cause serious injuries. When age increases, so does mass and
speed resulting in more serious fractures. The age when girls usually fracture a
bone is twelve and for boys the age is fourteen. Also, girls statistically have fewer
fractures than boys. About half of boys and one-fourth of girls are likely to have a
fracture during childhood. The wrist is also the most likely part of the body to be
injured. As sport activities increase, the fractures in children increase as well,
especially for boys who participate in either wrestling or football. Much like bone
types in the different stages of childhood are varying, so the bone fracture injuries
in infants, children, and adolescents vary. Careful evaluation for the best treatment
of each child is needed.

Treatment

When a child experiences a fracture, he or she will have pain and will not be able
to easily move the fractured area. A doctor or emergency care should be contacted
immediately. In some cases even though the child will not have pain and will still
be able to move, medical help must be sought out immediately. To decrease the
pain, bleeding, and movement a physician will put a splint on the fractured area.
Treatment for a fracture follows a simple rule: the bones have to be aligned
correctly and prevented from moving out of place until the bones are healed. The
specific treatment applied depends on how severe the fracture is, if it's an open or
closed fracture, and the specific bone involved in the fracture (a hip fracture is
treated differently from a forearm fracture for example) Different treatments for
different fractures: The general treatments for common fractures are as follows:

Cast immobilization
Because most fractures heal successfully after having been repositioned, a simple
plaster or fiberglass cast is commonly used.

Functional cast or brace

A cast, or brace, that allows limited movement of the nearby joints is acceptable
for some fractures.

Traction

This treatment consists of aligning a bone or bones by a gentle, steady pulling

action. The pulling may be transmitted to the bone or bones by a metal pin through
a bone or by skin tapes. This is a preliminary treatment used in preparation for
other secondary treatments.

Open reduction and internal fixation

This treatment is only used when an orthopedic surgeon assigns it to restore the
fractured bone to its original function. This method positions the bones to their
exact location, but there is a risk for infection and other complications. The
procedure involves the orthopedist performing surgery on the bone to align the
bone fragments, followed by the placement of special screws or metal plates to the
outer surface of the bone. The fragments can also be held together by running
metal rods through the marrow in the center of the bone.

External fixation

This treatment also requires surgery by an orthopedist. Pins or screws are placed
into the fractured bone above and below the fracture site. The orthopedic surgeon
repositions the bone fragments and pins or screws are connected to a metal bar or
bars outside the skin which holds the bones in their proper position so they can
heal. The external fixation device is removed after an appropriate time period.

Prognosis

Fractures in children generally heal relatively fast, but may take several weeks to
heal. Most growth plate fractures heal without any lasting effects. Rarely, bridging
bone may form across growth plates, causing stunted growth and/or curving. In
such cases, the bridging bone may need to be surgically removed. A growth plate
fracture may also stimulate growth, causing a longer bone than the corresponding
bone on the other side. Therefore, the American Academy of Orthopaedic
Surgeons recommends regular follow-up for at least a year after growth plate
fractures.

Soft tissue injury

A soft tissue injury is the damage of muscles, ligaments and tendons throughout
the body. Common soft tissue injuries usually occur from a sprain, strain, a one-off
blow resulting in a contusion or overuse of a particular part of the body. Soft tissue
injuries can result in pain, swelling, bruising and loss of function.

Causes of soft tissue injuries

Soft tissue injuries occur when the body's muscles, tendons or ligaments
experience a degree of trauma. Oftentimes, these injuries happen suddenly – for
instance, stepping too sharply and spraining an ankle – or may occur gradually as a result
of overuse.

Types of soft tissue injuries

Sprains

A sprain is a type of acute injury which results from the stretching or tearing of a
ligament. Depending on the severity of the sprain, the movement on the joint can
be compromised since ligaments aid in the stability and support of joints. Sprains
are commonly seen in vulnerable areas such as the wrists, knees and ankles. They
can occur from movements such as falling on an outstretched hand or a twisting of
the ankle or foot.

The severity of a sprain can be classified:

 Grade 1: Only some of the fibers in the ligament are torn, and the injured
site is moderately painful and swollen. Function in the joint will be
unaffected for the most part.
 Grade 2: Many of the ligament fibers are torn, and pain and swelling is
moderate. The functionality of the joint is compromised.
  Grade 3: The soft tissue is completely torn, and functionality and strength
on the joint is completely compromised. In most cases, surgery is needed to
repair the damage.

