The skeleton is an active organ of development with well-characterised growth patterns and documented responses to trauma [1]. Fractures occur more often in the paediatric age group than in healthy adults [2]. The radiographic structure and growth features of healthy and injured bones, as well as the fracture dynamics in young patients, must be understood to treat fractures [3]. However, records from the arbitration committees of the German Medical Associations demonstrate that youngsters are too often treated like small adults. Fracture treatment complaints throughout skeletal growth are higher than typical. Initial clinical evaluation is limited to inspection. Testing for the primary indications of fracture (abnormal mobility, crepitation) would result in undue suffering for the child and must thus be avoided. It is necessary to inspect the peripheral for associated injuries (blood supply, sensation and mobility).

In paediatric traumatology, conventional radiography remains the gold standard for fracture diagnosis. In every instance, two projections of radiographs of the damaged location and adjacent joints are obtained. The images must be meticulously evaluated and the fractures must be inspected for indications of instability [4]. Sonography can reliably diagnose some shaft fractures (compression fractures). Magnetic resonance imaging and computed tomography have no place in acute diagnosis. Fractures in children and teenagers exhibit typical characteristics related to maturation. The epiphyseal cartilages serve as shock absorbers during axial trauma. Additional torsion or shear stresses cause growth plate damage [5].

Growth Prognosis 

Before planning the treatment of a fracture during the time of skeletal development, it is necessary to construct a growth prognosis so that, in the event of displaced fractures, both the potential for spontaneous correction and the risk of growth disorder may be evaluated. Both spontaneous correction and growth disorder are only conceivable if the remaining growth period is long enough and both are dependent on:

• Age/Sex

• Stage of development

• Site of fracture

• the direction of motion

• Extent of displacement [6]

It is known the growth dynamics and fusion times of the various growth plates. The proximal growth plate of the humerus and the distal growth plate of the forearm are responsible for 80% of longitudinal growth in their respective segments of the upper extremity and merge late (14 to 16 and 14 to 18 years, respectively). 40% to 60% of longitudinal growth in the lower leg is due to the growth plates at the knee joint

If a growth plate contributes actively to growth over an extended length of time, it has a greater capacity for spontaneous correction of posttraumatic malalignment but also a greater susceptibility to growth disorders. Upper limb growth plates are less susceptible to growth abnormalities and more likely to rectify malalignments [7]. Lower limb physes are significantly more susceptible to growth problems. In the sagittal plane, misalignments are repaired more effectively than in the coronal plane. Only non-specific compensations are made for rotational abnormalities in the setting of physiological alterations in torsion.

Treatment Techniques 

There are both nonsurgical and surgical treatment methods available. The choice of treatment depends on the degree of initial displacement as well as the fracture's age, location and stability [8]. Fractures without displacement or with acceptable displacement are treated conservatively. An acceptable displacement is one that will be repaired by the expected length and thickness growth of the wounded bone. In accordance with fracture location and patient age, the literature provides copious details on the expected degree of repair [9]. If reduction is necessary, a manipulation technique must be used that eliminates the possibility of redistribution. If this cannot be accomplished with immobilisation alone, surgical stabilisation is required [10].

Joint surface reconstruction in the epiphysis is often accomplished with Kirschner wires or compression screws following open reduction [11]. Additionally, arthroscopic monitoring of decrease is possible. Typically, metaphyseal fragments can be effectively reduced using a closed method but fixation is frequently necessary. This can be accomplished with Kirschner wires (in which case additional plaster cast immobilisation is necessary) [12], screws or in some circumstances by inserting an intramedullary rod [13]. Diaphyseal fractures are typically treated surgically today. Elastic stable intramedullary nailing (ESIN) is the procedure of choice for longitudinally stable transverse fractures. External fixators are an option for fractures that are longitudinally unstable and oblique, spiral or multifragmentary [14].

Plate fixation is utilised seldom in teenagers with fractures proximal to joints. Interlocking nails are utilised exclusively for diaphyseal fractures in patients nearing the conclusion of their growth spurt. Each technique has specific indications. Always take into account the patient's burden, the intensity and duration of transient function-limiting malalignments and individual preferences.

Proximal Upper Arm 

Rarely do intra-articular epiphyseal fractures occur throughout the era of skeletal development. This region is most commonly affected by physeal separations and metaphyseal fractures, with the potential for spontaneous correction of up to 40° before adulthood [15]. Reduction and ESIN are used to treat fractures with a greater degree of angulation and displacement than the width of the shaft. Inappropriate is internal fixation with Kirschner wires (instability) or plates (invasiveness).

