Daily Archives: April 4, 2013

As winter fades to spring and spring turns to summer it is the time of year that children look at the greening grass and think: monkey bars, merry go rounds, swings and slides. The playground is a wonderful place for children to exercise, socialize, work on their balance and muscle memory and, oh yes, get hurt. Let me first say that of all of the things I just listed, the getting hurt part is something parents should be concerned about, watchful to try and prevent, but accidents do happen and the positive effects of play and exercise far out way the dangers lurking in the playground.

Some of the more common injuries on the playground are fractures or broken bones. But one of the best parts of being a child or young adolescent is that many of the fractures that would require surgery in adults can be realigned or set and placed in a cast or splint (a partial cast that allows for the injured limb to swell without concerns of cutting off the circulation) and will heal in children. Healing is only part of the solution however. One reason that adults require more surgery is that if the bones are not in good alignment then it can lead to long-term functional problems. For instance if you break your forearm as an adult and it is even a few degrees from being perfectly aligned it can limit the movement of the elbow and wrist and lead to problems. The reason for this is even though the older bone in adults is continuously being turned over and changed into new bone we are no longer growing, so the broken bone has limited potential to reshape itself. In children however they continue to grow and as the normal remodeling process occurs they are also growing so it allows them to straighten their bones and correct any misalignment after their fracture. For instance the forearm fracture in adults has to have normal alignment for us to treat it in a cast (and even then it is probably better to treat it with surgery) but in children we can sometimes accept up to 15 degrees of misalignment and they will not only heal but will straighten the bone over time and x-rays years later may show no sign of ever having a fracture.

The most common fractures in children occur in the forearm and wrist. About 50 percent of all fractures in children involve these two areas with three out of four of those fractures occurring at the wrist. Typically these injuries occur from a fall when a child tries to catch themselves with their arm outstretched.

The simplest of these fractures is called a Taurus fracture or buckle fracture. What occurs during these injuries is the bone doesn’t actually break all off the way through instead it bends on one side and buckles on the other. This occurs because in young bone the bone is much more rubbery than adult bone so it is able to bend before it breaks.

Another fracture of the forearm is called a green-stick fracture, which similar to a buckle fracture the bone doesn’t break all of the way through. Like the name implies and you can probably imagine if you were to go outside right now and take a green branch off of the tree and try and break it over your knee you are unlikely to be successful. And if you look at the stick you will find that the side of the branch closest to your knee bent around your knee but didn’t break but the side opposite this did break partially through. These fractures can sometimes be problematic because if they bend a lot but do not break completely we have to take the child to the operating room and complete the fracture so that we can realign it. But wait, you just said kids can realign their bones as they grow. Although this is true if the fracture is complete in green-stick fractures were it is mostly a bend the bone doesn’t realize it is broken and tends to keep the same shape and has less chance to remodel and return to its normal shape.

Fractures that break completely through the bone sometimes still do not need to be reset, especially those at the wrist. This is because most of the growth that occurs in the radius, which is the bigger bone of your forearm at the wrist, allows for an enormous amount of potential to remodel. This allows for even more leeway in how much angulation we can accept before we need to reset the fracture. Nonetheless some wrist fractures and a fair number of forearm fractures do need to be reset before being casted. But for the most part as long as we can get them in good alignment the long term consequences are small.

One particular fracture that can be a little more problematic however is the wrist fracture that goes through the growth plate. The major issue here is that if the growth plate is injured it can stop growing and lead to “growth arrest” which depending on the child’s age may or may not be a major issue. Sometimes if these fractures do not realign easily it is best to take the child to surgery to ensure that the growth plate is not repeatedly injured predisposing it to growth arrest. Typically the surgery requires realigning the bone under x-ray guidance and holding it temporarily with pins that can be removed 4-6 weeks later as well as a cast.

Although there are potential dangers lurking in the playground, the benefits of play far outweigh the risks. Statistically it will probably happen: 75 percent of boys will break at least one bone, 50 percent two and 25 percent three. Girls have about a 50 percent chance of breaking at least one bone before they reach adulthood. So be aware and watchful, but if it happens remember accidents do happen and it probably was nobody’s fault – which is sometimes hard for parents to keep in mind when their child is hurt. Remember that kids are able to heal in ways that make the long-term consequences of broken bones much less concerning than in adults.

By JEREMIAH CLINTON, MD – Bitterroot Orthopedics & Sports Medicine