Part 1
By Dr Anil Menedal, MS (Orthopaedics)
Elbow fractures in children
When a child falls on an outstretched arm, the velocity of the fall combined with the pressure of hitting the ground could be enough to fracture or break a bone around the elbow. These fractures that occur in, or around, the elbow account for about 10% of all fractures in children.
This child has a severe right supracondylar humerus fracture with complete displacement of the fracture fragments.
Supracondylar – The upper arm bone (humerus) breaks slightly above the elbow. This is the most common elbow fracture and one of the more serious because it can result in nerve damage and impaired circulation.
If your child complains of elbow pain after a fall and refuses to straighten his or her arm, see a doctor immediately.
During the physical examination, we will check to see whether there is any damage to the nerves or blood vessels.
X-rays are necessary. They will determine what kind of fracture occurred and whether the bones moved out of place. Because a child’s bones are still forming, we may request x-rays of both arms for comparison.
This x-ray shows that the supracondylar humerus fracture has been put into the correct position and held in place with two pins.
Treatment depends on the type of fracture and the degree of displacement.
Nonsurgical treatment – If there is little or no displacement, your arm may be immobilized in a cast or splint for 3 to 5 weeks.
Surgical treatment – If the fracture forced the bones out of alignment, we will have to manipulate them back into place. Sometimes this can be done without surgery, but more often, surgery will be needed. Pins, screws, or wires are used to hold the bones in place.
Forearm fractures in children
Fractures of the forearm can occur near the wrist at the farthest (distal) end of the bone, in the middle of the forearm, or near the elbow at the top (proximal) end of the bone.
A child’s bones are also subject to a unique injury called a growth plate fracture. Growth plates are made of cartilage near the ends of children’s bones. They help determine the length and shape of the mature bone.
Fractures in a child’s bones begin to heal much more quickly than an adult’s bones. If you suspect a fracture, you should obtain prompt medical attention for the child so that the bones can be set for proper healing.
Forearm fractures account for 40% to 50% of all childhood fractures. In most cases, a broken forearm causes severe pain. Your child’s forearm and hand may also feel numb.
We will also test to make sure that the nerves and circulation in your child’s hand and fingers have not been affected.
Treatment depends on the type of fracture and the degree of displacement.
Some mild fractures, such as buckle fractures, may simply need the support of a splint or cast until they heal. For more severe fractures that have become angled, we may be able to push (manipulate) the bones into proper alignment without surgery, as long as the bones have not broken through the skin.
Surgery to align the bones and secure them in place may be required if:
* The fracture is unstable – the ends of the broken bones will not stay lined up.
* Bone segments have been displaced.
* The bones cannot be aligned properly through manipulation alone.
* The bones have already begun to heal at an angle or in an improper position.
If the fracture disrupts the growth plate at the end of the bone, we will probably want to watch it carefully for several years to ensure that growth proceeds normally.
Clubfoot
Parents know immediately if their newborn has a clubfoot. Some will even know before the child is born, if an ultrasound was done during the pregnancy. A clubfoot occurs in approximately one in every 1,000 births, with boys slightly outnumbering girls. One or both feet may be affected.
Doctors still aren’t certain why it happens, though it can occur in some families with previous clubfeet. In fact, your baby’s chance of having a clubfoot is twice as likely if you, your spouse or your other children also have it.
The appearance is unmistakable: the foot is turned to the side and it may even appear that the top of the foot is where the bottom should be.
The involved foot, calf, and leg are smaller and shorter than the normal side.
It is not a painful condition. But if it is not treated, clubfoot will lead to significant discomfort and disability by the teenage years.
Nonsurgical treatment – Treatment should begin right away to have the best chance for a successful outcome without the need for surgery. Over the past 10 to 15 years, more and more success has been achieved in correcting clubfeet without the need for surgery. The Ponseti method has been responsible for this. With this method, we change the cast every week for several weeks, always stretching the foot toward the correct position. The heel cord is then released followed by one more cast for three weeks.
Once the foot has been corrected, the infant must wear a brace for two years to maintain the correction. This has been extremely effective but requires the parents to actively participate in the daily care by applying the braces. Without the parents’ participation, the clubfoot will almost certainly recur. That’s because the muscles around the foot can pull it back into the abnormal position.
Surgical treatment – On occasion, stretching, casting and bracing are not enough to correct your baby’s clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to12 months of age, surgery corrects all of your baby’s clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still while it heals. It’s still possible for the muscles in your child’s foot to try to return to the clubfoot position, and special shoes or braces will likely be used for up to a year or more after surgery. Surgery will most likely result in a stiffer foot than nonsurgical treatment, particularly as the years pass by.
Without any treatment, your child’s clubfoot will result in severe functional disability. With treatment, your child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however. You should expect it to stay 1 to 1½ sizes smaller and somewhat less mobile than the normal foot. The calf muscles in your child’s clubfoot leg will also stay smaller.