General Principles of Fracture Management - Fracture Patterns and Description in Children - UpToDate

2017613 Generalprinciplesoffracturemanagement:FracturepatternsanddescriptioninchildrenUpToDate
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Generalprinciplesoffracturemanagement:Fracturepatternsanddescriptioninchildren
Authors: DavidJMathison,MD,MBA,DeweshAgrawal,MD
SectionEditor: RichardGBachur,MD
DeputyEditor: JamesFWiley,II,MD,MPH

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2017.|Thistopiclastupdated:Jun18,2015.
INTRODUCTIONThistopicdiscussestheuniquepropertiesofpediatricfracturesandillustratesdifferent
classificationsystemsthatexisttoidentifyanddescribethem.Managementofspecificfracturesisdiscussed
separatelyandcanbefoundbysearchingfortheanatomicregionofinterest.
Commonfracturepatterns(eg,transverse,oblique,spiral)seeninbothchildrenandadultsarediscussedin
detailseparately.(See"Generalprinciplesoffracturemanagement:Bonehealingandfracturedescription",
sectionon'Orientation:Transverse,oblique,andspiral'.)
BACKGROUNDMusculoskeletalinjuriescompriseapproximately12percentofthe10millionannualvisits
toUnitedStatespediatricemergencydepartments[1].Skeletalfracturesaccountforasignificantproportion
oftheseinjuriesandcauseconsiderablecostandmorbiditytochildren.Despiteaggressivecampaignsfor
injuryprevention,theoverallrateoffractureshasbeenincreasing[25].
Fracturesinchildrenexhibituniquepatterns.Becauseofthedistinctivepropertiesofthegrowingbone,
specialattentionisrequiredtodifferentiatenormalvariantsand,forthephysealfracture,toguarantee
adequatehealingwhileavoidinggrowthdisturbance.(See'Physealfracturedescription'below.)
FRACTUREDESCRIPTIONINCHILDRENDescribingafractureentailsathoroughexplanationofboth
theclinicalscenarioandtheradiographicfindings(table1).
Theclinicalnarrativeshouldinclude:
Age
Gender
Mechanismofinjury
Anatomiclocation
Softtissueinvolvement(eg,openorclosed)
Keyphysicalexaminationfindings,especiallyneurovascularstatus
Theradiologicinterpretationofthefractureencompassesthefollowing(see"Generalprinciplesoffracture
management:Bonehealingandfracturedescription",sectionon'Fracturedescription'):
Typeofimaging(includingmodalityandviewselection)
Anatomiclocation
Fracturepattern
Relationshipoffragments
Physealinvolvement(ie,SalterHarrisclassification)
Apophysealdisruption
Jointorsofttissueinvolvement
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PLAINRADIOGRAPHVIEWSAnaccurateradiologicevaluationbeginswithobtainingtheappropriate
imagingstudy.Multipleviewsarerequiredtovisualizefracturepatternsinvariousplanes.Standard
radiographicseriesinfractureevaluationsoftheextremitiesareoftentwoorthreeviewsandvarybythe
anatomicregionofinterest(table2).
Theassessmentofachildwithsuspectedfracture,especiallyofthelongbonediaphysis,requiresevaluation
ofthejointbothaboveandbelowthesiteofinjury.Insomeinstances,radiographsoftheseareasarealso
needed.Forexample,theMonteggiafractureisawelldescribedfractureoftheproximalonethirdoftheulna
withdislocationoftheradialhead.Iftheclinicianobtainsonlydedicatedforearmviewsatthesiteofthe

fracture,theelbowdislocationcanbemissed.(See"Proximalfracturesoftheforearminchildren",sectionon

'Monteggiafractures'.)
FRACTUREPATTERNSTheperiosteumofpediatricbonehassignificantosteogenicpotentialandis
comparativelymoremetabolicallyactivethantheadultperiosteum.Thisactiveperiosteumpromotescallus
formation,unionoffractures,andremodelingduringthehealingprocess.Theperiosteumisalsothickerand
strongerinchildren,whichlimitsfracturedisplacement,reducesthelikelihoodofopenfractures,and
maintainsfracturestabilityincomparisontoadultfractures[6,7].Thequalitiesandfunctionofthepediatric
periosteumareresponsibleforsomeoftheuniquefracturepatternsseeninchildren[6,8,9].Examplesof
thesefracturesincludebuckle,greenstick,andplasticdeformation(orbowing).
