Fractures of bones in children. Causes, symptoms, treatment of bone fractures in children

• Which doctors should you contact if you have Fractures in children

What are bone fractures in children

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. Children's bones are 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, osteoepiphyseolysis 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.

Pathogenesis (what happens?) during a bone fracture in children

Subperiosteal fractures 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.

Epiphysiolysis and osteoepiphysiolysis- 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.

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. Apophyses, unlike epiphyses, are located outside the joints, have a rough surface and serve to attach muscles and ligaments. An example of this type of damage is the displacement of the medial or lateral epicondyle of the humerus.

Symptoms of bone fracture in children

With complete fractures of the bones of the extremities with displacement of bone fragments, the clinical manifestations are practically no different from those in adults. 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.

Diagnosis of bone fracture in children

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.

Treatment of bone fracture in children

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 limb necrosis).

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 epiphyseolysis), as the child grows, a deformity that was not present during the treatment period may be revealed, which should always be remembered when evaluating the prognosis.

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 ranging 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-articular 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:

• with intra-articular and periarticular fractures with displacement and rotation of the bone fragment;
• with a two or three attempt at a closed reposition, if the remaining displacement is classified as unacceptable;
• with interposition of soft tissues between fragments;
• with open fractures with significant soft tissue damage;
• with incorrectly fused fractures, if the remaining displacement threatens with permanent deformation, curvature or stiffness of the joint;
• 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 periods of immobilization are lengthened, since the reparative processes in these cases are slowed down.

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-articular 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-articular and periarticular injuries, is contraindicated, as this procedure promotes the formation of excess bone callus and can lead to myositis ossificans and partial ossification of the joint capsule.

Children who have suffered damage near the epimetaphyseal zone need long-term dispensary observation (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.).

For the full development of the child's body, a sufficient intake of not only vitamins, but also other minerals, the lack of which affects health, is necessary. Increasingly, children under one year of age are diagnosed with hypocalcemia, a lack of calcium in the body. Calcium for children up to 1-1.5 years old is one of the important mineral substances, the norm of which should be supplied to the body daily. It is necessary for the health of bones, teeth, heart, as well as the general formation of the body.

Calcium helps in the absorption of many substances, including iron, and is also responsible for the functioning of the nervous system. Calcium, together with magnesium, ensures the functioning of the cardiovascular system, and, in combination with phosphorus, takes care of the formation of teeth and bones. In order for calcium to be absorbed, it is important that a sufficient amount of vitamin D enters the body. What is the best drug to choose? After the examination, the doctor will prescribe the necessary medications.

The Importance of Calcium for Children

Already from birth, calcium plays a role in the formation of bones and teeth, is responsible for processes such as the contraction of muscle fibers and the functioning of the nervous system. Calcium ions directly affect blood clotting, improve the functioning of the endocrine system. Sufficient intake of calcium protects children from the occurrence of allergic reactions, and also protects against inflammatory processes.

If a child is not getting enough calcium from birth, this can lead to the following problems:

• rickets;
• osteoporosis;
• deformation of the lower extremities (O- and X-shaped type);
• the edges of the crown may soften;
• the appearance of tubercles on the crown of the head and in the forehead area;
• the back of the head may become flat, and the skull may become asymmetric;
• brittle and bad teeth;
• weak bones, which leads to frequent fractures.

This is a partial list of calcium deficiency problems.

The occurrence of rickets is associated not only with a lack of calcium in the blood, but also with vitamin D and phosphorus, which help it to be absorbed. It is very important for a small, not yet strong organism that it contains all the necessary vitamins. Also, a lack of calcium in the body of children under 1-2 years of age leads to osteoporosis, which may not manifest itself for a long time, and turning into a more serious condition, provokes frequent bone fractures.

Causes of insufficient intake of calcium in the child's body

Normally, every day the child should receive 500-1000 mg of calcium. Since babies under 1-2 years old most often feed on breast milk, the mother needs to eat right, as well as take calcium gluconate (Calcium D3 Nycomed) and other vitamins to make up for the deficiency during the feeding period. It is worth remembering: if the rate of calcium in the blood of a nursing mother is underestimated, this adversely affects the health of the child.

