11/11/2020

Management of Common Fractures in Children 
and Adolescents 

A/Prof Arjandas Mahadev
Head  & Senior Consultant  
Department of Orthopaedic Surgery
KK Women’s and Children’s Hospital

SCOPE
TRAUMA PHYSIOLOGICAL PATHOLOGICAL DEVEPLOPMENTAL

COMMON FLATFEET APPROACH TO A DDH

UPPER LIMB LIMPING CHILD
FRACTURES

COMMON LOWER Transient synovitis CLUBFEET

LOWER LIMB MALALIGNMENT
FRACTURES

TRANSITIONAL INTOEING Perthes TORTICOLLIS

FRACTURES

NON ACHES AND PAINS SCFE SCOLIOSIS

ACCIDENTAL
INJURY

Management of Common Fractures in

Children and Adolescents I.
• Paediatric vs Adult Bones: Differences
• Common Upper Limb Fractures
• Common Lower Limb Fractures

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The Epidemiology of Childhood Fractures in Singapore : A 10 Year

Study
WM Siow, A Mahadev - Unpublished
Bimodal distribution Modal peaks: 7 and 11 years old
Median age: 7.64 ± 0.05 years old

No.
0

N=34425
0

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Age

The Epidemiology of Childhood Fractures in Singapore : A 10 Year

Study
WM Siow, A Mahadev - Unpublished
Male modal peaks: 7 yrs & 11 yrs Male median: 8.18 ± 0.06 yrs
Female modal peaks: 5 yrs & 10 yrs Female median: 6.66 ± 0.07 yrs
No.
1600

1400
N=34425
1200

1000

800

600

400

200

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Age

Paediatric vs Adult Bones: Differences
Properties Differences
Biomechanical - Lower Modulus of Elasticity
- Lower Bending Strength
- Lower Torsional Strength
Clinical Application
- Plastic Deformation
- Greenstick Fractures
- Buckle Fractures

Anatomical - Presence of Physis - Salter Harris Fractures more likely

than dislocations
- Secondary Centers of Ossification - Mimic fracture lines

- Thick, Vascular and Highly - Inherently more stable fractures

Osteogenic Periosteum
Physiological - Rapid Healing - Shorter immobilisation
- Large Potential for Remodelling - More amenable to conservative
management.

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Paediatric vs Adult Bones: Differences
Properties Differences
Biomechanical - Lower Modulus of Elasticity
- Lower Bending Strength
- Lower Torsional Strength
Clinical Application
- Plastic Deformation
- Greenstick Fractures
- Buckle Fractures

Anatomical - Presence of Physis - Salter Harris Fractures more likely

than dislocations
- Secondary Centers of Ossification - Mimic fracture lines

- Thick, Vascular and Highly - Inherently more stable fractures

Osteogenic Periosteum
Physiological - Rapid Healing - Shorter immobilisation
- Large Potential for Remodelling - More amenable to conservative
management.

Biomechanical Properties
More Haversian canals
– Lower Modulus of Elasticity
– Lower Bending strength
– Lower Torsional strength

Biomechanical Properties
Stress

Strain

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Biomechanical Properties
Greenstick vs Buckle Fractures

Greenstick Fractures Buckle/Torus Fractures

Paediatric vs Adult Bones: Differences
Properties Differences
Biomechanical - Lower Modulus of Elasticity
- Lower Bending Strength
- Lower Torsional Strength
Clinical Application
- Plastic Deformation
- Greenstick Fractures
- Buckle Fractures

Anatomical - Presence of Physis - Salter Harris Fractures more likely

than dislocations
- Secondary Centers of Ossification - Mimic fracture lines

- Thick, Vascular and Highly - Inherently more stable fractures

Osteogenic Periosteum
Physiological - Rapid Healing - Shorter immobilisation
- Large Potential for Remodeling - More amenable to conservative
management.

