Features of fractures of various types in children: accompanying symptoms, diagnosis and treatment, causes of frequent bone injuries. Fractures in children What are fractures

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The anatomical features of the structure of the skeletal system of children and its physiological properties determine the occurrence of certain types of fractures that are characteristic only for this age.

It is known that young children often fall during outdoor games, but they rarely have bone fractures.

This is due to the lower body weight and well-developed cover of the soft tissues of the child, and consequently, the weakening of the impact force during a fall.

baby bones thinner and less durable, but they are more elastic than the bones of an adult. Elasticity and flexibility depend on the smaller amount of mineral salts in the bones of the child, as well as on the structure of the periosteum, which in children is thicker and richly supplied with blood. The periosteum forms, as it were, a case around the bone, which gives it greater flexibility and protects it in case of injury.

The preservation of the integrity of the bone is facilitated by the presence of epiphyses at the ends of the tubular bones, connected to the metaphyses by a wide elastic growth cartilage, which weakens the force of impact. These anatomical features, on the one hand, prevent the occurrence of a bone fracture, on the other hand, in addition to the usual fractures observed in adults, they cause the following skeletal injuries typical of childhood: fractures, subperiosteal fractures, epiphysiolysis, osteoepiphysiolysis and apophyseolysis.

Fractures and fractures like a green branch or a wicker rod are explained by the flexibility of bones in children.

This type of fracture is observed especially often when the diaphysis of the forearm is damaged. In this case, the bone is slightly bent, on the convex side the outer layers undergo a fracture, and on the concave side they retain a normal structure.

Subperiosteal fractures are characterized by the fact that the broken bone remains covered by the periosteum, the integrity of which is preserved. These injuries occur under the action of a force along the longitudinal axis of the bone. Most often, subperiosteal fractures are observed on the forearm and lower leg; displacement of the bone in such cases is absent or is very slight.

Epiphyseolysis and osteoepiphyseolysis - traumatic detachment and displacement of the epiphysis from the metaphysis or with a part of the metaphysis along the line of the growth epiphyseal cartilage.

They occur only in children and adolescents before the end of the ossification process (Fig. 14.1).

Epiphysiolysis occurs more often as a result of the direct action of force on the epiphysis and, according to the mechanism of injury, is similar to dislocations in adults, which are rarely observed in childhood. This is due to the anatomical features of the bones and the ligamentous apparatus of the joints, and the place of attachment of the articular capsule to the articular ends of the bone is essential.

Epiphysiolysis and osteoepiphysiolysis are observed where the articular bursa attaches to the epiphyseal cartilage of the bone: for example, the wrist and ankle joints, the distal epiphysis of the femur. In places where the bag is attached to the metaphysis so that the growth cartilage is covered by it and does not serve as a place for its attachment (for example, the hip joint), epiphyseolysis does not occur. This position is confirmed by the example of the knee joint.

Here, in case of injury, epiphysiolysis of the femur occurs, but there is no displacement of the proximal epiphysis of the tibia along the epiphyseal cartilage.

Apophysiolysis - detachment of the apophysis along the line of the growth cartilage

At the same time, with fractures, subperiosteal fractures, epiphyseolysis and osteoepiphyseolysis, movements can be preserved to a certain extent without displacement, there is no pathological mobility, the contours of the injured limb, which the child spares, remain unchanged, and only when palpated, pain is determined in a limited area corresponding to the fracture site. In such cases, only X-ray examination helps to make the correct diagnosis.

A feature of bone fractures in a child is an increase in body temperature in the first days after injury from 37 to 38°C, which is associated with the absorption of the contents of the hematoma.

In children, it is difficult to diagnose subperiosteal fractures, epiphysiolysis, and osteoepiphysiolysis without displacement. Difficulty in establishing a diagnosis also arises with epiphyseolysis in newborns and infants, since even radiography does not always clarify due to the absence of ossification nuclei in the epiphyses.

In young children, most of the epiphysis consists of cartilage and is passable for X-rays, and the nucleus of ossification gives a shadow in the form of a small point. Only when compared with a healthy limb on radiographs in two projections, it is possible to establish the displacement of the ossification nucleus in relation to the bone diaphysis.

Similar difficulties arise during birth epiphyseolysis of the heads of the humerus and femur, the distal epiphysis of the humerus, etc. At the same time, in older children, osteoepiphyseolysis without displacement is easier to diagnose, since the separation of the bone fragment of the metaphysis of the tubular bone is noted on radiographs.

Misdiagnosis is more common in fractures in young children. Lack of history, well-defined subcutaneous tissue, which makes palpation difficult, and the lack of displacement of fragments in subperiosteal fractures make it difficult to recognize. Often, in the presence of a fracture, a bruise is diagnosed.