Abonefailswhentheloadingforcesexceedtheloadbearingcapacity.Dependinguponboththeforceofthe
injuryandthepropertiesoftheboneinvolved,loadfailureresultsinafractureinseveraluniquepatterns.
Threefundamentalforcescausefractures:shear,compressive,andtensile.Boneisleastabletowithstand
shearforces,followedbytension,thencompression[10].
Tensilebonefailurecausesfracturesperpendiculartothedirectionofloading(transverse),whereas
compressionforcescauseobliquestressesinaplaneapproximately45degreestothebone'slongaxis[11].
Bendingforcesresultinatensilestresstotheconvexsideandacompressivestresstotheconcaveside,
resultingintransverseandobliquefracturesonthetensileandcompressivesidesrespectively.Thistensile
compressivepatternfrombendingcancausearesultantbonewedgereferredtoasabutterflyfragmentor
thecharacteristicgreenstickfracture.Torsion(rotational)forcesleadtomorecomplexfracturesbycausinga
smallcracktoextendintoaspiralpattern(figure1).Manyfractures,however,involvecombinationsofforces
andthereforedevelopcomplexfracturepatterns(figure2).
Fracturesspecifictothepediatricpatientarediscussedhere.Commonfracturepatterns(eg,transverse,
oblique,spiral)seeninbothchildrenandadultsarediscussedindetailseparately.(See"Generalprinciplesof
fracturemanagement:Bonehealingandfracturedescription",sectionon'Orientation:Transverse,oblique,
andspiral'.)
Buckle(torus)Bucklefracturesfollowcompressionfailure,oftenatthejunctionbetweentheporous
metaphysisandthedenserdiaphysis(image1).Theseinjuriestypicallyoccurinthedistalradiusafter
longitudinaltrauma(eg,fallonanoutstretchedhand),butarealsoseeninthedistaltibia,fibula,andfemur.
Bucklefracturesarealsoknownastorusfractures,(derivedfromtheGreek"tora,"meaningringandreferring
totheradiologicresemblancetotheraisedbandaroundthebaseofaGreekcolumn,andalsofromtheLatin
"tori,"forswellingorprotuberance).Bucklefracturesarebydefinitionstableandcanoftenbemanagedwith
splintingandasingleorthopedicfollowupvisit[12].(See"Distalforearmfracturesinchildren:Diagnosisand
assessment",sectionon'Torus(buckle)fractures'and"Distalforearmfracturesinchildren:Initial
management",sectionon'Torus(buckle)fracture'.)
PlasticdeformationAplasticdeformity(orbowingfracture)occurswhenalongitudinalforceexceedsthe
bone'sabilitytorecoiltoitsnormalposition(image2).Ifthetensionsidecannotpropagatethefracture,
microscopicfracturescanoccurtodissipatetheimpactenergy,thuscreatingaplasticdeformity.Plastic
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deformitiesaremostcommonlyseenintheulna,theradius,andoccasionallyinthefibula.Ifthedeformation
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islessthan20degreesorifthedeformityoccursinayoungchild(<4yearsofage),theangulationoften
URL,DOI,
correctsitself[13].Otherwise,closedreductionoroperativeinterventionmaybenecessarytostraightenthe
bone.(See"Midshaftforearmfracturesinchildren",sectionon'Plasticdeformation'.)
GreenstickAgreenstickfracturedescribesabonethatisbentwithafracturelinethatdoesnotextend
completelythroughthewidthofthebone(image3).Thegreenstickfracturemaybethemostsignificantrisk
factorforrepeatfracture,occurringinasmanyas84to100percentofforearmrefractures[1416].(See
"Midshaftforearmfracturesinchildren",sectionon'Greenstickfractures'and"Distalforearmfracturesin
children:Diagnosisandassessment",sectionon'Greenstickfractures'and"Distalforearmfracturesin
children:Initialmanagement",sectionon'Greenstickfracture'.)

Physeal(growthplate)Thediagnosisandmanagementofspecifictypesofphysealfracturesis
discussedseparatelyandcanbefoundbysearchingfortheanatomicregionofinterest.
Thegrowthplateorphysisrepresentsamajoranatomicaldifferencebetweenadultandpediatricbone.
Growinglongbonesinchildrenarecomposedofthefollowingsegments:diaphysis(shaft),metaphysis
(wheretheboneflares),physis(growthplate),andepiphysis(secondaryossificationcenter)(figure3).
