SKELETAL TRAUMA IN CHILDREN: OVERVIEW
The concepts of skeletal system injuries in children are quite different from those of adults. Children at different stages of development have varying responses of the skeletal system to trauma. Most of the anatomic and physiological features of the pediatric skeletal system result in a diminished propensity for serious skeletal injuries in comparison to adults.
The muscles, tendons, and ligaments of children are more resilient and forgiving of injury than are those of adults. The forces associated with accidents in young children are usually not great, in part because the leverage is reduced by the relatively small size of the extremities. Another important factor is the variation in bone composition at different ages. The presence of growth centers in the child also modifies the skeletal response to injury. Injuries to the immature skeleton carry the important potential for subsequent growth disturbances.
The skeleton of the young child is more pliable than that of adults, principally because the Haversian canals at this age are relatively large and contain more water. A proportionately lower mineral content in growing bone than in the mature skeleton is an additional, but less important, factor. These properties impart greater elasticity and plasticity to the bone.
The periosteum is thicker, more elastic, and less firmly attached to the bone in children than in adults. When injured, the periosteum of the child is likely to remain intact and attached to the fracture fragments. The periosteum provides a hinge-like mechanism between the fracture fragments and thereby aids in fracture reduction and stability; fracture nonunion is rare in children.
The changes in activity that tend to occur at different ages with normal growth and development greatly influence the types of skeletal injuries that occur in children. Child abuse is an important cause of skeletal injuries in infants and toddlers. Falls are the most common mechanisms of injury in ambulatory children. Outstretched arms usually dampen falls; this diminishes the impact to the head, but increases the likelihood of injuries to the elbow and forearm. The radius is the most commonly fractured bone in children. Clavicle fractures are also common, usually due to the transmission of force from an impact against the shoulder. Although falls most often lead to injuries of the upper extremity, exceptions occur when the child falls backward with substantial force. These falls carry a greater risk for skull fractures and intracranial injuries. In infants, intentional injury is an important cause of skull fractures.
Bicycle accidents, skateboard injuries, contact sports injuries, motor vehicle crashes, and pedestrian accidents are common in adolescents and older children. The types of injuries that are associated with these mechanisms of trauma are much like those identified in adults. Many sports activities are associated with relatively specific types of musculoskeletal injuries in the immature skeleton.