As a result of improper treatment in such cases, limb curvature and impaired function are observed. In some cases, repeated X-ray examination, performed on the 7-10th day after the injury, helps to clarify the diagnosis, which becomes possible due to the appearance of initial signs of fracture consolidation.

The leading principle is a conservative method of treatment (94%).

In most cases, a fixing bandage is applied. Immobilization is carried out with a plaster splint, as a rule, in the middle physiological position covering 2/3 of the circumference of the limb and fixing two adjacent joints. A circular plaster cast is not used for fresh fractures in children, since there is a risk of circulatory disorders due to increasing edema with all the ensuing consequences (Volkmann's ischemic contracture, bedsores, and even necrosis of the limb).

In the process of treatment, periodic X-ray control (once a week) is necessary for the position of bone fragments, since secondary displacement of bone fragments is possible. Traction is used for fractures of the humerus, lower leg bones, and mainly for fractures of the femur. Depending on the age, location and nature of the fracture, adhesive plaster or skeletal traction is used.

The latter is used in children older than 3 years. Thanks to traction, the displacement of fragments is eliminated, a gradual reposition is carried out, and the bone fragments are held in a reduced position.

In case of bone fractures with displacement of fragments, one-stage closed reposition is recommended as soon as possible after the injury.

In especially difficult cases, reposition is performed under periodic X-ray control with radiation protection of the patient and medical personnel. Maximum shielding and minimum exposure allow visually guided repositioning.

Of no small importance is the choice of method of anesthesia.

Good anesthesia creates favorable conditions for repositioning, since the comparison of fragments should be done in a gentle way with minimal tissue trauma. These requirements are met by anesthesia, which is widely used in a hospital setting.

In outpatient practice, reposition is performed under local or conduction anesthesia. Anesthesia is carried out by introducing a 1% or 2% novocaine solution into the hematoma at the fracture site (at the rate of 1 ml per one year of a child's life). When choosing a treatment method for children and establishing indications for repeated closed or open reposition, the possibility of self-correction of some types of remaining displacements in the growth process is taken into account.

The degree of correction of the damaged segment of the limb depends both on the age of the child and on the location of the fracture, the degree and type of displacement of the fragments.

At the same time, if the growth zone is damaged (with epiphysiolysis), as the child grows, a deformity may be revealed that was not present during the treatment period, which should always be remembered when evaluating the prognosis (Fig. 14.2). Spontaneous correction of the remaining deformity is the better, the younger the patient.

The leveling of displaced bone fragments in newborns is especially pronounced.

In children under 7 years of age, displacements in diaphyseal fractures are permissible in length from 1 to 2 cm, in width - almost to the diameter of the bone and at an angle of not more than 10 °. At the same time, rotational displacements are not corrected during growth and should be eliminated.

In children of the older age group, more accurate adaptation of bone fragments and the elimination of deflections and rotational displacements are required. With intra- and periarticular fractures of the bones of the extremities, an exact reposition is required with the elimination of all types of displacements, since the unrepaired displacement of even a small bone fragment during an intra-articular fracture can lead to blockade of the joint or cause varus or valgus deviation of the axis of the limb.

Surgery for bone fractures in children is indicated in the following cases:

1) with intra- and periarticular fractures with displacement and rotation of the bone fragment;
2) with a two or three attempts at a closed reposition, if the remaining displacement is classified as unacceptable;
3) with interposition of soft tissues between fragments;
4) with open fractures with significant damage to soft tissues;
5) with incorrectly fused fractures, if the remaining displacement threatens with permanent deformation, curvature or stiffness of the joint;
6) with pathological fractures.

Open reposition is performed with special care, gentle surgical access, with minimal trauma to soft tissues and bone fragments, and is completed mainly by simple methods of osteosynthesis.

Complex metal structures are rarely used in pediatric traumatology. More often than others, a Kirschner wire is used for osteosynthesis, which, even with transepiphyseal conduction, does not have a significant effect on bone growth in length. Bogdanov's rod, CITO, Sokolov's nails can damage the epiphyseal growth cartilage and are therefore used for osteosynthesis in diaphyseal fractures of large bones.

In case of incorrectly fused and incorrectly fused bone fractures, false joints of post-traumatic etiology, the compression-distraction devices of Ilizarov, Volkov-Oganesyan, Kalnberz, etc. are widely used.

The timing of fracture consolidation in healthy children is shorter than in adults. In debilitated children suffering from rickets, hypovitaminosis, tuberculosis, as well as with open injuries, the immobilization period is lengthened, since the reparative processes in these cases are slowed down (Table 14.1).

With insufficient duration of fixation and early loading, secondary displacement of bone fragments and a repeated fracture are possible. Ununited fractures and false joints in childhood are an exception and usually do not occur with proper treatment.