Growthplatesaresusceptibletofractureandrepresentaweakpointinpediatricbone.Becausethetensile
strengthofpediatricboneislessthanthatoftheligaments,thesameinjurymechanismcausinga
ligamentousinjuryinadults(sprainorstrain)ismorelikelytocauseaboneinjuryinchildren:thephysiswill
separateorfracturebeforedisruptionor"spraining"ofanadjacentstrongandflexibleligament[68,17].
Accuratedescriptionofthesepediatricfracturesisessentialtocommunicatingtheseriousnessofboneinjury.
(See'Physealfracturedescription'below.)
Physealinjuriesoccurin21to30percentofpediatriclongbonefractures[18,19],morecommonlyinvolving
thedistalgrowthplatesoftheradiusandulna[20].Ingirls,growthplateinjuriesoccurbetweenages9and
12,whileinboystheytypicallyoccurlater,betweenages12and15[21].Althoughamajorityofthese
fractureshealwithoutincident,approximately30percentofthesephysealfracturescauseagrowth
disturbance(prematureclosureandunilaterallongboneshortening)[6].Appropriateanatomicalignmentis
criticalforoptimalgrowthandminimaldeformityfollowingphysealfractures[7].Thecontributionofspecific
physestolongitudinalgrowthintheextremitiesvariesbysite(figure4).
Histologically,theweakestpartofthephysisisthethirdzone(zoneofhypertrophiccartilage),and
accordinglythemostcommonsiteforphysealfractures(figure3).Ininfancyandearlychildhood,thephysis
isrelativelythickandtheepiphysisismostlycartilaginous,servingasashockabsorberandtransmitting
forcestothemetaphysis.Duringadolescence,whentheepiphysisbeginstoossify,theseforcesareless
absorbedandconsequentlytransmittedtothephysis.
Thelongitudinalgrowthoflongbonesoccursprimarilyatthephysis.Thegerminalareaofthephysisborders
theepiphysis.Theepiphysealcartilagecellsgrowtowardthemetaphysisandformcolumnsofcells.These
columnsdegenerate,undergohypertrophy,andthencalcifyatthemetaphysistoformnewbone(figure
3)[22].Thegrowthandchangethatoccuratagrowthplatepromoterapidhealingoffractures.However,
injurytothephysisitselfcanleadtoasymmetricgrowthandsubsequentdeformity[6,23,24].Theepiphyseal
cartilagecellsstopduplicatingattheendofpuberty.Theentirecartilageiseventuallyreplacedbyboneand
epiphyseallinesremainatthesite[22].
Oncethephysiscloses,thenadultpatternsoffractureareseen.Thetimingofphysealclosurevariesin
individualpatientsandbyboneandpatientsex(figure5).
ApophysealavulsionCertainphysescontainfibrocartilageinsteadofcolumnarcartilage(eg,tibial
tuberosity,inferiorpoleofthepatella).Theseareasaretensileresponsiveapophysealcentersandhave
uniquefailurepatternsthatresultfromtheintersectionoftheossificationcenterandthefibrocartilage.These
apophysealcentersarepronetooverusetractionavulsions,termedapophysitis.Characteristicapophyseal
overuseinjuriesincludeOsgoodSchlatterdisease(tibialtuberosity)andSindingLarsenJohansson
syndrome(inferiorpoleofthepatella).Unlikephysealinjuries,apophysealinjuriesdonotinterferewith
URL,DOI,
growthandaremostlyselflimitedinjuriesinadolescentathletes.(See"Overviewofthecausesoflimpin
children",sectionon'Osteochondrosisandapophysitis'and"OsgoodSchlatterdisease(tibialtuberosity
avulsion)"and"Approachtochronickneepainorinjuryinchildrenorskeletallyimmatureadolescents",
sectionon'SindingLarsenJohanssondisease(patellarapophysitis)'.)
SPECIALCIRCUMSTANCES
StressfracturesThesefracturesrepresentoveruseinjuriesthatarisefromaccumulatedmicrotrauma
afterrepetitivestrain.Theloadsfromstressfracturesarelessthanwhatthebonecanwithstand,but

cumulativefatiguedamagecancausesmallbutprogressivecracksintheperiosteum.Stressfracturesare
morecommonlyseeninadolescentsthanyoungerchildrenandmorefrequentlyaffectfemales.Thecommon
sitesofstressfracturevarydependinguponthesport(table3).However,themostcommonsitesofstress
fracture,indecreasingorderoffrequency,arethetibia,fibula,parsinterarticularis(ie,spondylolysis),and
femur.(See"Overviewofthecausesoflimpinchildren",sectionon'Stressfractures'and"Overviewofstress
fractures".)