There are cases when a sufficient amount of calcium enters the body, but it is not absorbed due to a lack of vitamin D. Proper foods will not be able to fully compensate for the deficiency in children under 2 years old, so doctors recommend, in addition to changing the diet, taking calcium gluconate preparations (Complivit, Calcium D3 Nycomed), with which other vitamins most often go in addition. It is worth knowing that in the summer, vitamins in the child's body are synthesized in sufficient quantities, including vitamin D, so you should not take additional vitamins at this time of the year, because. excess can lead to hypervitaminosis. Vitamins, the norm of which is too high, can provoke colitis and other intestinal diseases in a child.

The child's body should receive the daily intake of calcium in the following dosage:

• 400-500 mg - the norm at the age of 0 to six months;
• 500-700 mg is the norm at the age of six months to a year.
• 700 mg and above should be ingested by a child from 1 year old.

Unlike other vitamins, an excess of calcium in the blood does not affect the baby's health in any way; up to 1-2 years, the excess comes out through urine and feces. If we talk about the excess calcium in the blood coming through drugs along with other trace elements (Complivit, calcium D3 Nycomed), for example, vitamins B and D, then this can lead to salt deposits in the kidneys. To the drugs in the instructions for use, you can find out about side effects.

Symptoms and signs of a lack of substance in a child

It is problematic to determine the lack of calcium in the blood of a child under one year old, since he does not walk yet, and only a specialist can detect hypocalcemia. The main symptoms, when the rate of calcium gluconate in the blood is underestimated, are manifested in the following:

• during crying, you can notice the trembling of the chin;
• increased sweating in the back of the head;
• in the places of the head, where the child most often comes into contact with the pillow, hair erasure is noticeable;
• from loud sounds the child shudders.

Also, a lack of calcium in the body of a child under 2 years old can be determined by cracked corners of the mouth, anemia, cramps and poor condition of the nails. Products and vitamins in preparations (Calcium D3 Nycomed) help to compensate for the lack of trace elements in the body, after which the symptoms and signs gradually disappear, and the child gets better.

Treatment of hypocalcemia

Since the absorption of calcium in the blood of an infant directly depends on the mother, she should first review the food and take drugs (for example, Aufbaukalk, Complivit D3 Nycomed). To the preparations in the instructions for use it is indicated which vitamins are in addition.

• cottage cheese;
• cheeses;
• chicken eggs;
• liver;
• butter;
• dairy and dairy products;
• chocolate.

Also, when it will be possible for the child to introduce complementary foods, and these products should be present in his diet. Reviews of many mothers who changed their diet and food indicate that some symptoms went away immediately, the child often stopped being capricious and crying.

If food products have not helped to compensate for the lack of calcium in children under 2 years old, then the doctor may prescribe medications. What is the best drug for use in children and adults? Medications that have proven themselves and have positive reviews:

• Complivit Calcium D3 Nycomed.

Complivit calcium D3 Nycomed is designed specifically for children under 1-2 years old. Complivit also includes vitamin D for better absorption. Suspension Complivit D3 Nycomed has a sweetish taste, which will not cause problems for the mother while taking the medicine. Instructions for use: dilute the powder in ½ glass of water, shake before giving. Complivit calcium D3 Nycomed has contraindications.

Aufbaukalk. A natural preparation containing calcium gluconate, which can be used from six months of the child. Aufbaukalk has a release in 2 jars, from which you need to give the drug in the morning and evening. Aufbaukalk should be taken as directed.

Calcium gluconate. Very cheap drug, produced in its pure form. Calcium gluconate is prescribed to the mother during lactation. Calcium gluconate in combination with Aquadetrim should be given to children under one year old, in this combination the symptoms disappear after 2 days. Instructions for use: take 2 g 3 times a day.

Which is better to give the drug to a child, the doctor must decide, depending on how low the level of calcium in the body is. How to take the drug, you can find out in the instructions for use.

Bone fractures in children

What are bone fractures in children -

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. Children's bones are 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, osteoepiphyseolysis 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.

Pathogenesis (what happens?) during a bone fracture in children:

Subperiosteal fractures 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.

Epiphysiolysis and osteoepiphysiolysis- 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.

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. Apophyses, unlike epiphyses, are located outside the joints, have a rough surface and serve to attach muscles and ligaments. An example of this type of damage is the displacement of the medial or lateral epicondyle of the humerus.