THE GROWTH PLATE

Rockwood and Wilkins'

Fractures in Children,
7th edition

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Salter Harris Classification

Physeal plate 
Manipulation and reduction  Surgery resection 
Rockwood and Wilkins' .Fractures in Children, 
7th edition

Growth plate is weaker than ligaments

Salter Harris Fractures more likely than 
dislocations 

SALTER HARRIS I

Rockwood and Wilkins'

Fractures in Children,
7th edition

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SALTER HARRIS I
11 year old
with ankle inversion
injury.

SH I distal fibula

SALTER HARRIS II

Rockwood and Wilkins'

Fractures in Children,
7th edition

SALTER HARRIS II

Distal radius fracture

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SALTER HARRIS III

Rockwood and Wilkins'

Fractures in Children,
7th edition

SALTER HARRIS III

13 year old
with ankle
injury.

Tillaux fracture

SALTER HARRIS IV

Rockwood and Wilkins'

Fractures in Children,
7th edition

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SALTER HARRIS IV
2 year old
with elbow
injury.

Lateral condyle fracture

C R I T O E

8 year old boy

DISTAL RADIUS
Bayonet Fracture

Thick, Vascular and Highly

Osteogenic Periosteum
- less than 10 years old

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4 weeks post fracture

10 weeks post fracture

16 weeks post fracture

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Paediatric vs Adult Bones: Differences
Properties Differences
Biomechanical - Lower Modulus of Elasticity
- Lower Bending Strength
- Lower Torsional Strength
Clinical Application
- Plastic Deformation
- Greenstick Fractures
- Buckle Fractures

Anatomical - Presence of Physis - Salter Harris Fractures more likely

than dislocations
- Secondary Centers of Ossification - Mimic fracture lines

- Thick, Vascular and Highly - Inherently more stable fractures

Osteogenic Periosteum
Physiological - Rapid Healing - Shorter immobilisation
- Large Potential for Remodelling - More amenable to conservative
management.

Fracture Remodeling
Wolff’s law
ASM1
• Bone remodels in response to mechanical stress
• Bone is laid down on the tension side (osteoblasts) and
resorbed on the compression side (osteoclasts)

Bone is laid down on Bone is resorbed on the

the tension side compression side
(osteoblasts) (osteoclasts)

Factors affecting remodeling

Age Type of displacement
– Best before the age of 10
years old
– Translation
• Usually will remodel
Fracture site
– Physeal > Metaphyseal > – Angulation
Diaphyseal • Will remodel in the
– Two thirds of remodeling plane of motion
process occurs at physis
– Rotation
Relationship to joint • Less likely to remodel
– Active growth plates more (unless near joint with
remodelling rotation eg. hip and
– Remodels along plane of shoulder)
motion.

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Slide 29

ASM1 Arjandas S/O Mahadev, 01/07/2020

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Factors affecting remodeling

Age
– Best before the age of 10
years old
Fracture site
– Physeal > Metaphyseal >
Diaphyseal
– Two thirds of remodeling
process occurs at physis
Relationship to joint
– Active growth plates more
remodelling
– Remodels along plane of
motion.

11 year old Male 11 year old Male
– 6 months post facture

Proximal humerus fractures Has great potential remodelling

• Very near active growth plate
• Shoulder has 6 degrees of motion

Fracture Remodeling – Joint 
Considerations
Remodeling maximal in the
plane of action of the joint
– Varus/valgus deformity of the
elbow will not remodel

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Principle of cast management
• Indication for Manipulation and Reduction depends on
– Degree of displacement
– Integrity periosteal sleeve and soft tissue
– Contraindication to casting
• Acceptability of Reduction and Alignment depends on
potential for Remodeling
– Age
– Fracture site
– Relationship to joint
– Type of displacement
• Maintenance of Reduction after casting
– 3 point contact necessary to maintain closed reduction
– Length of cast: one joint above and below
– Duration of casting