Upper Arm Shaft

Fractures of the upper arm shaft are uncommon. Long oblique or spiral fractures can be treated with a cast or splint, allowing for an early return to function. Axial misalignments beyond 10° will not spontaneously correct and must be addressed [16]. ESIN is ideally suited for managing transverse fractures. Due to the high incidence of spontaneous remission, the infrequent occurrence of primary radial nerve palsy is not necessarily an indication for surgery. Despite this, individuals who get early physiotherapy after surgical stabilisation benefit.

Proximal Forearm 

Fractures of the proximal forearm are uncommon but can occur at any age. There are intra- and extra-articular fractures of the olecranon (cave: Monteggia fracture). Intra-articular step-offs are accurately decreased and fixed [17]. The majority of proximal radius fractures are extra-articular radial neck fractures. Although the proximal radial growth plate contributes only a minor fraction of total longitudinal growth, realignment of the growth plate up to the tenth year of life can result in significant rectification of axial errors (up to 50°) [18]. In older children, axial deviations exceeding 20 degrees necessitate closed reduction, such as ESIN [19]. Elevation using the joystick approach may result in the rupture of the final remaining blood-supplying periosteal connection. Open reduction is required for total dislocation of the radial head [20]. Fractures of the intra-articular head only occur when growth is complete.

In some instances, physiotherapy may even be counterproductive in the treatment of elbow injuries. This is a trait shared by all elbow ailments. Chronic physeal separations, periarticular calcifications and persistent movement limits have been recorded, however they must be separated from sporadic, unaffected aseptic bone necrosis.

Biceps Shaft 

The vast majority of greenstick fractures occur in the forearm. In up to 30 percent of instances, bone refractures within twelve months due to unequal fracture healing. If the concave side is cracked therapeutically (risk of instability) or if the convex side is crushed, the likelihood of refracture is reduced. If forearm fractures are decreased without operational stabilisation, there is a substantial risk of redislocation (up to 50 percent). Therefore, these fractures should be treated with ESIN in patients older than 3 years [21]. This minimally invasive surgical procedure delivers optimum therapeutic outcomes with a low rate of complications [22]. Greenstick and complete fractures may impede pronation and supination of the forearm because of alterations in skeletal geometry [23]. Therefore, post-traumatic axial malalignments should be treated.

In the Monteggia fracture, a fracture of the ulna (completely displaced shaft fractures, bowing fracture, olecranon fracture) is accompanied by dislocation of the radius head. Despite several accounts of this combined injury in the medical literature, the radial head dislocation is frequently neglected [24]. Therefore, in every patient with a diaphyseal or metaphyseal ulnar fracture, dislocation of the head of the radius must be aggressively ruled out. On every radiographic projection, the neck of the radius is aligned with the capitellum's centre. Fresh radial head dislocations require just axial correction, occasionally followed by ulnar osteosynthesis, whereas the treatment of old dislocations is complex, requiring angulation osteotomy of the ulna and is prone to problems [25].

In the case of a fracture, the first step in treatment is always to alleviate the pain. A forecast of future development is a crucial foundation upon which to build a treatment strategy. The paediatric traumatologist's skill set should include both non-surgical and surgical approaches, as these are complementary rather than competitive.Incorrect assessment of growth potential, misinterpretation of radiographs and technique errors account for the vast majority of cases of poor treatment of elbow joint ailments.Angulated distal forearm fractures have a high possibility for correction compared to non-angulated distal forearm fractures, however axial malalignments after forearm fractures lead to lasting deficits of pronation and supination if left untreated.

1. Marzi, I. Editor. Kindertraumatologie. Steinkopff, 2006.

2. Jones, I.E. et al. “How Many Children Remain Fracture Free during Growth? A Longitudinal Study of Children and Adolescents Participating in the Dunedin Multidisciplinary Health and Development Study.” Osteoporosis International, vol. 13, 2002, pp. 990-995.

3. Wilkins, K.E. “Principles of Fracture Remodeling in Children.” Injury, vol. 36, suppl. 1, 2005, pp. A3-A11.

4. Jacoby, S.M. et al. “Pediatric Elbow Trauma: An Orthopaedic Perspective on the Importance of Radiographic Interpretation.” Seminars in Musculoskeletal Radiology, vol. 11, 2007, pp. 48-56.