Plainradiographicfindingsusuallyarenotapparentuntilonetotwoweeksaftertheonsetofsymptoms.They
includelucencyorperiostealreactionwithnewboneformationincorticalbonecallusdoesnotappearuntil
fourweeksaftertheonsetofsymptoms.Magneticresonanceimaging(MRI)hasbecomethepreferredtest
whenplainfilmsarenegativeandthediagnosisisessential.Itisextremelysensitiveanddefinestheanatomy
andextentofinjurymorepreciselythanscintigraphy.(See"Overviewofthecausesoflimpinchildren",
sectionon'Stressfractures'and"Overviewofstressfractures",sectionon'Approachtostressfracture
imaging'.)
ChildabuseCliniciansshouldbecognizantofcertainfracturepatternsthatareassociatedwithchild
abuse.(See"Orthopedicaspectsofchildabuse",sectionon'Fracturepatterns'.)
Anyfractureinachildyoungerthanoneyearofageoranylowerextremityfractureinanonambulatorychild
shouldraisesuspicionofabuse.Specificfracturepatternsofconcernincludeposteriorribfractures,
metaphyseallesions(buckethandleorcornerfractures)(image4),bilaterallongbonefractures,complex
skullfractures,andspinousprocessfractures.Inaddition,arepeatfractureoccurringatanunusuallocation
forrepeatinjuryissuspiciousforchildabuse,andcarefulhistoryandsocialassessmentshouldbe
performed.(See'Repeatfracture'belowand"Orthopedicaspectsofchildabuse".)
Afractureinaradiographicstageofhealingthatdoesnotcorrespondtotheclinicaldescriptionormultiple
fracturesinvariousstagesofhealingshouldalsoarousesuspicionofabuse.Determiningtheageoffractures
isdiscussedseparately.(See"Orthopedicaspectsofchildabuse",sectionon'Fractureage'.)
Anysuspicionofchildabuseshouldpromptinvolvementofanexperiencedchildprotectionteam(eg,social
worker,nurse,physicianwithmoreextensiveexperienceinthemanagementofchildabuse),ifavailable.In
manypartsoftheworld(includingtheUnitedStates,UnitedKingdom,andAustralia),amandatoryreportto
appropriategovernmentalauthoritiesisalsorequired.(See"Childabuse:Socialandmedicolegalissues",
sectionon'Reportingsuspectedabuse'and"Physicalchildabuse:Diagnosticevaluationandmanagement".)
PathologicfractureAfractureinabonethatisweakenedbyanunderlyingabnormalityistermeda
pathologicfracture.Patientswithbonetumors,rickets,McCuneAlbrightsyndrome,juvenileosteoporosis,
chronicrenalinsufficiency,osteogenesisimperfecta(OI),andosteopetrosisareallatgreaterriskfor
fractures.Theproximalfemurandhumerusarethemostfrequentsitesforpathologicfracturesand
unicameral(simple)bonecysts,aneurysmalbonecysts,andnonossifyingfibromasarethemostcommon
tumors[25].(See"Benignbonetumorsinchildrenandadolescents".)
OIisthemostcommonmetabolicbonedisorderthatcausespathologicfractures[26].FeaturesofOIinclude
multiplefractures,asuggestivefamilyhistory,andclinicalmanifestationsthatcanincludeshortstature,
scoliosis,basilarskulldeformities,hearingloss,bluesclerae,opalescentteeth,ligamentouslaxity,andeasy
bruisability.(See"Osteogenesisimperfecta:Clinicalfeaturesanddiagnosis".)
URL,DOI,
RepeatfractureRefracturescharacterizerepeatorrecurrentfracturesattheinitialsiteofinjury.
Refracturesmakeuponly1in1000ofallchildren'sfractures,occurringfrequentlyintheforearmand
complicating5to13percentofforearmfractures[14,16,27].Riskfactorsforrefractureincludeincomplete
bonyunion,residualangulation,earlycastremoval,radialorulnardiaphysealfracture,andgreenstick
fracturepattern[15,16,2831].(See"Midshaftforearmfracturesinchildren",sectionon'Complications'and
"Distalforearmfracturesinchildren:Initialmanagement",sectionon'Complications'.)