Maintenance of Reduction
• 3 point contact necessary to maintain closed reduction
– Palm molding to avoid pressure points

• One joint above and below

• Duration of immobilization
• 4 weeks for upper limb
• 8 weeks for lower limb

Surgical Management 
• Stable reduction is not possible or cannot be
maintained

• When cast immobilization is contraindicated

– Major soft tissue injury
– Suspicion of compartment syndrome
– Vascular compromise

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RADIUS ULNA FRACTURES
• Unlike in adults radius/ulna can usually be
treated by M&R
– Translation
– Rotation
– Angulation

• Surgery indicated if unable to achieve stable

acceptable alignment

6 YEAR OLD BOY FOOSH

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11 year old boy

Fell on the outstretched
Forearm after rollerblading

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TENs – Titanium Elastic Nailing

15 year old male

Tackled during rugby

Treated with plates and

screws

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MONTEGGIA FRACTURE
Radial head MUST align with Capitulum
in all view

MONTEGGIA FRACTURE

SUPRACONDYLAR FRACTURES

Monkey bars are for monkeys: a study on playground equipment related

extremity fractures in Singapore.
Mahadev A, Soon MY, Lam KS.Singapore Med J. 2004 Jan; 45(1): 9-13.

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SUPRACONDYLAR FRACTURES
• Most common fracture in our hospital
requiring surgery
• Classification
– Grade I – Cast Immobilisation
– Grade II - M & R
– Grade III - M & R and CRPP

Rockwood and Wilkins'

Fractures in Children,
7th edition

SUPRACONDYLAR FRACTURES
Grade I

SUPRACONDYLAR FRACTURES
Grade I

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SUPRACONDYLAR FRACTURES
Grade II

Baumann’s angle = 75º Anterior Humeral line Bisect capitulum

SUPRACONDYLAR FRACTURES
Grade II

Baumann’s angle = 75º Anterior Humeral line Bisect capitulum

SUPRACONDYLAR FRACTURES
Grade III

CLOSED REDUCTION AND PERCUTANEOUS PINNING

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SUPRACONDYLAR FRACTURES
Closed Reduction

Axial Force to correct varus malalignment

SUPRACONDYLAR FRACTURES
Closed Reduction

Flexion to correct the extension of fragment

SUPRACONDYLAR FRACTURES

CLOSED REDUCTION AND PERCUTANEOUS PINNING

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CUBITUS VARUS

6 year Chinese boy

Neurovascular Complications

LATERAL CONDYLE FRACTURE
• SH IV fracture with joint extension
• Displacements >2mm needs ORIF
• If undisplaced needs close surveillance
• Can lead to non union, elbow deformity and instability if
untreated
– Intrarticular with surrounding synovial fluid
– Constant pull of the common extensor
– Poor blood supply

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LATERAL CONDYLE FRACTURE

DISTAL RADIUS
Different varieties
Buckle fractures
• Very stable
• No M&R required
• May treat with Brace only
Salter Harris II
• Below elbow cast after M&R
Distal 1/3 fracture of the radius
• Above elbow cast after M &R
• Bayonet acceptable for those < 10 years old if delayed
presentation

BUCKLE FRACTURE DISTAL

RADIUS

Treated with a wrist brace

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SALTER HARRIS II DISTAL

RADIUS

10 year old boy

Below elbow
cast

DISTAL RADIUS
Bayonet Fracture

8 year old boy

After M&R
Above elbow cast

PAEDIATRIC FEMUR
FRACTURES

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FEMUR FRACTURES
• General Concerns
– Adequate pain relieve
– ATLS for multiply Injured

• Be aware of possible Non Accidental Injuries NAI

– In those not ambulating
– Mentally retarded
– Non communicative yet

• Be aware of pathological fractures

7 year old with Right

Subtrochanteric fracture

TREATMENT OPTIONS
• Simple splints
• Traction and Hip Spica
• Elastic Stable Intramedullary Nailing (ESIN)
• Bridging Plate Osteosynthesis
• Open Reduction and Plating
• External Fixator
• Solid Nails

