In this section
Skeletal injury in childhood is common, due largely to patterns of childhood play and behaviour. It also has complexities absent in the adult, because the child's skeleton is more flexible than the adult's, and actively growing.
Approximately 15% of extremity fractures in children involve disruptions of the growth plate, which is 2 - 5 times weaker than any other structure in the paediatric skeleton.
The rest of the paediatric skeleton has different mechanical properties, as well as greater plasticity, than that of the adult. This explains the unique nature of some paediatric fractures (i.e. torus fractures, greenstick fractures and plastic deformation) and
the relative infrequency among children of fracture propagation and comminution.
Although the "severity" of fractures is usually less in the paediatric trauma victim than in the adult, it must be remembered that the elastic nature of a child's bones allows a greater level of energy absorption prior to the fracture. This needs to be
remembered, so the degree of the soft tissue trauma associated with a fracture is not underestimated.
Spinal injuries are rare in children, but due to their clinical importance, a high index of suspicion needs to be maintained in trauma situations. This is particularly true of the cervical spine and flexion distraction injuries in the lumbar spine. (
See chapter 1.12 for Spinal Injuries)
In all aspects of trauma management,
the primary survey is the first priority
Limb trauma is rarely life threatening. During the primary survey, only those musculoskeletal injuries that may be life-threatening, due to loss of blood or spinal cord injury are included.
Excluding a significant pelvic fracture is an essential part of any trauma assessment.
An AP pelvis x-ray is required in all trauma patients except in those who are:
This image is required early (with lateral cervical spine) if there is unexplained haemodynamic instability.
If there is any doubt, the pelvis AP X-Ray should be performed as part of the initial trauma series.
Pelvic fractures may be
With the exception of isolated superior or inferior pubic rami fractures, they should all be discussed with the senior member of the Orthopaedic Unit.
Paediatric pelvic fractures rarely require operative fixation, and are only occasionally life-threatening.
They do, however highlight the possibility of visceral, genito-urinary and neurological injury. (see
chapter 1.8 for uretheral injury)
If signs of haemodynamic instability are also present, a PELVIC BINDER or large sheet can be wrapped around the pelvis at the level of the ASIS, and tied tightly to "close the book".
Do not freeze or use dry
Transportation of the patient should
not be delayed to search for amputated parts! Leave word as to
destination, and indicate how to preserve the amputated parts to
the person in charge at the scene of the accident.
Simple Guide Grade 1
<1 cm wound Grade 2 1-10 cm wound Grade 3 >10 cm wound
Included in this will be
All trauma patients require log-roll and assessment of the thoracolumbar spine by inspection and palpation.
The examination should include:
It is important during this stage to identify limb-threatening injuries, including
The cardinal signs of vascular injury are quoted to be:
Unfortunately, the presence of a pulse on Doppler examination, or by palpation, does not exclude the possibility of significant vascular injury. Therefore, constant reassessment must be maintained. The presence or suspicion of vascular injury should be
urgently discussed with a vascular specialist.
Compartment syndrome occurs with injuries producing a rise in the interstitial pressure within a closed (or only partially-opened) osseofascial compartment, to the point that tissue circulation is compromised.
Decide whether the fracture requires reduction.
Always obtain post-reduction X-rays to ensure that the position of the fracture is acceptable in plaster. Always check post-reduction renovascular status. A change should prompt consultation with an Orthopaedic surgeon.
Every child who is to be discharged with a fracture must have appropriate discharge and follow-up arrangements in place.
If a plaster has been applied, verbal instructions regarding plaster care and the dangers of encircling plasters must be given to the parents or guardian. In addition, the "Plaster instructions" Parent Information Leaflet should be given to the parents or
If an encircling plaster has been applied, a plaster check should be arranged for the following day, preferably by the patient's GP. A covering letter to the GP is required.
General practitioner follow-up
Undisplaced greenstick fractures or fractures (such as a fractured middle-third of clavicle), which are unlikely to require further treatment, may be referred to the patient's GP for follow-up.
All other fractures should be followed up in the Fracture clinic. Most fractures should be followed up in 7 days with an Xray performed prior to the clinic.
Ensure the patients have access to adequate analgesia for their child and are aware how to use it.
Right clavicular fracture
a. Middle third Sling for 2-3 weeks.
b. Medial/lateral third - Seek advice.
Surgical neck fracture
a. Surgical neck
Humerus shaft fracture
d. Epicondylar:seek advice.
e. Intra-articular: seek advice.
b. Distal end
Radius and ulna fracture
Check carefully for rotation at fracture site.
Fracture of middle finger
Fracture 1st metacarpel / cuniform /navicular / distal calcaneum