Postgraduate Medicine

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Fractures in Children

Walter P. Blount

To cite this article: Walter P. Blount (1954) Fractures in Children, Postgraduate Medicine, 16:3,
209-216, DOI: 10.1080/00325481.1954.11711663
To link to this article: https://doi.org/10.1080/00325481.1954.11711663

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 ediatrics
IN GENERAL PRACTICE

Fractures in Children
WALTER P. BLOUNT*
Milwaukee Children's Hospital, Milwaukee

FRACTURES in children are different from deformities. The degree of correctability de-
those in adults. The principles of treatment pends on three variables:
are simple. Alignment is the chief require- 1. The age of the child.
ment. The fracture should not be grossly angu- 2. The distance of the fracture from the
lated nor rotated. Accurate apposition and end of the bone.
normal length are not necessary in children. 3. The amount of angulation.
ln most cases, excellent results are obtained The younger the child and the nearer the frac-
by simple traction or closed reduction and a ture to the end of the bone, the greater the
cast.1 The exceptions which often require open deformity that is acceptable.
reduction are three relatively common frac- Third, there may be disastrous angulation
tures at the elbow and a few rare joint frac- and shortening from injury to an epiphysial
tures. Elsewhere, an open reduction in a child plate. The younger the child the worse the
is diffi.cult to justify. deformity.
In children, bones are not only living but
Fractures oj the Femur
growing. Continued growth after the fracture
is important for three reasons. First, growth Fractures of the shaft are uniformly weil
is frequently accelerated for severa} months treated with Russell traction in older children
following a fracture. This simple physiologie and with double overhead traction in younger
phenomenon is not "compensatory" but it ones. Avoid constricting bandages which may
tends to equalize shortness from overriding. cause ischemie necrosis. Proper adjustment
Second, molding will correct minor angular of weights and pulleys will align any such
fracture. Adduction of the proximal fragment
*Chairman, Ortbopaedic Section, Milwaukee Children's Hoapital.
Milwaukee, Wiscon1in. is corrected by traction with greater force

September 1954 209

on the other leg so as to tilt the pelvis caudad is ali the treatment that is necessary. Trans-
on the side opposite the fracture. Excessive verse fractures of the middle and distal thirds
flexion of the proximal fragment of an upper may require closed reduction under anesthesia
third fracture is corrected by changing to with the same fixation. Ankle fractures are less
overhead traction or by adding more upward common and usually involve the epiphysis.
pull on the knee sling to flex the distal frag- Closed reduction is almost invariably ~atis­
ment. It is easy to prevent rotational deform- factory. When reduction is delayed and dis-
ity by keeping the feet in the same relative placement is moderate, one should accept the
position. End-to-end apposition is not only deformity rather than attempt open operation
unnecessary but undesirable in a displaced or violent closed reduction, which increase the
fracture. To obtain legs of equal length, it is likelihood of arrested growth. The amount of
best to leave l cm. of overriding. A leg that deformity depends on the extent of injury to
is too long is just as bad as one that is too the growing cells of the epiphysial plate by
short. With the average displaced fracture, the initial trauma or the subsequent treatment.
the femur overgrows 1 cm. Callus forms more The subsequent angulation and shortening
rapidly and union is stronger with side-to-side should be recognized promptly and corrected
than with end-to-end apposition. Skeletal by osteotomy with epiphysial stapling of the
traction should not be necessary in an uncom- opposite tibia before it is too late for these
plicated case. Cast treatment is less reliable procedures to be of value. 4
than traction; however, it may be indicated at
Fractures of the Upper Extremity
times. 2
Subtrochanteric fractures must be consid- Fractures of the clavicle are weil treated in
ered in relation to the hip. The local irregu- young children with a figure-of-eight bandage
larity of bayonet apposition soon disappears of stockinet stu:ffed loosely with cotton. ln
with molding. Angulation with the apex later- older children a plaster yoke is preferable
ally produces, in addition to the local deform- when the fracture is displaced. Open reduc-
ity, a coxa vara. The angulation of the shaft tion is never warranted.
will straighten out, but the coxa vara will per- Subtubercular fractures of the humerus are
sist. Coxa valga and rotational deformities best treated by a hanging cast (figure l) .
are equally permanent.3 Proper rotation will be maintained. Shorten-
Open reduction is occasionally necessary in ing of l cm. is desirable and will be equalized
fractures through the distal femoral epiphysis by subsequent overgrowth in most cases.
and usually in those of the proximal epiphysis Moderate degrees of angulation will be over-
and neck of the femur. The first of these may come (figures 2 and 3 ) .
be a surgical emergency because of circulatory ln children under 12, epiphysial fractures
embarrassment. With these exceptions, open at the proximal end of the humerus may be
reduction is not indicated. We have collected treated in the same way. Even with displace-
the results of sorne casually performed opera- ment and moderate angulation, the rapid
tions. The tragic complications include: sep- restoration of function and bony contours is
sis and death, chronic osteomyelitis, deformity remarkable. Growth arrests have not been
with joint sti:ffness, repeated refracture, and observed. The same fracture in adolescents
persistent nonunion. When the results with should be reduced in abduction and immobi-
conservative treatment are so uniformly good, lized with the forearm over the head. Opera-
an open operation is difficult to justify. tion causes permanent restriction of motion. 5
Supracondylar fractures of the humerus are
Tibial Fractures usually produced by hyperextension at the
In children, a spiral fracture of the tibia elbow with a faU on an outstretched hand. Im-
frequently occurs without fracture of the fibu- mediate closed reduction and fixation in mod-
la. Five to seven weeks in a cast extending erate flexion produce a high percentage of
from toes to midthigh with the knee in flexion excellent results. Accurate reduction lessens