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FACTORS AFFECTING TREATMENT

Age of the patient

• Newly born
• Before ambulation
• Before school going
• Preadolescent

FACTORS AFFECTING TREATMENT

Age of the patient

• Newly born • Usually due to birth

• Before ambulation trauma
• Before school going • Pavlik harness for
• Preadolescent about a month
• Simple splints will
suffice

2 Day old

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Newborn with Pavlik Harness

FACTORS AFFECTING TREATMENT

Age of the patient

• Newly born • Hip spica no great

inconvenience
• Before ambulation • Good fracture
• Before school going stabilisation due to low
velocity injury
• Preadolescent • Absence from school not
a big issue
• Good fracture healing
with greater tolerance for
shortening and
angulation

Early 1 leg hip spica.

Allows for sitting.
Better accepted.

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2 year old girl ‐ 3 weeks post‐ fracture

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2 year girl with midshaft femur fracture

3 months post injury 9 months post injury

2 years post injury

FACTORS AFFECTING TREATMENT

Age of the patient

• Newly born • Difficult to maintain

reduction as fractures are
• Before ambulation a result of high velocity
• Before school going injuries.
• Poor remodeling for
• Preadolescent shortening and
angulation
• Loss of school days with
spica.
• Usually require surgical
stabilisation

14 year old boy.

Road traffic accident.
Open fracture distal third
R femur.

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14 year old boy.

Road traffic accident.
Open fracture distal third
R femur.
- Post Operative

TIBIA FRACTURES
Aim is to restore and maintain acceptable
– Length
– Alignment
• Translation
• Angulation
• Rotation
• Above knee cast backslab acutely
• Followed by above knee full cast for 8
weeks
OPEN FRACTURE
COMPARTMENT SYNDROME

Tibia Fracture Alignment Guide
Parameter Acceptable values

Apposition
Shortening
Coronal (varus/valgus)
Sagittal (anterior/posterior)
≥ 50%
≤ 2cm
≤ 5o if > 8 year old
≤10o if < 8 year old
≤ 5o if > 8 year old
≤10o if < 8 year old

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TIBIA FRACTURES

Toddler’s Fracture
- Above Knee Cast

Management of Common Fractures in

Children and Adolescents II
• Transitional fractures of Adolescents
• Non-accidental Injuries

FRACTURES IN
ADOLESCENCE

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13 year old girl
Slipped and fell with Right ankle
pain and swelling

1 week after

Migration of growth plate

closure during adolescence

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TILLAUX FRACTURES

Rockwood and Wilkins'

Fractures in Children,
7th edition

12 year old girl
Slipped and fell
Injured the right ankle

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TRIPLANE FRACTURE

Coronal Axial
Sagittal

TRIPLANE FRACTURE

Rockwood and Wilkins'

Fractures in Children,
7th edition

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Non Accidental Injury (NAI)

Specificity of Skeletal Trauma for

Abuse
High specificity Moderate specificity
• Classic metaphyseal • Multiple fractures, especially
bilateral
lesions
• Fractures in various stages of
• Posterior rib fracture
healing
• Scapular fracture
• Epiphyseal separation
• Spinous process fracture • Vertebral body fracture or
• Sternal fracture subluxation
• Digital fracture
• Complex skull fractureLow
specificity
• Clavicular fracture
• Long-bone shaft fracture
• Linear skull fracture
Data from Kleinman PK, ed. Diagnostic Imaging of Child Abuse. Baltimore: Williams & Wilkins, 1987.

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Classic Metaphyseal lesions (CML).

Only the margins of the physis 
(femur, illustrating a corner fracture). 

Across the width of the ossified physis
(tibia illustrating a bucket handle fracture) 

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QUESTIONS

Thank you
Arjandas.Mahadev@kkh.com.sg

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