Delayed consolidation of the fracture area can be observed with insufficient contact between fragments, soft tissue interposition, and with repeated fractures at the same level.

After the onset of consolidation and removal of the plaster splint, functional and physiotherapeutic treatment is indicated mainly for children with intra- and periarticular fractures, especially when movements are limited in the elbow joint. Physiotherapy exercises should be moderate, gentle and painless.

Massage near the fracture site, especially with intra- and periarticular injuries, is contraindicated, since this procedure promotes the formation of excess bone callus and can lead to myositis ossificans and partial ossification of the articular bag.

Children who have suffered damage near the epimetaphyseal zone need long-term follow-up (up to 1.5–2 years), since injury does not exclude the possibility of damage to the growth zone, which can subsequently lead to limb deformity (post-traumatic deformity of the Madelung type, varus or valgus deviation of the axis of the limb, shortening of the segment, etc.).

Birth damage

Birth trauma includes injuries received during the birth act, as well as in the provision of manual assistance and resuscitation of a child born in asphyxia.

More often in newborns, fractures of the clavicle, fractures of the femur and humerus, damage to the skull and brain are observed. Fractures of the bones of the forearm and lower leg are extremely rare.

Clavicle fracture

The fracture, as a rule, is localized in the middle third of the diaphysis and may be complete or incomplete (subperiosteal). In the area of ​​the fracture, there is a slight swelling due to edema, hematoma, displacement of fragments and pathological mobility. With complete fractures, the child holds the arm in a forced position and does not move it, which gives rise to an erroneous diagnosis of Erb-type palsy due to damage to the brachial plexus.

The most constant sign of a clavicle fracture in newborns is crepitus fragments. With subperiosteal fractures, the diagnosis is often made by the end of the 1st week of a child's life, when a large callus appears in the clavicle area.

Fractures of the humerus and femur in children

Traumatic epiphysiolysis of the proximal and distal ends of the humerus and femur are rare. This circumstance, as well as the fact that X-ray diagnostics is difficult due to the absence of ossification nuclei, often leads to untimely diagnosis of these injuries.

In diaphyseal fractures of the humerus and femur with complete displacement of bone fragments, pathological mobility at the level of the fracture, deformity, traumatic swelling and crepitus are noted. Any manipulation causes pain to the child. Fractures of the femur are characterized by a number of features: the leg is in a flexion position typical for a newborn at the knee and hip joints and is brought to the stomach due to physiological hypertension of the flexor muscles. X-ray confirms the diagnosis.

There are several treatments for newborns with diaphyseal fractures of the humerus and femur.

In case of a fracture of the humerus, the limb is immobilized for a period of 10-14 days. The arm is fixed with a plaster splint from the edge of a healthy scapula to the hand in the middle physiological position or with a U-shaped cardboard splint in the position of shoulder abduction up to 90°.

After immobilization, movements in the injured limb are restored as soon as possible without additional procedures and manipulations. With a fracture of the femur in newborns, Schede traction is most effective. The period of immobilization is the same. When controlling the position of fragments, one should take into account the degree of permissible displacement of bone fragments (displacement in length up to 2-3 cm, in width - on the full diameter of the bone, at an angle - no more than 25-30 °), since self-correction and leveling will occur as they grow. remaining displacement; rotational displacements are not eliminated.

Traumatic epiphysiolysis in newborns has a typical picture and is more pronounced, the more the fragments are displaced. Generic epiphysiolysis of the distal end of the humerus is often accompanied by paresis of the radial or median nerve.

X-ray diagnostics is practically impossible due to the lack of bone tissue in the area of ​​the epiphyses, and only by the end of the 7-10th day on repeated radiographs can one see the callus and retrospectively resolve the issue of the nature of the former fracture.

The most typical mistake in this pathology is that a traumatic dislocation of the bones of the forearm is diagnosed and an attempt is made to reposition, which, of course, is doomed to failure. The treatment consists of a one-stage closed reposition “by eye” followed by fixation in a light plaster splint in the mid-physiological position. In the catamnesis, a varus deviation of the axis of the forearm may be noted due to the internal rotation of the condyle of the humerus that was not eliminated during the treatment.

With epiphyseolysis of the proximal end of the femur, a differential diagnosis is made with congenital dislocation of the hip.

The injury is characterized by swelling, significant pain during movement, and bruising is possible. Good results in the treatment of newborns with the specified damage gives the use of splint-spacers. Immobilization time. 4 weeks With epiphysiolysis of the distal end of the femur in newborns, there is a sharp edema and deformity in the area of ​​the knee joint. During the examination, a characteristic symptom of a "click" is determined.

X-ray reveals displacement of the nucleus of ossification of the distal epiphysis of the femur, which facilitates diagnosis and allows, after reposition, to control the position of the fragments. The terms of dispensary observation of children who have suffered a birth injury depend on the severity and localization of the injury, but by the end of the first year of life it is possible, in principle, to resolve the issue of the outcome of the injury received at birth.