210 POSTGRADUATE MEDICINE

 FIGURE 1. Case 1. A 10
year old boy had a suh-
tubercular fracture of the
left humerus which could
not be reduced by conserv-
ative measures. Hanging
cast applied with ~ross
angulation and shortening.

FIGURE 2. Case 1. Four

months later union was
firm. The patient had no
complaints. Molding had
reduced the deformity.

FIGURE 3. Case 1. Antero-

posterior and lateral views
three and a half years
later. The fracture cannot
be detected clinically. The
roentgenogram shows only
slight change in the inter-
nai architecture. The left
humerus is only 1 cm.
short.

September 1954 211

the likelihood of vascular embarrassment. forearm without constriction, or by a Kirsch-
If there has been severe soft tissue damage uer wire through the olecranon or the base of
or if reduction has been delayed, there will be the thumb. 6 Prompt blocking of the sympa-
extreme swelling. Attempted manipulative re- thetic ganglia is frequently effective.
duction is then undesirable. Elevation with If the symptons are weil advanced or do not
traction on the forearm and the elbow in mod- subside with conservative treatment, no time
erate flexion is the method of choice. As long should be lost in exploring the cubital fossa
as alignment is accurate, posterior displace- and volar aspect of the forearm. The tough
ment of the distal fragment is not of great sig- fascia is slit, permitting the explosive extru-
nificance. After three weeks in bed, the patient sion of edematous muscles and hematoma. An
is allowed to get up with the arm in a sling. injured or markedly constricted brachial ar-
When the swelling is gone, it may be desir- lery should be resected. This relieves vaso-
able to interrupt traction in bed and to obtain spasm and the reflex involvement of the inti-
an accurate reduction by manipulation under mate vasculature of the muscles. Delay is
anesthesia. Open reductions in children are disastrous. Within three or four hours, irre-
likely to cause limitation of motion. Physical versible changes will take place. 7
therapy will do more harm than good.
Delay in the reduction of a fracture in an Elbow Fractures Frequently
Requiring Open Reduction
adult frequently necessitates open reduction.
ln a child, a fracture which is ordinarily Fracture of the lateral condyle is often dis-
treated conservatively rarely requires open missed as a sprain. The displacement is largely
reduction because of delay. If the degree of rotational and the immediate local symptoms
malunion is not acceptable and cannot be cor- are less arresting than those of supracondylar
rected by closed manipulation, it is usually fracture. The articular cartilage of the frag-
better to wait until the fracture is solidly ment is opposed to the fractured surface of the
healed and then correct the deformity by oste- shaft and held there by the attached extensor
otomy. Delay may make an ordinarily justi- muscles of the forearm. Even if it is promptly
fiable open reduction un wise ( see below) . reduced by closed methods, the fragment is
There is danger of Volkmann's ischemia in often displaced again by the pulling of the
ali elbow fractures. Prompt gentle reduction muscles. Successful reduction must be proved
and immobilization without constriction offer by frequent roentgenograms. If unreduced,
the best defense. If the radial pulse is present, the fracture does not unite and the fragment
it should not be obliterated by the manipula- rides up. With growth there is an increase in
live reduction. If it is absent before treatment the carrying angle, deformity, weakness and
is started and if the capillary circulation is pain in the elbow. The most significant dis-
good, the pulse may be disregarded. An ab- ability is delayed ulnar nerve paisy, which
sent radial pulse is not an indication for opera- usually appears about 20 years after the in-
tion. Most significant as warnings of impend- jury. Prompt open reduction and internai fixa-
ing ischemia are: pain in the hand, swelling, tion are usually the best treatment. Delay
coldness, cyanosis or pallor of the fingers. The makes the operation more difficult and usually
most important of these is pain. A well-re- results in sorne deformity.
duced fracture in a child should not require The medial epicondyle may be avulsed by
sedation other than aspirin. If there is evi- valgus strain of the elbow with or without dis-
dence of circulatory embarrassment, ail con- location. It is only an apophysis and has no
stricting bandages should be removed from part in longitudinal growth. If the displace-
the elbow and forearm, angulation should be ment is slight, immobilization in flexion for
reduced to about 120 degrees and ice bags three weeks is ali thal is necessary. If the dis-
applied. Satisfactory position of the frag- placement is more than 5 mm. in a boy, open
ments and elevation of the forearm are main- reduction and pin fixation must be considered.
tained by traction applied to the skin of the If the fracture remains untreated, the resulting

