Hand and Upper Extremity Fractures in Children and Adolescents

Authored by Jeffrey Wint, MD

A child’s bone is different than a fully-grown adult’s. There are different types of fractures in children than adults. There are special patterns of injury and fracture for children of different age as well. These differences influence the treatment and care of a fracture in a child’s upper extremity.

When a child fractures a bone, the degree of injury, the location, the type of bone injured as well as the age of the child plays a significant role in how a hand surgeon determines what is proper for fracture treatment.

A healthy child’s bone is always growing. This happens by adding length and width and mass to each bone. There are two types of bones to consider in the hand, wrist and upper limb. There are the long bones of the fingers, forearm and arm, and there are smaller rounder bones of the wrist (called the carpal bones).

As a child grows the long bones add length but also add width and mass. A long bone’s shape and proportion shifts with age and growth. Younger children’s long bones are more rubbery, have a better blood supply, have a thicker special layer of tissue surrounding the bone called the periosteum and most importantly have special areas called growth plates. Growth plates at either one or both ends of the long bone help to make the bone grow with the child. Growth plates are the parts of bone responsible for linear growth. When the child enters teenage years, the bones thicken and get heavier and stronger relative to their length.

Eventually the growth plates start to disappear and long bone growth slows. While the older child still has growth plates, eventually they fuse and stop adding any length to the bone. As this happens the older child’s bones start to take on more and more adult features. For several years more the long bones still add mass and get thicker and stronger until young adulthood. The rounder carpal bones of the wrist grow in size as well but have the same shape throughout life. The carpal bones do not have growth plates.

In an x-ray, a child’s bone may look different depending upon their age. While children’s bones are similar in overall design and shape to adults, they have many layers of cartilage surrounding the hard calcified center only the calcium containing part of a bone can be seen on a standard x-ray. The bones may seem not connected or uniform in young children. In small children often the wrist bones are not even seen on an x-ray. As the child ages, the bones add calcium to the outer cartilage layers and not only get larger but also appear to change in shape on x-ray and looking an x-ray picture more like an adults do. Hand surgeons can obtain other types of studies such as ultrasound or MRI to investigate children’s bones when an x-ray picture does not show proper detail.

Hand surgeons use descriptive words such as displacement, angulation or rotation to describe a bone injury. Fractures are discussed based upon where the fracture takes place either in the shaft or the end of the bone. There are more several terms used to describe children’s fractures. Some of these terms are Greenstick, Torus or Buckle, and Growth Plate fracture.

A Greenstick fracture takes its name from the image of a broken wet or “green” twig that does not “snap’ like a dried twig does. It means that the bone may have incompletely broken through. In part it is the rubbery quality of a young child’s bone that leads to a Greenstick fracture. Depending upon the remaining position of the incomplete fracture of the bone, how much it is angled or rotated the hand surgeon may recommend that the Greenstick fracture be completed. In other words, the hand surgeon will actually break the bone further to correct a bent or rotated bone in order to set it in the proper position.

A torus or buckle fracture occurs when the bone bends just a bit. The bone may “buckle” much like a small dent in an aluminum can. These fractures are usually stable but often movement of the injured part hurts and the tissues are swollen or bruised. Often these fractures are in good position and just need support and avoidance of further injury in cast or splint.

A growth plate fracture means that the force of the fracture went though the growth plate. A growth plate fracture can be non-displaced with just a small hairline crack in the growth plate or displaced requiring reduction or putting the bone back in place.

For a non-displaced growth plate fracture, often the initial x-ray may not even suggest a fracture, pain, tenderness and swelling at the areas where the growth plate is may be all that is present. An exam may indicate the growth plate is tender but the x-ray picture is negative. This is because the growth plate on an x-ray doesn’t have the “white” appearing calcium in it and a fracture though the growth plate does not show up. Treatment for this non-displaced fracture involves repeat exam, and perhaps repeat x-rays as well as support in a splint or cast until healed.

For a displaced or angulated growth plate fracture often reduction of the fracture following reduction a cast or splint is applied. At times if a reduction cannot be done, a pin must be placed to hold the two ends the bone near the growth plate in place.

Children can also get other types of fracture where the bone snaps fully or displaced or rotated. Depending upon how old the child is and how displaced, angulated or rotated the fracture is, the hand surgeon may recommend just casting or splinting. This is because very young children often correct some amount of angulations as their bones grow. This is more common for younger children. Your hand surgeon can explain this in detail depending upon the age of the child, and the fracture.

Taking care of children’s fractures involves many factors. Often what seems right for one child of the same age with seemingly the same fractures is not right for a child of a different age. Hand surgeons are trained to understand these changing differences amongst growing children’s bones of different ages, location, and their special appearance on an x-ray. Then make the decisions needed to treat children’s fractures of the fingers, hand, wrist, forearm, and upper extremity.