The periosteum of children's bones is very thick - bones are soft so 'bend or bow' rather than 'snap and splinter'
Greenstick fracture - incomplete fracture
Cortex on the tension side of the fracture fails but the cortex on the compression side of the fracture remains intact
Torus fracture - crease of the bone and periosteum
Plastic deformation - bad bend which stays bent, but isn't obviously fractured
In children it is common for ligaments or tendons to avulse their soft bony attachments
Growth plate allows for rapid healing massive remodelling potential
Children tolerate immobilisation better (shorter rehabilitation)
The growth plate
The growth plate (physis) is a lucency between the epiphysis and metaphysis - can appear similar to a fracture
The physis is the weakest part of a developing bone, so is prone to injury
Growth plate injury may be complicated by growth deformity
The 'Salter-Harris' classification is used to grade growth plate fractures - prognosis is poorer as classification prgresses
Salter-Harris fractures
In normal bones, the epiphysis is always centered on the metaphysis
In Salter-Harris fractures, the epiphysis is not centered on the metaphysis due to a fracture involving the growth plate
Non-accidental injury (NAI)
History
History that does not match the nature or the severity of the injury
Vague parental accounts or accounts that change during the interview - inconsistency
Accusations that the child injured him/herself intentionally
Delay in seeking help
Child dressed inappropriately for the situation
Features
Obvious/supected fractures in a child under 2yrs
Injuries in various stages of healing, especially burns and bruises
More injuries than usually seen in children of the same age
Injuries scattered on many areas of the body
Increased intracranial pressure in an infant
Suspected intra-cranial trauma in a young child
Any injury that does not fit the description of the cause given
Management
Reduce, retain, rehabilitate
Children are more amenable to conservative treatment - plaster, traction, less invasive fixation - due to increased modelling postential
Exceptions to the rule of conservative management in children - displaced intra-articular fractures, displaced growth plate injuries, some open fractures
Plaster of Paris
Diaphyseal fracture - joint immobilised above and below to prevent rotation
Metaphyseal fracture - adjacent joint immobilised
Techniques of fixation
Diaphyseal - flexible nails
Metaphyseal - K wires
Epiphyseal - K wires and screws
External fixation - try and avoid in children where possible
Used in contaminated wounds, acute vascular injury, burns and multiple injuries
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