Clavicle fractures

In children, a clavicle fracture is caused by an indirect injury from a fall on an outstretched arm, on the area of ​​the shoulder or elbow joint. Less often, a clavicle fracture is caused by direct trauma - a direct blow to the collarbone. More than 30% of all clavicle fractures occur between the ages of 2 and 4 years.

With incomplete fractures of the clavicle, deformation and displacement are minimal.

The function of the hand is preserved, only its abduction above the level of the shoulder girdle is limited. Subjective complaints of pain are minor, so such fractures are sometimes not detected and the diagnosis is made only after 7-14 days, when a callus is found in the form of a thickening on the collarbone. In fractures with complete displacement of fragments, the diagnosis is not difficult.

Fractures of the clavicle heal well, and function is fully restored with any treatment method, but the anatomical result may be different. Angular curvature and excess callus under the influence of growth over time disappear almost without a trace.

In most cases, a Dezo-type bandage is sufficient to fix fragments for the entire period of treatment. For fractures with complete displacement in older children, stronger fixation is required with the shoulder retracted and the external fragment of the clavicle elevated. This is achieved with the help of an eight-shaped fixing bandage or a Kuzminsky-Karpenko crutch-gypsum bandage.

Surgical treatment is used extremely rarely and is indicated only in case of a threat of perforation by a fragment of the skin, injury of the neurovascular bundle and interposition of soft tissues.

Fractures of the scapula

A characteristic feature of fractures of the scapula is swelling, clearly delimited, repeating the outline of the scapula in shape (symptom of Comolli's "triangular pillow").

This is due to subfascial hemorrhage over the body of the scapula as a result of damage to the vessels that feed the scapula. Multiaxial radiography clarifies the diagnosis. Treatment consists of immobilization in a Dezo bandage.

Rib fractures

The diagnosis is established on the basis of clinical manifestations and X-ray data. The child accurately indicates the location of the injury. Careless movements increase the pain.

There is a slight cyanosis of the skin, shortness of breath, shallow breathing due to fear of increased pain. Compression of the chest during the examination also causes pain to the child, so you should not resort to palpation if the patient has a negative reaction.

Treatment of patients with uncomplicated rib fractures consists of intercostal novocaine blockade along the paravertebral line on the side of the lesion, anesthesia of the fracture with 1-2% novocaine solution and injection of 1% pantopon solution at an age dosage (0.1 ml per year of the child's life, but not more than 1 ml ).

With pronounced symptoms of pleuropulmonary shock, it is advisable to perform a vagosympathetic blockade on the side of the lesion according to Vishnevsky. Immobilization is not required, since tight bandaging of the chest limits the excursion of the lungs, which adversely affects the recovery period (complications such as pleurisy and pneumonia are possible).

With a direct and strong impact on the chest, multiple fractures of the ribs can occur in combination with damage to internal organs.

Significant ruptures of the lung tissue and damage to blood vessels are accompanied by severe bleeding into the pleural cavity, which is fatal.

Damage to the bronchi, causing tension pneumothorax, is also dangerous. The continued flow of air into the pleural cavity collapses the lung, displaces the mediastinum, mediastinal emphysema develops. Bulau drainage or active aspiration is appropriate for minor injuries to the lungs and bronchi. With ruptures of the bronchi, increasing hemopneumothorax, open trauma, urgent surgical intervention is indicated.

Fractures of the sternum

When the fragments are displaced, sharp pain can cause pleuropulmonary shock. X-ray examination of the chest only in a strictly lateral projection allows you to identify the site of the fracture and the degree of displacement of the bone fragment.

Local anesthesia of the damaged area is effective, and in case of symptoms of pleuropulmonary shock - vagosympathetic blockade according to Vishnevsky. With a significant displacement of bone fragments, a closed reposition is performed or, according to indications, surgical intervention with fixation of fragments with suture material.

Humerus fractures

Characteristic types of damage to the proximal end of the humerus in children are fractures in the area of ​​the surgical neck, osteoepiphyseolysis and epiphysiolysis, and the displacement of the distal fragment outward with an angle open inwards is typical.

In fractures with displacement of bone fragments, the clinical picture is typical: the arm hangs down along the body and the abduction of the limb is sharply limited; pain in the shoulder joint, swelling, tension of the deltoid muscle; with a significant displacement (abduction fracture), a peripheral fragment is palpated in the axillary fossa. Radiography is performed in two (!) projections.

When indicated, reposition is performed, as a rule, in a hospital under general anesthesia and periodic monitoring of the x-ray screen. After reposition for abduction fractures, the arm is fixed in the mid-physiological position. With an adduction fracture with displacement of fragments, it is not always possible to compare bone fragments by conventional reposition, and therefore it is advisable to use the method developed by Whitman and M.V. Gromov.

