Fractures

Question 1

Growth Plates (Epiphyseal Plates)

Answer 1

Growth plates (epiphyseal plates) are found in the bones of children but not adults. They are the area at the ends of long bones that allow the bones to grow in length. They are made of hyaline cartilage and sit between the epiphysis and the metaphysis. Once the epiphysis and the metaphysis fuse during the teenage years, the growth plates become the epiphyseal lines.

The growth plate is generally stronger than the rest of the bone.

Question 2

Bones in Children

Answer 2

Children have growth plates, whereas adults do not. Children have more cancellous bone, which is the spongy, highly vascular bone in the centre of long bones. Adults have more cortical bone, which is the compact, hard bone around the outside. This makes children’s bones are more flexible but less strong. This makes children prone to “greenstick” fractures, where one side of the bone breaks whilst the other stays intact. Bones in children have very good blood supply and are able to heal much more quickly with less long term deformity compared with adults.

Question 3

Types of Fracture

Answer 3

Buckle (torus)
Transverse
Oblique
Spiral
Segmental
Salter-Harris (growth plate fracture)
Comminuted
Greenstick

Question 4

Fractures at Growth Plate

Answer 4

Fractures through the growth plate can cause issues with growth in that bone. Growth plate fractures are graded using the Salter-Harris classification. The higher the Salter-Harris grade, the more likely the fracture is to disturb growth.

Use the SALTR mnemonic to remember the types:

Type 1: Straight across
Type 2: Above
Type 3: BeLow
Type 4: Through
Type 5: CRush

Question 5

Management of Fractures

Answer 5

lways keep safeguarding in mind when children present with fractures. Does the story make sense? Has this happened before? When there is doubt, discuss the case with a senior and consider a safeguarding referral.

The first principle is to achieve mechanical alignment of the fracture by:

Closed reduction via manipulation of the joint
Open reduction via surgery
The second principle is provide relative stability for a period of time, to allow healing. This can be done by fixing the bone in the correct position while it heals. There are various ways the bone can be fixed in position:

External casts
K wires
Intramedullary wires
Intramedullary nails
Screws
Plate and screws

Pain Management
Pain management in children is slightly different than adults. The World Health Organisation have a pain ladder for children that has only two steps:

Step 1: Paracetamol or ibuprofen
Step 2: Morphine
If a child requires morphine they generally need admission for a serious illness.

TOM TIP: Examiners like to test your knowledge on the pain medications that are not used in children. Codeine and tramadol are not used in children as there is unpredictability in their metabolism, so the effects vary too greatly to make them safe and effective options. Aspirin is contraindicated in children under 16 due to the risk of Reye’s syndrome (except in certain circumstances such as Kawasaki disease).