PHYSEALFRACTUREDESCRIPTIONSeveralclassificationschemesforphysealfractureshavebeen
devised,includingtheSalterHarris,Ogden,Peterson,andmanyothers,mostofwhicharespecifictocertain

anatomicallocations[3234].Ofthese,theSalterHarrisclassificationiseasilyappliedandappropriateforthe

majorityofphysealfractures.Itisalsothemostwidelyusedsystem,andrepresentsasmuchameansof
communicationbetweenhealthcareprofessionalsasaclassificationschema.
TheSalterHarrisclassificationsystemgradesphysealfracturesastypesIthroughV.Whilecontroversialand
jointdependent,theseverityofinjurytothegrowthplategenerallyincreaseswitheachSalterHarrisgrade
[3537].Complicationsofphysealinjuryincludegrowtharrest,permanentdecreasedrangeofmotion,and
angulardeformity[38].ThefollowingmnemoniccanbehelpfultorememberthedifferentSalterHarristypes
whenthelongboneisinaverticalorientationwiththeepiphysisatthebottom.Themnemonicreferstothe
fracturelineanditsrelationshiptothegrowthplate(figure6)[39]:
S("Straightacross")TypeI(lowriskforgrowthplateinjury)
A("Above")TypeII
L("Lower"or"BeLow")TypeIII
T("Two"or"Through")TypeIV
E("End")orER("ERasureofthegrowthplate")TypeV(highriskforgrowthplateinjury)
R
SeveralmodificationsandadditionshavebeenmadetotheSalterHarrisschematic[40,41],including
Ogden'ssystemthatincludesinjuriestosurroundingelementssuchastheperiosteum,zoneofRanvier,and
perichondrium(figure3andfigure7)[42].WhilethefiveSalterHarristypes(withOgden'selaboration)
encompassthemainstayforphysealinjuries,additionaltypeshavebeendescribed.(See'OgdenTypeVI'
belowand'OgdenTypeVII'below.)
Thesephysealinjuriesaremorecommonduringtimesofrapidgrowth,suchasadolescence,andgenerally
occurthroughthehypertrophiczoneofthephysis[5].
SalterI(OgdenIAB)Thefracturelineextendsthroughthezoneofhypertrophiccartilage(zone3),
causingtheepiphysisandphysealelementstoseparatefromthemetaphysis(figure3andimage5).TypeI
injuriescanhavenormalradiographsandthediagnosisisthereforeoftenmadeclinicallywhenfocal
tendernessisfoundoverthegrowthplate.
AtypeIBOgdenfractureischaracterizedbythefracturelineextendingthroughtheprimaryspongiosa
bonelayerresultinginathinlineofbonedisplacedwiththeepiphysis.TypeIBfracturesusuallyoccurin
childrenwithsystemicdiseasessuchasmyeloproliferativedisorders.Subsequentgrowthisusually
normalwithTypeIAandIBfractures(figure7).
ATypeICOgdenfracturehasanassociatedinjurytothegerminalportionofthephysis.TypeIC
fracturescancausegrowtharrestandoccurrarelyafteragetwotothreeyears(figure7).
SalterII(OgdenIIAD)Thefracturelineextendsthroughthephysisandthenpropagatesacrossthe
physealmetaphysealjunctionintothemetaphysis(figure6).TypeIIfracturesarethemostcommonphyseal
fractures.TheresultantmetaphysealwedgeinaSalterIIorOgdenTypeIIAfractureiscalledtheThurston
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URL,DOI,
AtypeIIBinvolvesfurtherextensionofthefracturelinebidirectionallythroughthemetaphysiscreatinga
freemetaphysealfragmentormultiplefragments.
AtypeIICfractureisatransversephysealfracturethatincludesathinlayerofmetaphysisalongwiththe
metaphysealtriangularcornersegment.
AtypeIIDfractureischaracterizedbytheangulationofthetwosegmentsresultinginthemetaphyseal
segmentcompressingthephysisandcreatinganosseousbridgethatleadstopermanentgrowtharrest
(figure7).

SalterIII(OgdenIIIAD)Thefracturelineextendsthroughthephysisandthenspreadsthroughthe
epiphysisintotheintraarticularspace(image7).Ifthetransversefractureextendsacrossthecompletewidth
ofthephysis,twoepiphysealsegmentsmaybeformed.
