Pathologic fractures are relatively common in children. Fractures frequently occur through osteopenic bone in children with neuromuscular disorders and through bone weakened by tumors.
Be concerned if the trauma required for fracture is less than normal. Normal infants and young children’s bones can fracture with simple falls. Usually a history and screening examination will separate normal children from those with underlying osteopenic problems.
Treatment of Pathologic Fractures
Generalized disorders include those that decrease or increase bone density. Manage fractures through osteopenic bone in children with conditions such as cerebral palsy, spina bifida, osteogenesis imperfecta with a minimum period of immobilization because mobilization increases deossification and increases the risk of additional fractures. Dysplasias increase bone density and may also be prone to fracture.
Cast treatment for conditions such as developmental hip dysplasia increase the risk of fracture. The period of greatest vulnerability is shortly after cast removal, as joints are stiff and bone is weakened by immobilization.
Benign bone lesions are often the sites of fracture.
Small localized tumors If the lesion is small and the trauma significant, immobilize in a cast until union has occurred. Usually, it is best to allow the fracture to heal and then deal with the lesion. For larger lesions, especially those involving the upper femur, stabilization and bone grafting may be necessary.
Fibrous dysplasia Consider early augmentation with a flexible intramedullary rod to increase bone strength and reduce the risk of fracture. This treatment usually shortens the period of convalescence.
Unicameral bone cysts Most cysts should be allowed to heal and then be managed. Those of the upper femur require special consideration. Most require internal fixation to prevent malunion. Graft and fix during the same operative session. Avoid threaded or large fixation across any growth plate in the child under age 8–10 years. Smooth K wires may be applied across the proximal femoral physis. Bend the pins over to avoid migration.
Nonossifying fibromas are common sites of fractures. If they involve more than 50% of the transverse bone area, they may require grafting.
Malignant tumors Be most concerned about missing a fracture through a malignant tumor such as an osteogenic sarcoma. Ask if the child or adolescent had night pain before the fracture. Night pain is often an indicator of a malignant tumor. Carefully review the radiograph with attention to the character of the bone. Early identification of the pathologic aspect of the fracture is the primary concern.