212 POSTGRADUATE MEDICINE

nonunion causes little disability and may be radial head. If both are treated promptly,
the desirable end result in girls. If there is closed reduction is usually successful. Open
ulnar nerve involvement, or if the medial reduction of a dislocated radial head may be
epicondyle is incarcerated in the elbow joint, necessary. Fractures of the proximal third of
operation is usually indicated. If the patient is the ulna associated with dislocation of the
seen soon after the fracture occurs the medial radial head ( Monteggia) usually do not re-
epicondyle is replaced. If the operation is quire internai fixation of the ulna, as in adults.
delayed, it may be preferable to excise the When the radial head is reduced by manipula-
fragment and suture the aponeurosis of the tion or by open operation, the ulna is splinted
flexor muscles to the medial condyle. If an in- by the radius. If an intramedullary pin is used
carcerated epicondyle is not operated on in the ulna, it should be removed in three
within three months the result is better if it is weeks. Dislocation of the radial head in chil-
left untreated. dren, either with or without associated frac-
ture, should not be reduced by open operation
Fractures of the Radial Neck
after a delay of three months. The dislocation
Fractures of the radial neck illustrate weil causes no disability in the child, although it
the difference between fractures in children may be unsightly. Delayed open reduction re-
and adults. ln children there is characteristic- sults in permanent limitation of motion. After
ally angulation of the fragment and displace- the child is fully grown the radial head may
ment toward the radial side. Angulation of 50 be excised.
degrees can be reduced to 20 degrees by
manipulation. A cast with the elbow at right Fractures of the Forearm
angles is applied for three weeks. The marked Greenstick fractures of the distal third of
limitation of ali elbow motions will gradually the forearm may be left unreduced if the angu-
disappear; function and roentgenographic ap- lation is moderate. The angulation will gradu-
pearanc~ will be almost normal eventually. ally disappear. Angulated fractures of the mid-
If there is a 90 degree angulation so that dle third will not straighten out entirely except
the fractured surface cornes to lie against the in very young children. Pronation and supina-
shaft of the radius, satisfactory closed reduc- tion will be limited. Greenstick fractures at
tion is rarely possible. ln the past, uninformed this level should be broken through complete-
surgeons removed the radial head as in adults. ly. They will then remain in good position if
The loss of the growth center caused radial the arm is enclosed in a plaster cast from
deviation of the hand, shortening of the fore- knuckles to midarm with the elbow at right
arm, increase in the carrying angle and weak- angles and the forearm in midsupination. If
ness of the elbow.8 Never remove the radial a greenstick fracture is not broken through,
head in a growing child. Prompt open reduc- the deformity is likely to recur due to muscle
tion and accurate replacement are indicated. pull in the cast. Wedging of the cast or the
Internai fixation is usually unnecessary. When use of a pressure pad is an invitation to Volk-
the dislocation of the radiohumeral joint is mann's ischemia. No force should be necessary
accurately reduced and the elbow is flexed, in maintaining the reduction of a forearm
pronation and supination will not dislodge fracture. The appearance of pain is a danger
the fragment. The result should be uniformly signal.
good. Delay in reduction or careless surgery Displaced fractures of the proximal third
will produce the same permanent limitation can usually be reduced in supination and held
of motion that follows extensive trauma with in a plaster cast. Overriding is not objection-
dislocation of the ulnar-humeral joint. able. Satisfactory alignment can be maintained
Olecranon fractures rarely occur as isolated by fixed traction on the fingers with a cast.
injuries in children. Fixation in extension is Function will be normal. The same is true of
permissible. Not infrequently, olecranon frac- fractures of the middle third except that they
tures are associated with dislocation of the should be immobilized with the forearm in

September 1954 213

FIGURE 4. Case 2. A girl,
age seven years, had a green-
stick fracture of the distal
ends of both bones of the
left forearm. A long arm
cast was applied with the
elbow at a right angle and
the forearm in midposition.
Pronation would have been
better.

