Pediatric Soft Tissue Injuries and Fractures

This article summarizes soft tissue injuries and fractures, both of which are common in the pediatric population. To dive even further into musculoskeletal disorders, check out this article, too!

Soft tissue injuries

These can be classified as contusions, dislocations, strains, and sprains. 

• A contusion is a bruise and it’s caused by direct impact such as the child falling and hitting their arm against one of their toys. 
• A dislocation occurs when two bones separate at the joint. In children, the most common location for dislocation is the shoulder. It can be incredibly painful and cause temporary immobilization and deformity of the joint. Dislocations are initially treated with RICE (rest, ice, compression, elevation) in hopes that the joint will move back into place on its own. If the dislocation does not resolve, it will require some kind of manual manipulation followed by immobilization (wearing a splint or sling for several weeks). Repeated dislocations or dislocations that have severely impacted nearby blood vessels, nerves and ligaments may require surgery.

• A strain occurs when the muscle or tendon tears due to being stretched beyond its capability. You may also hear this simply called a “pulled muscle.” A strain can range from mild (less than 5% of fibers are affected), to moderate (more damage and more fibers involved), to severe (complete rupture of the tendon or muscle). Mild and moderate strains are treated with RICE, but severe strains may require a cast and even surgery.
• A sprain is an injury to the ligaments surrounding a joint that is connecting two bones together. As with a strain, there are three types. A mild sprain involves a small amount of stretching of the ligaments, a moderate sprain involves a bit of tearing of the ligament, and a severe sprain involves a complete tear of the ligament. Sprains are also treated with RICE, but severe injuries may require longer-term immobilization and possibly even surgery.

Fractures

There are some key differences between fractures in children and adults. In children they tend to be more common in the distal forearm (ulna and/or radius), they often occur on the growth plates since this area is weaker (about ⅓ of childhood fractures are growth plate fractures), and pediatric bones heal more quickly than adult bones. For example, a toddler may only need to wear a cast for four weeks compared to about six to eight weeks in an adult. 

Additionally, younger children are not able to convey signs and symptoms in the same way as an adult. Along with showing signs of discomfort or pain, some signs of fracture in a young child are refusal to crawl or walk and refusal to use the affected limb.

In children, fractures are most commonly associated with motor vehicle accidents, falls and sports activities. Fractures in infants should be evaluated further as there is potential for “nonaccidental trauma” in this population. PRO TIP: If the x-ray shows fractures in multiple stages of healing…think nonaccidental trauma or osteogenesis imperfecta, which is a genetic condition in which the bones break very easily. A child with osteogenesis imperfecta will often have blue sclera and be of short stature.

There are several types of fractures: 

• Incomplete fracture – Occurs when only one side of the bone is fractured and the other side is either unaffected or bends in slightly.
  • Stress fractures – These are tiny cracks in the bone that can occur due to repetitive trauma and are more likely to occur in active children. The bones most commonly affected by these hairline fractures are the legs, feet, arms and spine. Stress fractures are typically treated with RICE and avoidance of weight-bearing while the fracture is healing.
  • Greenstick fractures – In this type of incomplete fracture, one side of the bone is broken and the other is intact but bent. Greenstick fractures are usually treated with closed reduction and casting, though some fractures will require surgery. Since adult bones do not bend, greenstick fractures only occur in children.
  • Torus fractures – Also called “buckle” fractures, these are the most common type of fracture in the pediatric population. They tend to occur around the wrist as the child tries to catch himself when falling. Torus fractures are often treated with a removable brace and they tend to heal quickly.
• Complete fracture – This type of fracture occurs when both sides of the bone are affected. A complete fracture is going to be less stable than an incomplete fracture and require more intensive treatment. Treatment for complete fractures can range from casting and traction to surgery and will depend on the type and severity of the fracture.
  • Segmental fracture – A segmental fracture occurs when the bone is broken in two different locations and a section of bone has become separated.
  • Comminuted fracture – This type of fracture occurs when the bone is broken into more than two pieces.
  • Transverse fracture – These fractures occur perpendicular to the long axis of the bone.
  • Oblique fracture – This fracture type occurs at an angle.
  • Spiral fracture – In this unique type of fracture, the bone is broken with a twisting motion and the fracture line wraps around the bone. They are usually caused by falls and other traumas. It used to be thought that spiral fractures were highly specific for child abuse. However we now know these types of fractures can occur from falls when the child’s main weight load is on the leg. As the child falls, the bone is subjected to rotational force, causing the spiral fracture.
  • Open fracture – Also called a compound fracture, in this type of injury the broken bone or bone fragment causes an open wound or break in the skin. Open fractures carry a high risk for infection and will always require surgery.
• Physeal fractures – Also called “growth plate” fractures, these fractures occur in the weakest area of bone. A potential complication of this type of fracture is that the child can have issues with growth of the bone. Treatment for growth plate fractures involves immobilization (cast or splint), manipulation or surgery, and physical therapy.
• Compression fractures – Compression fractures of the spine typically occur in children with either osteogenesis imperfecta or in those who use steroid medications long-term. They can also be due to a fall or motor vehicle accident and treatment can range from rest and a back brace to surgery.

I hope this helps  you understand soft tissue injuries and fractures in the pediatric population. For more pediatric articles, click here.

Review Pediatric Musculoskeletal Disorders for your exams, clinicals, and NCLEX while you’re on the go by tuning in to episode 283 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.

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References:

Alves, C. (2019). Bracing in clubfoot: Do we know enough? Journal of Children’s Orthopaedics, 13(3), 258–264. https://doi.org/10.1302/1863-2548.13.190069