Symptoms of a bone fracture in children:

With complete fractures of the bones of the extremities with displacement of bone fragments, the clinical manifestations are practically no different from those in adults. 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.

Diagnosis of bone fracture in children:

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.

Treatment of bone fracture in children:

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 limb necrosis).

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 epiphyseolysis), as the child grows, a deformity that was not present during the treatment period may be revealed, which should always be remembered when evaluating the prognosis.

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 ranging 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-articular 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:

• with intra-articular and periarticular fractures with displacement and rotation of the bone fragment;
• with a two or three attempt at a closed reposition, if the remaining displacement is classified as unacceptable;
• with interposition of soft tissues between fragments;
• with open fractures with significant soft tissue damage;
• with incorrectly fused fractures, if the remaining displacement threatens with permanent deformation, curvature or stiffness of the joint;
• 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 periods of immobilization are lengthened, since the reparative processes in these cases are slowed down.

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-articular 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-articular and periarticular injuries, is contraindicated, as this procedure promotes the formation of excess bone callus and can lead to myositis ossificans and partial ossification of the joint capsule.

Children who have suffered damage near the epimetaphyseal zone need long-term dispensary observation (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.).

Which doctors should be consulted if you have Fractures of bones in children:

• Traumatologist
• Surgeon
• Orthopedist

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Other diseases from the group Injuries, poisoning and some other consequences of external causes:

Bone fractures in children

Children rarely have bone fractures, despite frequent falls during outdoor games, however, in addition to the usual fractures observed in adults, there are some types of fractures that are characteristic only for children, which is explained by the anatomical structure of the skeletal system and its physiological properties. in children.

 Smaller body weight and well-developed cover of the child's soft tissues weaken the impact force during a fall.

 Bones are thinner, less strong, but more elastic. Elasticity and flexibility are due to the lower content of mineral salts in the bones.

 The periosteum is thicker and richly supplied with blood, which gives the bone greater flexibility and protects it from injury.

 Epiphyses at the ends of the tubular bones, they are connected to the metaphyses by a wide elastic growth cartilage, which weakens the impact force.

Typical fractures

 Breaks and fractures by type green branch or wicker due to the flexibility of the bones.

 Subperiosteal fractures are more likely to occur when a force is applied along the longitudinal axis of the bone. The broken bone is covered by an intact periosteum.

 Epiphysiolysis and osteoepiphyseolysis - traumatic detachment and displacement of the epiphysis in relation to the metaphysis or with a part of the metaphysis along the line of the growth cartilage until the end of the ossification process. Epiphysiolysis occurs as a result of the direct action of force on the epiphysis. The place of attachment of the articular capsule to the articular ends of the bone matters: epiphysiolysis and osteoepiphysiolysis occur where the articular bag is attached to the epiphyseal cartilage of the bone, for example, at 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 of its attachment (for example, the hip joint), epiphyseolysis does not occur.

 Apophysiolysis - detachment apophysis along the line of the growth cartilage. Example: displacement of the internal and external epicondyles of the humerus. Features of the clinical picture

 In case of fractures, there are no symptoms characteristic of a complete fracture: movements are limited, there is no pathological mobility, the contours of the damaged limb do not change, palpation causes local pain. Diagnosis is aided by x-rays.

 In the first days after injury, children experience an increase in temperature up to 37-38 °C, which is associated with the absorption of hematoma contents.

Diagnostics

 In newborns and infants, there are no or poorly expressed nuclei of ossification in the epiphyses, therefore, radiological diagnosis of subperiosteal fractures, epiphysiolysis and osteoepiphysiolysis without displacement is difficult. The displacement of the ossification nucleus in relation to the bone diaphysis can only be detected when compared with a healthy limb on radiographs in two projections. In older children, osteoepiphysiolysis is diagnosed more easily: on radiographs, a detachment of a bone fragment of the metaphysis of the tubular bone is found

 In young children, the impossibility of a complete history taking, well-defined subcutaneous tissue, which makes palpation difficult, and the lack of displacement of fragments in subperiosteal fractures make it difficult to recognize and lead to diagnostic errors

 Swelling, pain, dysfunction of the limb, fever resemble the clinical picture of osteomyelitis. An x-ray is needed to rule out a fracture.