FIGURE 5. Case 2. When the

cast was removed five weeks
later the angular deformity
had greatly increased. It
now measured 40 degrees.
The child had a bad cold so
that anesthesia was unwise.
The angular deformity was
allowed to remain and the
mother was informed that
the crooked arm would
straighten spontaneously in
a year or two. It did.

214 POSTGRADUATE MEDICINE

 FIGURE 6. Case 2. Antero·
posterior and lateral reent·
genograms of the left distal
forearm three and a half
years after the original in·
jury. The angular deformity
has completely disappeared.
Length is the same and
function is normal.

midsupination. Slight shortening is not sig- ties will be overcome by molding. ln older
nificant but angulation is not permissible. children more accurate reduction is necessary.
Malposition is an indication for more efficient Bayonet apposition is satisfactory. Alignment
conservative treatment and not for open re- can he maintained by traction. There is no
duction. justification for open reduction. The compli-
A complete fracture of both hones at the cations which occasionally follow operation
distal end of the forearm is usually angulated are inexcusable when the results with closed
with the apex volarward and with dorsal dis- methods are so good. 9
placement of the distal fragments (figure 4) .
There is a strong tendency for the angulation Epiphysial Fractures
to return after a reduction (figure 5). lm-· ln general, epiphysial fractures are best
mobilization should he by a cast above the treated by closed methods (figure 7 ) . Unless
flexed elbow with the forearm in pronation. there has heen damage to the growing cells of
Checkup roentgenograms are imperative after the epiphysial plate at the time of injury,
one or two days and again after a week. If slight overgrowth is the rule and retarded
angulation of less than 25 degrees has re- growth an exception. Violent longitudinal
curred, it may he ignored in children of less thrusts producing crushing injuries to the
than 10 years (figure 6). The amount of de- epiphysial plate are likely to cause serious
formity which is acceptable must be calcu- deformities from epiphysial arrest (figure 8) .
lated for each individual case. The younger After two weeks, considerable displacement is
the child and the nearer the fracture to the usually to he preferred to a forceful closed
bone end, the more angulation one may ac- reduction or open operation. There are defi-
cept. ln newhorn infants tremendous deformi- nite exceptions to this rule, usually in cases of

September 1954 215

 FIGURE 8. Case 3 (February 23, 1951). Inversion of the
right foot recurred in spite of complete correction by
osteotomy on May 27, 1949.

FIGURE 7. Case 3 (October 19, 1946). A six year old girl

had an epiphysial fracture of the distal end of the right
tibia. The fracture was perfectly reduced but the medial
portion of the epiphysial plate was damaged by the
original injury.

fracture at the ends of the femur, as discussed

previously.
Summary
Fractures in children are different from
fractures in adults. The treatment of those
which look easy is occasionally difficult while
treatment of those which appear difficult is
often easy. With the exceptions noted, re-
duction and fixation are best obtained by
simple conservative means and open reduction
is difficult to justify. When there is a definite
FIGURE 9. Case 3 (February 25, 1952). Final correction
need for operation it should be performed of the deformity by transverse osteotomy and insertion
promptly. of a wedge of bone from the bank. The ankle was nor-
mal in appearance. The shortening had been equalized
This article is published by permission of Schweizerische by an operation on June 3, 1949 to staple the proximal
medizinische W ochenschrift. tibial epiphysis and curet the proximal fibular epiphysis.

REFERENCES

1. BLOUNT, W. P.: Fractures in children. American Academy of humerus in children. Canad. M. A. J. 40:546, 1939.
Orthopaedic Surgeons, lnstructional Course Lectures, 7 :194, 1950. 6. CA.RLI, CARLo: Trazione col filo nelle fratture sovracondiloidee
2. BLOUNT, W. P., Sc&AEFRR, A. A. and Fox, G. W.: Fractures of di gomito del bambin o. Chir. d. org. di movimento 18:311, 1933.
the femur in children. South. M. ]. 37:481, 1944. 7. BLOUNT, W. P.: Volkmann's ischemie contracture. Surg., Gynec.
3. BLDUNT,W. P.: Unusual fractures in children. American Acad· & Obst. 90 :244, 1950.
emy of Orthopaedic Surgeons, Inatructional Course Lectures, 8. Lzwts, R. W. and TamooEA.U, A. A.: Deformity of the wrist
11 :57' 1954. following resection of the radial head. Surg., Gynec. & Obst.
4. BLOUNT, W. P. and CLARK&, G. R.: Control of bone growth hy 64:1079, 1937.
epiphyaeal atapling. J. Bone & Joint Surg. 31·A:464, 1949. 9. BLOUNT, W. P., Sc&A.EFER, A. A. and JoHNSON, J. H.: Fractures
S. Aunm, L. ]. : Fracturea of the morphological neck of the of the lorearm in children. J. A. M. A. 120:111, 1942.

216 POSTGRADUATE MEDICINE