5. Aitken, A.P. and H.K. Magill. “Fractures Involving the Distal Femoral Epiphyseal Cartilage.” Journal of Bone and Joint Surgery. American Volume, vol. 34, 1952, pp. 96-108.

6. von Laer, L. et al. Frakturen und Luxationen im Wachstumsalter. 5th ed., Thieme, 2007.

7. von Laer, L. and R. Kraus. “Die Konservative Behandlung von Frakturen der Langen Röhrenknochen im Wachstumsalter.” Unfallchirurg, vol. 109, 2007, pp. 811-823.

8. Slongo, T.F. “The Choice of Treatment According to the Type and Location of the Fracture and the Age of the Child.” Injury, vol. 36, suppl. 1, 2005, pp. A12-A19.

9. May, G. and A. Grayson. “Towards Evidence-Based Emergency Medicine: Best BETs from the Manchester Royal Infirmary. BET 3: Do Buckle Fractures of the Paediatric Wrist Require Follow-up?” Emergency Medicine Journal, vol. 26, 2009, pp. 819-822.

10. Baharuddin, M. and I. Sharaf. “Screw Osteosynthesis in the Treatment of Fracture Lateral Humeral Condyle in Children.” Medical Journal of Malaysia, vol. 56, suppl. D, 2001, pp. 45-47.

11. Shamsuddin, S.A. et al. “Crossed-Pin versus Lateral-Pin Fixation in Pediatric Supracondylar Fractures.” Medical Journal of Malaysia, vol. 56, suppl. D, 2001, pp. 38-44.

12. Ursei, M. et al. “Surgical Treatment of Radial Neck Fractures in Children by Intramedullary Pinning.” Acta Orthopaedica Belgica, vol. 72, 2006, pp. 131-137.

13. Kraus, R. “Oberarmschaftfrakturen im Wachstumsalter.” Unfallmedizinische Schriften der Landesverbände der gewerblichen Berufsgenossenschaften, vol. 106, 2005, pp. 131-142.

14. Jacoby, S.M. et al. “Pediatric Elbow Trauma: An Orthopaedic Perspective on the Importance of Radiographic Interpretation.” Seminars in Musculoskeletal Radiology, vol. 11, 2007, pp. 48-56.

15. Linhart, W.E. “Schultergürtel und Oberarm. Das Verletzte Kind - Komplikationen Vermeiden, Erkennen, Behandeln.” Edited by L. Laer, Thieme, 2007, pp. 41-48.

16. Gicquel, P.H. et al. “Olecranon Fractures in 26 Children with Mean Follow-up of 59 Months.” Journal of Pediatric Orthopaedics, vol. 21, 2001, pp. 141-147.

17. Malmvik, J. et al. “Fracture of the Radial Head and Neck of Mason Types II and III during Growth: A 14-25 Year Follow-up.” Journal of Pediatric Orthopaedics B, vol. 12, 2003, pp. 63-68.

18. Waters, P.M. and S.L. Stewart. “Radial Neck Fracture Nonunion in Children.” Journal of Pediatric Orthopaedics, vol. 21, 2001, pp. 570-574.

19. Yarar, S. et al. “Stark Dislozierte Radiushalsfrakturen nach Minimal-Invasiver Joystick-Reposition und Prévot-Nagelung.” Unfallchirurg, vol. 110, 2007, pp. 460-466.

20. Schmittenbecher, P.P. et al. “Delayed Healing of Forearm Shaft Fractures in Children Following Intramedullary Nailing.” Journal of Pediatric Orthopaedics, vol. 28, 2008, pp. 303-306.

21. Qidwai, S.A. “Treatment of Diaphyseal Forearm Fractures in Children by Intramedullary Kirschner Wires.” Journal of Trauma, vol. 50, 2001, pp. 303-307.

22. Weinberg, A.M. et al. “Which Axial Deviation Results in Limitation of Pro- and Supination Following Diaphyseal Lower Arm Fracture in Childhood.” European Journal of Trauma, vol. 27, 2001, pp. 309-316.

23. Kemnitz, S. et al. “Radial Head Dislocation with Plastic Deformation of the Ulna in Children: A Rare and Frequently Missed Condition.” Acta Orthopaedica Belgica, vol. 66, 2000, pp. 359-362.

24. Günther, P. and L.M. Wessel. “Korrektureingriffe nach Ellenbogennahen Frakturen.” Unfallchirurg, vol. 105, 2002, pp. 478-482.