In the process of reposition, one of the assistants fixes the shoulder girdle, and the other performs constant traction along the length of the limb, maximally moving the arm upwards. The surgeon at this time sets the fragments in the correct position, pressing on their ends (carefully - the neurovascular bundle!).


The arm is fixed with a plaster splint, passing to the body, in the position in which the correct position of the fragments was achieved (Fig. 14.3).

The period of fixation in a plaster splint is 2 weeks (the time required for the formation of primary bone callus). On the 14-15th day, the thoracobrachial bandage is removed, the arm is transferred to the mid-physiological position and the plaster splint is again applied for 2 weeks (a total of immobilization period is 28 days). Against the background of physical therapy and physiotherapy, movements in the shoulder joint are restored in the next 2-3 weeks.

In epiphyseolysis and osteoepiphyseolysis with significant damage to the growth zone in the long term, a violation of bone growth in length can be caused. Dispensary observation is carried out for 1.5-2 years.

Fractures of the diaphysis of the humerus in children are rare.

The clinical picture is typical.

Fractures in the middle third of the humerus are dangerous due to possible damage to the radial nerve, which at this level goes around the humerus. Displacement of fragments can cause traumatic paresis or, in severe cases, damage to the integrity of the nerve. In this regard, all manipulations in case of a fracture in the middle third of the diaphysis of the humerus must be performed with extreme caution.

The method of simultaneous closed reposition followed by fixation in a plaster splint or the method of skeletal traction for the proximal metaphysis of the ulna is used, which gives the best result. If, during subsequent X-ray control, a secondary displacement of fragments is detected, then it is eliminated by the imposition of corrective rods. Pay attention to the correctness of the axis of the humerus, because the displacement of bone fragments along the length of up to 2 cm is well compensated, while angular deformities in the process of growth are not eliminated.

Fractures of the distal end of the humerus are common in children.

They account for 64% of all humerus fractures.

For the diagnosis of damage in the area of ​​the distal metaepiphysis of the humerus, the most convenient is the classification proposed by G. A. Bairov in 1960 (Fig. 14.4).

Trans- and supracondylar fractures of the humerus in children are not uncommon.

The fracture plane in transcondylar injuries passes through the joint and is accompanied by a rupture of the articular bag and capsular-ligamentous apparatus (95% of all injuries). In supracondylar fractures, the fracture plane passes through the distal metaphysis of the humerus and does not penetrate into the joint cavity (5%). The mechanism of damage is typical - a fall on an outstretched or bent arm at the elbow joint.

The displacement of the distal fragment of the humerus can be in three planes: anteriorly (with a flexion trans- or supracondylar fracture), posteriorly (with an extensor fracture), outward - in the radial direction or inwards - in the ulnar side; rotation of the fragment around the axis is also noted. With a significant displacement, there may be a violation of innervation as a result of an injury to the ulnar, radial, or transcondylar fractures of the humerus or median nerve.

It is important to detect violations of peripheral circulation in a timely manner. The pulse on the radial and ulnar arteries may be absent for 4 reasons: due to post-traumatic spasm of the arterial vessels, compression of the arterial vessel by a bone fragment or increasing edema and hematoma, and rupture of the neurovascular bundle (the most serious complication).

With trans- and supracondylar fractures of the humerus with displacement, conservative treatment is used in the vast majority of cases.

Closed reposition is performed under general anesthesia and periodic X-ray control. The introduction of novocaine into the fracture area does not provide sufficient anesthesia and muscle relaxation, which makes it difficult to manipulate fragments and keep them in the reduced position.

After a good comparison of bone fragments, pulse control is mandatory, since compression of the brachial artery by edematous soft tissues is possible. After reposition, a deep posterior plaster splint is applied in the position of the arm in which the bone fragments were fixed.

With significant edema, failure of simultaneous closed reposition, it is advisable to use the method of skeletal traction for the proximal metaphysis of the ulna with a load of 2 to 3 kg. If the fracture is unstable (more often observed with an oblique plane), you can use percutaneous fixation of bone fragments according to K. Papp (diafixation) or percutaneous osteosynthesis with crossed Kirschner wires according to the Jude method.

In case of failure of conservative treatment and unacceptable displacement of fragments, it may be necessary to open reposition.

The operation is performed in extreme cases: with repeated unsuccessful attempts at closed reposition, with interposition of the neurovascular bundle between fragments with the threat of Volkmann's ischemic contracture, with open and incorrectly fused fractures.