ATypeIIIBfracture,similartotypeIB,coursesthroughtheprimaryspongiosaphyseallayerresultingin
athinbonymetaphyseallinedisplacedwiththeepiphysealsegment(figure7).
TypeIIICinjuriesinvolveepiphysesinmostlynonarticularareas.
TypeIIIDfracturespenetratethegerminalzoneandinterruptthebloodsupplytotheavulsedsegment.
Thesefracturesaredifficulttovisualizeontraditionalradiographs.
SalterIV(OgdenIVAC)Thefracturelinespreadsfromthearticularsurface,throughtheepiphysis,
acrossthephysis,andthroughasegmentofthemetaphysis(image8).
ATypeIVBfractureischaracterizedbyfurthertransverseextensionofthefracturethroughpartorallof
thephysiscreatingadditionalepiphysealfragments(figure7).
TypeIVCfracturesinvolvedamagetotheadjacentcartilage,andtypeIVDfractureshavemultiple
metaphysealphysealepiphysealfragments,usuallyfromseveretrauma.
SalterV(OgdenV)Thisfractureisthoughttobecausedbyaforcetransmittedthroughtheepiphysisand
physis.Theresultantdisruptionofthegerminalmatrix,hypertrophicregions,andvascularsupplycausesa
severeinjurywithgrowtharrestandpoorprognosis(figure7).TypeVinjuriesusuallyoccurinjointsthatonly
moveinoneplane,suchasthekneeorankle.CausesoftypeVinjuriesincludeelectricshock,frostbite,and
irradiation[43].Themechanismforthisgrowtharrestisunknownbutmosttheorizethatcompression,
vascularinsult,oranotherwiseunrecognizeddirectinjuryarethemostlikelymechanisms[44].Since
displacementoftheepiphysiscanbeminimal,thisfracturepatternmaygounrecognizedoninitial
radiographsalthoughphysealinjurycanbedemonstratedonMRI.
OgdenTypeVIThisfractureistypicallyaresultofglancingtraumathatinvolvestheperipheral
perichondralareaincludingthezoneofRanvier(figure7)[40,42].
OgdenTypeVIIThefracturelineiscompletelyintraepiphyseal,fromtheepiphysealcartilageintothe
secondaryossificationcenter.Thesefracturesclassicallyoccurasavulsionsoffibrocartilaginouscomplexes
atossificationcenters,suchasthetibialtuberosity(figure7).
PetersonfracturesThePetersonclassificationsystemwasdevelopedbasedupontheepidemiologic
resultsof951physealfractures[21,45].ItdescribestwouniquepatternsnotreflectedintheSalterHarrisand
OgdensystemsPetersontypeIandVIfractures.APetersontypeIfractureisacompletetransverse
metaphysealdisruptionwithanadditionalextensionthatextendslongitudinallytothephysis.Thisinjury
typicallydoesnotcausesignificantgrowthdisturbance.APetersontypeVIfractureisapartialphysealloss
usuallyincludingtheepiphysis.Thisinjuryoccurslargelyfromlawnmowertraumawhichisfrequently
associatedwithneurovascularinjuryandsofttissuedamage.
AOpediatricclassificationTheArbeitsgemeinschaftfurOsteosynthesefragenorAOPediatric
ComprehensiveClassificationofLongBoneFractures(PCCF)isanadaptationofasimilarsystemusedin
URL,DOI,
adultorthopedictrauma[46].Thiselaboratetoolusesbodylocation(bone,segment)andmorphology
(severity,displacement)tomoredistinctlyidentifythebreadthofphysealandnonphysealpediatriclongbone
fractures.Sincetherearemorethan200differentcategorizationsaccordingtotheAOframework,this
classificationsystemmaybebetterusedforresearchpurposesratherthanroutineclinicaldocumentation.
SUMMARY
Describingafractureentailsathoroughexplanationofboththeclinicalscenarioandtheradiographic
findings(table1).(See'Fracturedescriptioninchildren'aboveand"Generalprinciplesoffracture

management:Bonehealingandfracturedescription",sectionon'Fracturedescription'.)
Anaccurateradiologicevaluationbeginswithobtainingtheappropriateimagingstudy.Multipleviewsare
requiredtovisualizefracturepatternsinvariousplanes.Standardradiographicseriesinfracture
evaluationsareoftentwoorthreeviewsandvarybytheanatomicregionofinterest(table2).(See'Plain
radiographviews'above.)
