The Skeletal System

Question 1

Naming to bone in the skeleton

Answer 1

Skull

Orbit

Maxilla

Mandible

Clavicle

Sternum

Ribs

Humerus

Lumbar vertebra

Radius

Iliac crest of pelvis

Ulna

Sacrum

Metacarpal

Carpal

Phalanges

Femur

Patella

Fibula

Tibia

Tarsal

Metatarsals

Phalanges

Question 2

Bone type

Answer 2

Long bone- length exceeds diameter eg femur or humerus

Short bones - length approximates to the diameter eg carpal bones

Flat bones - sandwich structure eg carnival bones and ribs

Irregular bones- vertebrae or mandible

Question 3

Function of bone

Answer 3

Support

Leverage

Protection

Blood cell production (red marrow)

Storage of lipids (yellow marrow) and minerals eg calcium and phosphate

Question 4

Bone anatomy

Answer 4

Adult

Diaphysis
Metaphysis

Child 
Diaphysis
Metaphysis
Physis (growth plate)
Epiphysis

Question 5

Bones in childhood

Answer 5

Key features

Growing- length, densisty, strength

Softer

Thinner

Lighter

More cartilage

Question 6

Bone growth

Answer 6

There are two periods of rapid growth in children

The first two years of life

Puberty

Question 7

One growth

Answer 7

Bone is a dynamic tissue that is built up and broken down in a continual process by the following cells

Osteoblasts - makes vine, lays down osteoid (soft bone) that then Beyoncé’s mineralised (hardened)

Osteocytes - mature osteoblasts that can repair and remodel bone

Osteoclasts - are multi- uncleared cells which resort bone during growth and healing

Question 8

Bone mass

Answer 8

Bone mass refers to the weight of a bone

Peak bone mass is from 19-25

Final height is when you stop growing

Fracture zone is when you start to become weaker from 50 years to death

Question 9

Osteoporosis

Answer 9

Bone mineral density or bone density: is a measurement of the weight and volume of a bone, which gives the density of a bone

Density = mass/ volume

Bone density is determined by a DEXA scab
(Dual energy X ray absorptiometry)

Low mineral density is know as osteoporosis And means that bones are prone to fracture and take longer to heal

Question 10

Osteoporosis

Answer 10

Osteoporosis in children is usually seen in association with

Chronic medical conditions:
Cerebral palsy, juvenile idiopathic arthritis, osteogenesis imperfecta

Medications:
Anticonvulsant medication, corticosteroids and some cancer treatments

Question 11

Bone growth determinants

Answer 11

Hormones that effect bone growth include

Growth hormone: drives the growth of bones until the adult size is reached

Thyroid hormone: required for skeletal development and peak bone mass

Testosterone: increases bone density

Oestrogen: are needed for maturation of the skeleton

PTH, vitamin D and calcitonin: all impact on Ca metabolism and bone growth

Question 12

Bone growth determinants

Answer 12

Environmental and life style effects on bone growth include

Good nutrition including calcium, protein, vitamins and minerals are required to produce strong bone growth

Vitamin D is necessary for calcium uptake

Exercise helps increase bone density and effects bone shape

Long term disease can stunt growth (see previous slides)

Question 13

Fractures in children

Answer 13

Fractures are normal part of growing up

Accidental fractures are common in children

• up to 66% of boys and around 40% of girls will sustain a fracture by their 15 th birthday
• 3.5% of children sustain a fracture each year in the UK

However they can also be indicative of abuse

Abusive fracture indicate a serious assault on a child

80% of abusive fractures are in children under 18 months

Question 14

Fractures in children

Answer 14

Children have a greater proportion of cartilage in their bones than adults

A child bone structure is significantly more flexible than adults

Children bones are thinner and less dense than adult bones

This means that in the event of a fracture the bone will bend and splinter rather than snap

Question 15

Childhood fractures and NAI

Answer 15

Non accidental injury’s should be consideration in all children with fractures, particularly so in children less than 18 months of age

Multiple fractures are more suspicious of abuse

The dating of fractures is an one act science

Question 16

Hold hood fractures and NAI

Answer 16

Need to think of other children in the family. Studies suggest that up to 12% of household contacts aged less than two may have a positive skeletal survey, with twins being a particularly high risk

Question 17

Fracture types

Answer 17

Closed (simple)

Open (compound)

Single- horizontal, oblique, spiral

Comminuted- multiple

Green stick - partial fracture

Torus- compression of cortex

Bowing- longitudinal force applied to bone

Question 18

Presentation

Answer 18

Usually there is a clear history of the incident being witnessed

Sometimes there is no history as the event may not have been witnessed

Fractures in very young children may present with non-specific symptoms and my only be revealed by X-ray

Once the fracture is identified does the fracture match the history

Question 19

Investigations

Answer 19

Plain X-ray

First line of investigation when there is a suspected accidental fracture

Fractures may not be obvious on X-ray immediately after the injury; they are easier to identify once the bone show some signs of healing

Question 20

Investigations

Answer 20

Skeletal survey

considered when there is suspected non accidental injury

This is a series of plain X-rays of all the bones in the body

Repeat skeletal survey images 11 to 14 days later may show healing fractures not originally visible

Question 21

Investigations

Answer 21

Radionuclides bone scan

Considered when there is suspected non accidental injury

This is a radionuclide bone scan uses a radioisotopes to identify a hot spot indicative of healing reaction at the site of a fracture

As skeletal surveys and bone scans can miss different fractures, consideration should be given to performing both in cases of NAI

Question 22

Management

Answer 22

Pain relief - analgesia and immobilisation

Immobilisation- splinting, back slab, full plaster cast

Reduction - if bones are misaligned then they might be able to be put back in place

Surgery- if the fracture is severe, surgery may be needed to realign and fix the broken bones with insertion of metal wires, plates, screws or rods

Question 23

Home healing

Answer 23

1 day - haematoma formation

3 days - inflammation

1 week - soft callus - granulation, matrix

3-6 weeks - callus - ossification, woven bone

8 weeks+ - re-modelling - absorb/deposit, strength, lamellar the bone

Question 24

Complications

Answer 24

Healing in an abnormal position- children have a greater capacity than adults for remodelling

Infection- more likely in open fractures

Vascular and nerve injury - usually from the fracture, but also needs to be monitored for if a plaster has been applied

Bone necrosis- damage to nutrient artery and reduced blood supply

Delayed healing- usually secondary to other issues such as infection or pre-existing bone disease

Abnormal growth- stunted, extra or curving growth eg due to damaged epiphyseal plate, this is rare

Non union and fat embolism - both rare in children

Question 25

Functional recovery

Answer 25

Bone fracture healing times vary considerably

The age and general health of the child

The bone affected as week as the type of bone

The type of fracture

Other aspects of the injury e.g infection

Fractures heal faster the younger the child - in a long bone repatriation return to full function may take 6 months

Question 26

Summary

Answer 26

Fractures in children are common and mostly are accidental

Need to consider if the history matches the findings

If NAI is a suspected children social care will need to be involved

Childhood fractures and stages of bone healing are important knowledge to have when speaking to families when a child has a fracture