Among the complications that are possible with this type of fracture, it should be noted ossifying myositis and ossification of the articular bag. They are observed in children who undergo repeated closed repositions, accompanied by the destruction of granulations and primary callus. According to N. G. Damier, ossification of the articular bag most often develops in children with a tendency to form keloid scars.

Internal rotation and medial displacement of the distal fragment of the humerus that were not eliminated during the treatment lead to varus deformity of the elbow joint.

If the axis of the forearm is deviated by 15° in girls and by 20° in boys, a corrective transcondylar wedge osteotomy of the humerus is indicated.

It is performed no earlier than 1-2 years after the injury according to the Bairov-Ulrich method (Fig. 14.5). It is important to pre-calculate the volume of the proposed bone resection. Produce radiography of two elbow joints in strictly symmetrical projections.

Spend the axis of the humerus and the axis of the bones of the forearm. Determine the value of the resulting angle a. The degree of physiological deviation of the axis of the forearm on a healthy arm is measured - angle /3, its value is added to the angle a and thus the angle of the proposed bone resection is determined.

The construction of the angle on the contourogram is carried out in the area of ​​the distal metaphysis of the humerus at the level or slightly below the top of the fossa of the olecranon.

The sides of the wedge should be as close as possible to each other in size. Stages of surgical intervention are shown in Fig. 14.6.

Fractures of the epicondyles of the humerus are characteristic lesions of childhood (most common in children 8 to 14 years of age).

They belong to apophysiolysis, since in most cases the fracture plane passes through the apophyseal cartilaginous zone. The most common avulsion of the medial epicondyle of the humerus.

Its displacement is associated with tension of the internal lateral ligament and contraction of a large group of muscles attached to the epicondyle.

Often, the detachment of this epicondyle in children is combined with a dislocation of the bones of the forearm in the elbow joint. With a rupture of the capsular-ligamentous apparatus, a displaced bone fragment can penetrate into the cavity of the elbow joint. In such a case, there is an infringement of the apophysis in the shoulder joint; possible paresis of the ulnar nerve. The consequences of untimely diagnosis of the torn medial epicondyle introduced into the joint cavity can be severe: articulation disorder in the joint, stiffness, hypotrophy of the muscles of the forearm and shoulder due to partial loss of hand function.

There are four ways to extract an osteochondral fragment from the joint cavity:
1) using a single-toothed hook (according to N. G. Damier);
2) reproduction of a dislocation of the bones of the forearm, followed by repeated reduction (during manipulation, the fragment can be removed from the joint and repositioned);
3) in the process of surgical intervention;
4) according to the method of V. A. Andrianov.

The method of closed extraction of the restrained medial epicondyle of the humerus from the cavity of the elbow joint according to Andrianov is as follows.

Under general anesthesia, the injured arm is held in an extended position and valgus in the elbow joint, which leads to the expansion of the joint space from the medial side. The hand is retracted to the radial side to stretch the extensors of the forearm.

With light rocking movements of the forearm and jerky pressure along the longitudinal axis of the limb, the medial epicondyle is pushed out of the joint, after which reposition is performed. If conservative reduction fails, an open reposition with fixation of the medial epicondyle is indicated.

A fracture of the capitate of the humerus (epiphysiolysis, osteoepiphyseolysis, epiphyseal fracture) is an intra-articular fracture and is most common in children aged 4 to 10 years.

Damage is accompanied by a rupture of the capsular-ligamentous apparatus, and the displacement of the bone fragment occurs outwards and downwards; quite often there is a rotation of the capitate elevation up to 90 ° and even up to 180 °. In the latter case, the bone fragment with its cartilaginous surface is facing the plane of the fracture of the humerus. Such a significant rotation of a bone fragment depends, firstly, on the direction of the impact force and, secondly, on the traction of a large group of extensor muscles attached to the lateral epicondyle.

In the treatment of children with a fracture of the capitate of the humerus, it is necessary to strive for an ideal adaptation of bone fragments.

Unresolved displacement of the bone fragment disrupts articulation in the humeroradial joint, leads to the development of pseudarthrosis and contracture of the elbow joint.

With epiphyseolysis and osteoepiphysiolysis of the capitate elevation with a slight displacement and rotation of the bone fragment up to 45-60 °, an attempt is made to conservative reduction. During reposition (to open the joint space), the elbow joint is placed in a varus position, after which pressure is applied to the bone fragment from the bottom up and from the outside inwards to reduce it.

If the reposition fails, and the remaining displacement threatens to cause permanent deformity and contracture, there is a need for surgical intervention. Open reduction is also indicated when the bone fragment has been displaced and rotated by more than 60°, since an attempt to reduce in such cases is almost always unsuccessful. In addition, during unnecessary manipulations, existing damage to the capsular-ligamentous apparatus and adjacent muscles is aggravated, the epiphysis and articular surfaces of the bones that form the elbow joint are excessively injured.