Strains

A strain is a type of acute injury that occurs to the muscle or tendon. Similar to
sprains, it can vary in severity, from a stretching of the muscle or tendon to a
complete tear of the tendon from the muscle. Some of the most common places
that strains occur are in the foot, back of the leg (hamstring), or back.

Bruising (contusion)

A contusion is the discoloration of the skin, which results from underlying muscle
fibers and connective tissue being crushed. This can happen in a variety of ways
such as a direct blow to the skin, or a fall taken against a hard surface. The
discoloration in the skin is present when blood begins to pool around the injury.

Tendinitis

Tendinitis is a type of overuse injury to the tendons, which demonstrates signs of

inflammation of tendons around a joint. Tendinitis is the most common cause of
shoulder pain and also leg pain . Tendinitis occurs when there is repetitive stress on
the subacromial bursa, which causes the bones to make contact with the tendons
and irritate them.

Diagnosis

Classifications

Acute injuries

Any type of injury that occurs to the body through sudden trauma, such as a fall,
twist or blow to the body. A few examples of this type of injury would be sprains,
strains and contusions.

Overuse injuries
An overuse injury occurs when a certain activity is repeated frequently and the
body does not have enough time to recover between occurrences. Examples
include bursitis and tendinitis.

Commonly injured tissues

With examples of each. Parentheses indicate location in body

 Ligaments

Anterior cruciate ligament (knee), medial collateral ligament (knee), ulnar

collateral ligaments (wrist/hand), interspinous ligaments (vertebrae)

 Muscles

Biceps brachii (upper arm), rectus femoris (thigh), transverse abdominis

(abdominals)

 Tendons

Patellar tendon (knee), calcaneal/Achilles tendon (foot/lower leg), biceps

tendon (shoulder/elbow)

 Nerves

Brachial plexus (shoulder), ulnar nerve (elbow/hand), peroneal nerve

(ankle/foot), cranial nerves I-XII(head)

 Bones

Femur (leg), humerus (arm), ribs (torso), metatarsals I-VI (foot), metacarpals
I-VI (hand)

 Cartilage

Menisci (knee), intervertebral discs (spine), acetabulum (hip)

Management
RICE method

The RICE method is an effective procedure used in the initial treatment of a soft
tissue injury.

Rest

It is suggested that the patient take a break from the activity that caused the
injury in order to give the injury time to heal.

Ice

Ice may be used in the acute phase of injury. The injury should be iced on and off in 20
minute intervals, avoiding direct contact of the ice with the skin. Ice diminishes
pain, metabolism, and muscle spasms. It also minimizes the inflammatory process
and edema, which helps one recover from a soft-tissue injury.

Compression

Bandaging the injury will compress it, and prevent any further bleeding or
swelling from occurring.

Elevation

Elevating the injury above the heart while resting will aid in the reduction of
swelling.

Anti-inflammatory medicine e.g Ibuprofen, Diclofenac e.t.c

Stretching and strengthening exercises can gradually be added to help avoid further injury

No HARM protocol

This mnemonic indicates what not to do within the first 48–72 hours after the
injury in order to speed up the recovery process.

Heat
 Applying heat to the injured area can cause blood flow and swelling to
increase.

Alcohol

Alcohol can inhibit the ability to feel if the injury is becoming more
aggravated, as well as increasing blood flow and swelling.

Re-injury

Avoid any activities that could aggravate the injury and cause further
damage.

Massage

Massaging an injured area can promote blood flow and swelling, and
potentially cause more damage if done too early.

Treatment

If severe pain persists after the first 24hours it is recommended that a nerve
conduction studies be done to localize nerve dysfunction (e.g. carpal tunnel
syndrome), assess severity, and help with prognosis. Electrodiagnosis also helps
differentiate between myopathy and neuropathy.

Ultimately, the best method of imaging soft tissue is magnetic resonance imaging
(MRI), though it is cost-prohibitive and carries a high false positive rate.

The following precautions can help prevent soft tissue injuries:

1. Stretch before you use your muscles.

2. Avoid bending or twisting the back or neck.
3. Avoid overexertion.
4. Use ladders to reach overhead objects and mechanical equipment to carry
and move heavy materials.
5. Use proper lifting techniques.