 It is often necessary to have a more detailed examination with measurement of the absolute and relative length of the limbs, determination of the range of motion in the joints.

General principles of treatment

 The leading method of treatment is conservative: a fixing bandage is used, immobilization is carried out with a plaster splint in a functionally advantageous position covering 2/3 of the limb circumference and fixing two adjacent joints. A circular plaster cast is not used for fresh fractures, because there is a risk of circulatory disorders due to increasing edema.

 Skeletal traction is usually used in children older than 4-5 years.

 In young children, repositioning should be done under general anesthesia.

 In children under 7-8 years of age, displacements in diaphyseal fractures in width by 2/3 of the diameter are acceptable with the correct axis of the limb. In the process of growth, self-correction of such deformations occurs.

 Open reposition is performed with special care, gentle surgical access, with minimal traumatization of soft tissues and bone fragments and is often completed with simple methods of osteosynthesis - knitting needles Kirchner extramedullary osteosynthesis.

 Terms of consolidation of fractures in healthy children are much shorter.

I will give a summary of the main points on diagnostics from the mentioned article.

Examination of children with fractures is often difficult because there are no clear guidelines for differentiating traumatic fractures from fractures caused by bone pathology. Although most fractures in children do not have serious consequences, recurrent fractures can be associated with a wide range of both primary bone diseases and secondary causes, which necessitates a careful history taking and physical examination.
Currently, there is no “gold standard” for the evaluation and treatment of children with fractures and low BMD, so the diagnosis of osteoporosis in pediatric practice should be based on a combination of clinical and radiological features.
Interpretation of densitometry data in growing patients is difficult because the actual BMD measured by the DXA method depends on many factors that change over time. Interpretation of BMD results should be based on the Z-score (SD vs. controls matched for age, gender, ethnicity) using databases for the specific densitometer model and patient population.

Fractures of the clock in the pediatric population (frequency up to 50% in boys and up to 40% in girls), in particular this applies to fractures of the distal ray. The peak incidence of fractures occurs between the ages of 11 and 15 years, which corresponds to the period of maximum growth rate and the lag in bone mass accumulation.

Rare vertebral compression fractures in children and vertebral and femoral fractures without significant trauma (eg, car accident) are considered unambiguously pathological.

The list of conditions associated with reduced bone strength in children is extensive (Table 1), but most of them can be ruled out with careful history taking, physical examination, and the use of specific diagnostic tests.
Primary skeletal diseases leading to juvenile osteoporosis are relatively rare, the most common of which is osteogenesis imperfecta: type I may be accompanied by blue staining of the sclera, dentin pathology, and the development of hearing impairment; heredity is traceable, genetic markers are available. In the absence of these features, the presence of idiopathic juvenile osteoporosis, a rare disease characterized by multiple pathological fractures in school-age children and spontaneous stabilization after puberty, may be suspected.

Secondary osteoporosis is a complication of a significant number of chronic diseases (Table 1), while a decrease in BMD may be a consequence of the underlying disease, a complication of therapy, or a combination of these factors. Vitamin D deficiency and reduced dietary calcium intake also lead to a decrease in BMD along with the development of rickets. A decrease in BMD was noted in children with idiopathic hypercalciuria.

Any child with a pathological fracture needs a BMD measurement. Densitometry is indicated for clinically significant fractures such as long bone fractures of the lower extremities, vertebral compression fractures, and 2 or more fractures of the long bones of the upper extremities.
In the case of multiple traumatic fractures, the screening decision is made on an individual basis, taking into account the number and severity of fractures.
Typically, DXA is performed on the lumbar spine, proximal femur, distal ray, or entire body.

Given the large number of causes of fractures against the background of a decrease in BMD, the examination plan should be based on the anamnesis and physical data. We recommend, at a minimum, obtaining routine hematological and biochemical parameters, ESR, intact parathyroid hormone, blood calcium and phosphorus, daily urine calcium, screening for celiac disease. A determination of 25-OH-D is also required.

Bone marrow biopsy, endoscopy/colonoscopy, liver biopsy, and genetic testing may be performed as indicated.
Bone remodeling markers can be useful at the stage of therapy selection, but require very careful interpretation in children.
I hope my colleagues will complement me.