Fractures

• Fracture is defined as a break in the continuity of bone.
• Children are not little adults. Paediatric bones are more elastic than adults. Their bones deform for a slightly longer time before they break. The injury patterns vary, in contrast to adults, and within the different paediatric subset, depending on skeletal age.
• Partial injuries are peculiar to children – called Greenstick fractures. These are incomplete fracture patterns. These fractures do not traverse the entire cortical thickness as the unbroken part undergoes just a plastic deformation.
• Fracture healing follows a similar pattern but is much faster than adults as the dynamics of blood supply are better.  Attempts to re-align the fractures (manipulations) are easier within two weeks from injury as the fractures would begin to mal-unite in the deformed position after that period.
• The fundamental difference in the anatomy of growing bones to adult bones is the presence and injuries around the growth plates or physis (plural - physes). Physeal fractures can result in growth abnormality if not managed appropriately - there is a low threshold for surgical intervention.
• All fractures in children should raise the possibility of Non-Accidental Injury (NAI).

NON – ACCIDENTAL INJURIES (NAI) and FRACTURE

In the context of fracture, suspect NAI if there is:

• Any fracture before walking age.
• Inconsistent history (i.e., the history 'doesn’t fit' the injury pattern).
• Inconsistent explanations (between parents /carers).
• Delayed presentation.
• Bruising patterns on the child.
• Long bone injury with head injury.
• Retinal haemorrhages.
• Misfitting fracture patterns such as :

• Transverse fracture in long bone.
• Metaphyseal corner fractures / Bucket handle fracture also known as Classical Metaphyseal Lesion.
• Rib fractures (Posterior ribs or at costochondral junctions).
• Skull fractures (depressed skull fractures or non-parietal skull fractures).
• Fractures at varying stages of healing on skeletal survey.

Priority is to place the child in a safe environment (i.e., admit the child to the ward) and seek assessment of a paediatrician to exclude life threatening injuries, nutritional status and social circumstances, to rule out sexual abuse and ensuring safety of the child.

This information is in accordance with NICE guidance on safeguarding.