Convenient quick access to the elbow joint according to Kocher. After reposition, the bone fragments are fixed with two crossed Kirschner wires.

A good result is achieved with the help of a compression device proposed by V.P. Kiselev and E.F. Samoilovich. Children who have suffered this injury are subject to dispensary observation for 2 years, since damage to the growth zone with the formation of deformation in the late stages is not excluded.

Traumatology and Orthopedics
Edited by corresponding member RAMS
Yu. G. Shaposhnikova

Fractures of bones in children happen not only because of pampering, sometimes the fragility of the bone tissue is to blame for this. Why does it occur, how to detect and treat it?

Our expert is pediatrician Anna Mikhailova.

Risk factors

Experts call this condition osteopenia, which means that the bone mineral density is below normal. According to various studies, violations of this kind are found in every third teenager aged 11–17 years.

There are four main risk factors:

Deficiency of calcium, the main "building material" for bone tissue.

Wrong nutrition. In addition to calcium, bones need protein, phosphorus, iron, copper, zinc and manganese, vitamins (from autumn to summer it is necessary to take vitamin-mineral complexes). And all these useful substances, as a rule, are present in those products that children like the least.

Hypodynamia - for the growth of bone mass, movement is necessary that loads and trains the bones.

"Hormonal storm": calcium metabolism in the body is under the strict control of the hormonal system, and during puberty, disturbances in its work are not uncommon.

Many chronic diseases also “interfere” with the normal absorption of calcium: the gastrointestinal tract, respiratory tract, liver, kidneys, thyroid gland ...

Cunning of the Invisible

Loss of bone density develops slowly and gradually, it is impossible to notice it by eye. But there are five indirect signs that should alert parents.

The child has caries.

“For some reason” hair splits, nails exfoliate and break.

From time to time there are pains in the legs, especially in the legs.

The student stoops more and more, his back gets tired after a long sitting at the lessons or the computer.

Your child is allergic, because of this he has dietary restrictions, he does not eat dairy products and fish.

Even one such symptom is a signal that the child needs to be examined and find out if he really lacks calcium.

Norm and deviations

First of all, the pediatrician will prescribe biochemical blood and urine tests, which can be used to understand whether phosphorus-calcium metabolism is disturbed. These partner minerals are involved in many vital metabolic processes and work hand in hand: the body cannot absorb calcium if there is not enough phosphorus, but if there is an excess of the latter, calcium is excreted from the body. That is why it is so important to keep them in balance. Comparing the data with the norms of indicators for a certain age and finding deviations, one can suspect the initial stage of osteopenia.

To clarify the diagnosis, densitometry is performed: assessment of bone tissue (often using the ultrasound method). Unlike adults, children analyze only the so-called Z-criterion - that is, deviations from the norm in indicators depending on the age and gender of the young patient, which are calculated using a special computer program.

Will we fix everything?

The process of healthy bone formation can be corrected as the child grows. For treatment, drugs containing calcium are prescribed.

The choice is large: for example, for the sake of prevention and with a slight deviation from the norm, calcium preparations with vitamin D are prescribed. If a deficiency of not only calcium, but also some trace elements is detected, complex preparations are used (they also include manganese, boron, copper, zinc, magnesium ).

Since some chronic diseases affect the absorption of calcium, children who have them are selected with special drugs, for example, for gastritis with high acidity, those that “protect” the process of its absorption from the aggression of gastric juice. The course of continuation of treatment is individual.

But drugs alone are not enough. The diet should reinforce the treatment: cottage cheese, cheese, kefir or yogurts, fish (salmon, sardines), meat, eggs, broccoli, bananas, legume dishes are recommended.

And of course, you need to make time for sports: at least for regular visits to the pool or fitness room. It is regular, and not from case to case. And if the child has posture disorders, flat feet, it is necessary to undergo treatment under the supervision of a pediatric orthopedic surgeon.

Typical fractures

Bone fractures in children - diagnosis

metaphysis of tubular bone

General principles of treatment

See also Fracture

ICD

The human body in the growth stage is able to accumulate calcium in its tissues. Due to this feature, the bones of a child are much stronger than those of an adult, but this does not mean that children are less at risk of a fracture. Due to the increased motor activity characteristic of most babies, their skeleton is constantly subjected to exorbitant loads. A small blow is enough to break the bones.

This often happens while the child is learning to walk. The lack of coordination and the ability to stand firmly on one's feet makes it difficult to group the lower limbs during falls, which sooner or later leads to a predictable result - their damage.

What are fractures?

Any injuries are classified, first of all, by their localization. Speaking about a broken leg in a child, one can mean damage to:

• hips;
• shins;
• ankles
• feet (including fingers).