Childrenexhibituniquefracturepatternsbecauseoftherelativecompressibilityoftheirbone,the
increasedfibrousstrengthoftheperiosteum,andthepresenceofthephysis(growthplate).Examplesof
thesefracturesincludebuckle,greenstick,andplasticdeformation(orbowing).(See'Fracturepatterns'
above.)
Thephysisissusceptibletofractureandthereforesimilarforcesthatcauseligamentousinjuriesinadults
leadtophysealbonefracturesinchildren.TheSalterHarrisclassificationsystemhasbecomethemost
widelyacceptedmethodfordescribingphysealfractures.PhysealfracturesaregradedastypesI
throughV(figure6).Specialattentionisneededforphysealinjuriesbecausegrowtharrestcanoccur.
(See'Physealfracturedescription'above.)
Oncethephysiscloses,thenadultpatternsoffractureareseen.Thetimingofphysealclosureinthe
extremitiesvariesinindividualpatientsandbyboneandpatientsex(figure5).(See'Physeal(growth
plate)'above.)
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Topic6536Version9.0
URL,DOI,
GRAPHICS
Describingafracture
Clinicaldescriptors Radiologicdescriptors
Age Typeofimaging
Gender Anatomiclocation
Mechanismofinjury Fracturepattern

Anatomiclocation Relationshipoffragments
Softtissueinvolvement Physealinvolvement
Keyphysicalexamfindings Apophysealdisruption
Jointinvolvement
Softtissueinvolvement
Graphic61020Version1.0
URL,DOI,
http://www.uptodate.com.secure.scihub.cc/contents/generalprinciplesoffracturemanagementfracturepatternsanddescriptioninchildren/pri 10/28
Radiographicviewsforidentifyingfracturesbylocation
Anatomicregion Plainradiographfractureviews
Wrist All:AP,lateral
Oblique:FracturesuspectedbutAP/lateralnegative*
Scaphoid:Scaphoidfracturesuspected
Elbow AP,lateral,oblique
Shoulder AP,scapularY

Knee AP,lateral,oblique (internalorexternallyrotated)
Sunrise(axial,tangential):patellarinjury
Foot AP,lateral
Oblique:Iffractureseen
Tibia,femur,humerus,andforearm AP,lateral
Ankle AP,lateral,andmortise
*Allowsviewofthescaphoidtrapezoidtrapeziumarticulation.
Providesadifferentprojectionofthefemoralcondylesandtibialtuberositiesaswellasacleanerviewofthemedialand
lateralmarginsofthepatella.
Themortiseviewrequires10to20degreesofinternalrotationandallowsthetibiaandfibulatobeviewedwithout
superimpositionononeanother.
URL,DOI,
Typesofstressonboneandresultingfractures
URL,DOI,
Fractureclassification:Parttwo
Reproducedwithpermissionfrom:Johnson,TR,Steinbach,LS(Eds):Essentialsof
Musculoskeletalimaging.Rosemonst,IL,AmericanAcademyofOrthopaedicSurgeons,2004,p.
4041.Copyright2004AmericanAcademyofOrthopaedicSurgeons.
URL,DOI,
Bucklefracture
APandobliqueviewsoftheleftforearm.Buckle(torus)fractureofthedorsolateralcortex
ofthedistalradialmetaphysis(arrows).Nodisplacementorangulation.
AP:anteriorposterior.
CourtesyofDavidMathison,MDandDeweshAgrawal,MD.
URL,DOI,
Plasticdeformation
Plasticdeformation(bowingdeformity)oftherightradius(arrow)andan
obliquemiddiaphysealulnarfracturewithposteriordisplacementofthedistal
fragmentwhichisoneshaftwidth(dashedarrow).
URL,DOI,
Midshaftgreenstickfracture
Boththeradiusandulnaarebentandthefracturelinedoesnotextend
completelythroughthewidthofthebone.
CourtesyofRichardGBachur,MD
URL,DOI,
Anatomyofthegrowthplate(physis)
Thegerminalzoneofthephysisborderstheepiphysis.Theepiphysealcartilagecellsgrow
towardthemetaphysisandformcolumnsofcells.Thesecolumnsdegenerate,undergo
hypertrophy,andthencalcifyatthemetaphysistoformnewbone.Thehypertrophiczone
(shadedred)istheusualsiteofphysealfractures.
URL,DOI,
Longitudinalbonegrowthoftheupperandlower
extremitiesbyphysis
Approximatepercentageoflongitudinalgrowthprovidedbytheproximaland
distalphysesforeachlongboneintheupper(A)andlower(B)extremities.
