If after even a mild injury a growing child refuses to use his/her upper limb or place full weight on his/her lower limb, there is usually a fracture.
Limb fractures in children do not necessarily show any signs of external injury.
X-ray is the first-line investigation to diagnose fractures.
Treatment decisions depend on the location, type and alignment of the fracture and the stage of the patient's growth.
Analgesics, casting and closed or open reduction can be used for treatment.
The possibility of abuse should be kept in mind.
Clinical examination
Whenever limb injury is suspected, both limbs should be completely exposed for comparison.
Small children should be held by a parent or caregiver when examined.
Is there malposition, oedema, bruising?
Examine the skin colour, warmth, circulation and sensation in the lower part of the limb.
Examine the healthy limb first. If you suspect a fracture, do not examine the range of joint movement on the injured side but first take a targeted x-ray.
Range of movement can be examined if no fractures can be seen on x-ray and joints are in correct position or a fracture is highly unlikely based on patient history.
Treatment
Not all children's fractures are visible on x-ray. Nevertheless, treatment should be started as for a well-aligned fracture if there is no other cause for the symptoms and there is a history of an evident injury.
The fracture should usually be reduced if it causes visible malposition of the limb.
Fractures involving a joint are often treated surgically.
Fracture alignment should be checked by x-ray, as necessary. Follow-up x-rays of incomplete fractures (bowing fracture, torus fracture) are unnecessary; this usually also applies to fractures treated surgically.
Healing of fractures in growing children can most reliably be assessed clinically. X-rays to assess ossification are rarely justified.
Fractures in children can be divided into four treatment classes.
Class 1. Fracture alignment is acceptable and cannot change or, alternatively, a change would be of no significance. Class 1 fractures need not be checked by a physician; the parent or caregiver can remove the plaster cast, collar cuff sling or bandage after the agreed time.
Class 2. Fracture alignment is acceptable but may become worse, and should this happen, the fracture needs to be realigned. Checkup visit and x-ray are necessary.
Class 3. Fracture alignment is unacceptable, and the fracture must be realigned. Checkup visit and x-ray are necessary.
Class 4. Fracture alignment is unacceptable and cannot be sustained reliably without fixation. The fracture is treated surgically.
Fractures belonging to treatment classes 1 and 2 can be treated in primary health care. For class 2 fractures, a paediatric orthopaedist should be consulted during the week.
In older children, it may be possible to realign class 3 fractures under local anaesthesia in primary health care. A paediatric orthopaedist should be consulted after realignment.
For younger children, realignment should be done under nitrous oxide or general anaesthesia.
Treatment class 4 patients should be treated under general anaesthesia in specialized care.