At the same time, one cannot ignore the specifics of the injury. Fractures are classified according to the following criteria:

1. maintaining the integrity of soft tissues;
2. the nature of the damage;
3. final position of the bone.

open and closed

In the language of physicians, a fracture is a violation of the integrity of bone fragments, but soft tissues can also suffer with such an injury. In this case, a lacerated wound is formed at the site of injury. Such fractures are called open. They have a number of characteristic differences from closed-type injuries, in which the integrity of the skin is not violated:

Complete and incomplete (fissures, subperiosteal and greenstick type)

Another important classification feature is the degree of damage to bone tissue. Depending on the severity of the damage, fractures are divided into complete and incomplete (partial). The latter include:

1. Cracks. Injuries of this type are single and multiple. Depending on the severity of the injuries received by the limb, the crack passes through the bone or along its surface (periosteum). Fractures of this type are usually classified according to shape and direction. Depending on the position relative to the axis of the bone, cracks are longitudinal, oblique, transverse and spiral.
2. Subperiosteal fractures of the "green twig" type. Such injuries are more common in young children due to age-related features of the structure of their skeleton. Due to the high concentration of useful trace elements in some tissues, their strength increases, and when a bone is broken, the periosteum remains unharmed. A similar effect can be observed if a green willow branch is bent: the wood will crack, but the bark covering it will retain its integrity.

Without displacement and with displacement

With a partial fracture - a crack or subperiosteal - the structure of the bone as such is not disturbed. Thanks to this, its fragments remain motionless. Such injuries are called non-displaced fractures. They are difficult to diagnose, but they are better treated.

With complete fractures, there is a risk that fragments of the damaged bone will take a physiologically unsuitable position for them (displacement will occur). Injuries of this type are fraught with complications.

The bone at the cleavage site is pointed, which threatens to damage the soft tissues (open fracture). In addition, the displacement of fragments prevents the restoration of an integral structure. Without their return to the proper position, it is not necessary to talk about the healing of the injury.

Features of childhood fractures

The younger the child, the more flexible his bones are. For this reason, fractures in preschool children are relatively rare and almost never complete. Most babies, after an unsuccessful fall on the leg, get off with a crack or subperiosteal “twig” without chipping displacement.

Recovery from injuries in children is much more intense than in adults, due to the accelerated process of tissue regeneration. Of course, this does not mean that a baby with a fracture does not need urgent medical attention. Moreover, the younger the child, the more dangerous it is to postpone the treatment of the damaged leg.

Without the intervention of doctors, a broken bone may heal incorrectly. At the stage of active development of the organism, this threatens with irreparable deformation of skeletal fragments (for example, in the thigh region) and a violation of the musculoskeletal function. That is why it is so important to diagnose the problem in time.

Signs of a fracture in a child

To detect bone damage, it is not necessary to take the baby for an x-ray (although this procedure has been and remains the best method for diagnosing injuries). The fact that the child received a fracture can be judged by the characteristic symptoms. Depending on the localization of injuries, the clinical picture of the traumatic condition may vary.

Fracture of the femoral bones, femoral neck

Hip fracture in children manifests itself in different ways. The symptomatology of an injury directly depends on which particular bone was damaged. In addition, the clinical picture of a fracture of the neck and any other part of the femur with and without displacement is very different. Comparative characteristics of such injuries are presented in the table:

Ankle fracture

An ankle fracture is the most common injury in active children. Its wide distribution is associated with the anatomical features of the structure of the human legs - with any movement, most of the load falls on this particular area.

The following symptoms indicate that the ankle bone is damaged:

• pain in the ankle area;
• swelling of local soft tissues;
• extensive hematomas and hemorrhages;
• dysfunction of the joint (limitation of foot mobility).

Fracture of the lower leg

In the human body, the lower leg is represented by two bones - the tibia and the fibula. Both of them are thick and massive, it is difficult to damage them. For this reason, a fracture of the lower leg is considered a specific injury, the symptomatic picture of which will directly depend on the source and nature of the damage received. Nevertheless, all such damages have common signs:

• pain in the knee joint, making it difficult to move;
• edema;
• small local hemorrhages.

Fractured toe

Finding a broken toe is the hardest part. Conventionally, the symptoms that help to do this are divided into 2 groups:

1. Probable. These include soreness, redness and swelling of the soft tissues, the unnatural position of the finger and the difficulties that arise when trying to move it.
2. Reliable. 100% signs of a finger fracture are pronounced bone defects detected by palpation - pathological mobility, deformity, shortening, etc.

Why does a child often break bones?

If any fall or blow turns into an injury for the baby, it is likely that he has a pathological predisposition to fractures. This is the name of the condition in which the integral structure of the bones is disturbed due to internal changes occurring in the body. Often the cause of pathological fractures are diseases:

• osteoporosis;
• osteomyelitis;
• bone neoplasms.