Reproducedwithpermissionfrom:RathjenKE,KimHKW.Physealinjuriesandgrowth
disturbance.In:RockwoodandWilkins'FracturesinChildren,FlynnJM,SkaggsDL,
WatersPM(Eds),LippincottWilliams&Wilkins,Philadelphia,2014.Copyright2014
LippincottWilliams&Wilkins.
URL,DOI,
Closureofphyses(growthplates)byageandsexintheupperandlower
extremity
Typicalage(andrange)ofclosureofphysesinthe(A)upperextremityand(B)lowerextremity.
Reproducedwithpermissionfrom:RathjenKE,KimHKW.Physealinjuriesandgrowthdisturbance.In:Rockwood
andWilkins'FracturesinChildren,FlynnJM,SkaggsDL,WatersPM(Eds),LippincottWilliams&Wilkins,
Philadelphia,2014.Copyright2014LippincottWilliams&Wilkins.
URL,DOI,
Commonsitesoflowerextremitystressfracturesinadolescentsbysport
Sport Stressfracturesite(s)
Baseball Tibia
Basketball Anteriorcortexoftibia,tarsalnavicular
Gymnastics Tibia,fibula
Iceskating Distalfibula

Running Proximaltibialmetaphysis,distaltibialmetaphysis,fibula,tarsalnavicular,midshaftoffemur,distal
femur,femoralneck
Soccer Patella
Swimming Proximaltibia
Volleyball Tibia
Adaptedfrom:YngveDA.Stressfractures.In:Careoftheyoungathlete,SullivanJA,AndersonSJ(Eds),American
AcademyofOrthopedicSurgeonsandAmericanAcademyofPediatrics,2000.
URL,DOI,
Buckethandlefracture
APandobliqueviewsoftherightankle.Metaphysealcorner(buckethandle)fractureof
thedistalaspectofthetibia(arrow).
AP:anteriorposterior.
URL,DOI,
SalterHarrisclassificationofphysealfractures
Thegrowthplateisshowningreen.Themnemonicreferstothefracturelineandits
relationshiptothegrowthplate.Themetaphysisistheboneabovethegrowthplate,andthe
epiphysisisthebonebelow.TypeIfracturesdisruptthephysis.TypeIIfracturesinvolvea
breakfromthegrowthplateupintothemetaphysis,withtheperiosteumusuallyremaining
intact.TypeIIIfracturesareintraarticularfracturesthroughtheepiphysisthatextendacross
thephysis.TypeIVfracturescrosstheepiphysis,physis,andmetaphysis.TypeVfracturesare
compressioninjuriestothephysis.
URL,DOI,
ComparisonofOgdenandSalterHarrisclassificationsofphyseal
fractures
TheSalterHarristypesIthroughVareequivalenttoOgdenIAthroughIVAandOgdenV.
RefertoUpToDatetopicsonfracturepatternsanddescriptioninchildrenfordetailed
descriptionoftheOgdenclassificationsystem.
URL,DOI,
SalterIfracture
Anteriorposterior(A)andoblique(B)viewsoftherightankle.SalterHarris
typeIfractureofthedistalfibula.Noticethelateralmalleolarsofttissue
swelling(arrowheads)withthewideningofthefibularphysis(arrow)anda
slightmedialdisplacementoftheepiphysis(dashedarrow).
URL,DOI,
SalterIIfracture
Obliqueandlateralviewsoftherightankle.SalterHarristypeIIfracturethroughthe
posterioraspectofthedistaltibialmetaphysiswithextensionofthefracturelinethroughthe
physis(arrowhead).TheresultantmetaphysealwedgeinthisfractureiscalledtheThurston
Hollandfragment(arrow).
URL,DOI,
SalterIIIfracture
Obliqueviewoftherightankle.SalterHarristypeIIIfractureofthemedial
aspectofthedistaltibiainanatomicalignment(arrow).
URL,DOI,
SalterIVfracture
Anteriorposteriorviewoftherightfoot.SalterHarristypeIVfractureofthe
proximalphalanxofthefirsttoewithassociatedsofttissueswelling(arrow).
URL,DOI,
ContributorDisclosures
DavidJMathison,MD,MBA Nothingtodisclose DeweshAgrawal,MD Nothingtodisclose RichardG
Bachur,MD Nothingtodisclose JamesFWiley,II,MD,MPH Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.

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