Fractures
Definition
A fracture is a break in the continuity of bone.
Children are not “small adults”
Paediatric bones are more elastic than adult bones. They can deform for longer before breaking, leading to different fracture patterns at different ages. Healing is also typically faster, reflecting better blood supply and ongoing growth.
Unique features of childhood fractures
- Greenstick fractures: incomplete fractures where one side of the cortex breaks and the other bends
- Growth plate (physeal) injuries: unique to children and may lead to growth disturbance or deformity if not managed appropriately
- Timing of reduction/manipulation: realignment is usually easiest in the first two weeks before malunion becomes established
Safeguarding consideration
All fractures in children should prompt consideration of non-accidental injury (NAI), particularly when the history is unclear, the mechanism does not fit the injury, or the child is very young.
When to suspect non-accidental injury (NAI)
- a fracture in a non-walking child
- inconsistent or changing history, or mismatch between injury and explanation
- delayed presentation
- conflicting accounts from carers
- concerning bruising patterns
- long bone fracture with head injury or retinal haemorrhages
Fracture patterns suggestive of NAI
|
Pattern |
Notes |
|
Transverse long bone fracture |
Unusual in accidental injury |
|
Metaphyseal corner / “bucket handle” fracture |
Also known as a classical metaphyseal lesion
|
|
Posterior rib fracture |
Often at costochondral junctions; associated with squeezing injury
|
|
Depressed or atypical skull fracture |
Especially non-parietal skull fractures
|
|
Fractures at varying stages of healing |
Seen on skeletal survey; highly concerning
|
Clinical priorities
Where NAI is a concern, priorities include ensuring the child is safe and completing a thorough assessment. This may involve admission to a safe setting, full paediatric review to exclude other injuries, and consideration of nutrition, development and social circumstances. Safeguarding procedures should be followed, with awareness that abuse may be physical, emotional, sexual, or related to neglect.
This approach aligns with NICE guidance: when to suspect child maltreatment.
