Broken bones in children - not so bad after all

The new inline skates have finally arrived. Lina wants to try them out straight away. She proudly shows her parents what she can do. As she rounds the bend, however, she loses her balance and falls. Her parents run to her. The ten-year-old has an abrasion on her knee and her wrist hurts. «My hand hurts so much,» she says, crying. Her father fetches a cold pack. Lina slowly calms down, but the pain doesn't subside.

«The so-called radial fracture of the wrist is one of the most common fractures in children,» says Thomas Dreher, Head of Paediatric Orthopaedics and Traumatology at the University Children's Hospital Zurich. It affects different age groups of children, including adolescents. Fractures to the forearm, shin or ankle are also not uncommon in teenagers. «In younger children, we often see injuries close to the elbow, i.e. fractures to the upper and lower arm, but also fractures to the lower leg,» explains Dreher.

Adolescents aged between 15 and 18 suffer more than twice as many bone fractures as small children.

Kristina Keitel, Chief Physician

According to Kristina Keitel, Chief Physician and Co-Head of the Emergency Centre for Children and Adolescents at Inselspital in Bern, fractures are related to life stages. «Injuries begin in infancy, when children learn to move, and then increase with sporting activity. Fractures are particularly common in adolescents.»

This is also shown by the figures from the German KiGGS study. Young children usually fall from a height, but only around ten per cent suffer a fracture. In contrast, adolescents aged 15 to 18 suffer more than twice as many fractures.

When a hernia is diagnosed, children and parents often get a fright. However, there is usually no reason to panic. This is because fractures heal quite quickly at a young age and complications are rare. But how are fractures treated and what should parents be aware of?

Soothe and cool first

As Lina's wrist is still hurting, her father calls the paediatrician. She asks what has happened and whether Lina can move her hand. After a brief conversation, she advises Lina's father to go to the paediatric emergency centre to have her arm x-rayed.

«Many paediatricians no longer have X-ray machines,» says Corina Wilhelm, a paediatric specialist with a practice in Thalwil. «But that's not always necessary. An ultrasound machine is often enough to rule out a fracture.» The paediatrician receives one or two calls a week from parents who are worried that their child may have suffered a fracture. Contacting the paediatrician first is never a bad idea, she says. Even in situations where treatment at a specialist centre is necessary - for example, if a deviation in the axis of the bone is visible from the outside - they can give instructions and help parents register at the centre.

Pain, swelling and limited function in the injured area can indicate a bone fracture. However, these symptoms can also be present in the case of a contusion, which is far more common in everyday practice. The only reliable clinical indication of a fracture is axial deviation, says Corina Wilhelm. And: «Parents should first of all cool the painful area or apply an ointment dressing. If the child is in pain, they can also be given a painkiller such as ibuprofen or paracetamol. Ibuprofen is preferred because it is also effective against swelling.»

The paediatrician treats the majority of broken bones directly at her practice. «I only have to send one in ten children with a broken bone to hospital.» Wilhelm is in close contact with the Zurich Children's Hospital. If she is unsure, she can seek advice there at any time. «A good network is very important in the treatment of fractures in children,» she says.

Scooters and trampolines: falls often happen with trendy sports

Lina and her parents are welcomed at the paediatric emergency centre. «Our priority is to take away the child's fear and pain,» says emergency physician Kristina Keitel. «Only then do we start the examination. What we look for first, especially if there has been a more serious fall, are internal concomitant injuries, i.e. to the abdomen and head,» says Keitel. If these can be ruled out, the actual fracture can be examined. Either with the help of an X-ray or an ultrasound machine. «In the case of small children who may be afraid, the parents can also help and, with our instructions, palpate themselves,» says Keitel. In addition to the usual medication, stronger drugs such as opiates are sometimes given to relieve the pain.

Sometimes a short anaesthetic is necessary when applying the plaster cast to bring the bones back into shape.

Lina's fall while inline skating is a classic, says the emergency physician. «It happens most often in sports that are currently in fashion, such as scootering or trampolining, but also when cycling or skiing.» The ten-year-old's wrist is actually broken. The impact when she was supporting herself was too strong. But Lina is lucky. She has a simple radial fracture in her wrist. It was enough to set the bone in shape under a short anaesthetic in the emergency ward and apply a plaster cast.

«We can treat nine out of ten fractures,» says Keitel. Then either a plaster cast or a splint is applied. Occasionally, immobilisation is not even required. «Sometimes, however, the fracture is complicated and requires surgery, in which case the child is sent to paediatric surgery,» explains Keitel.

In a few cases, surgery must be performed quickly, such as in the case of an ankle fracture. This is because the swelling becomes so severe within six hours that surgery becomes difficult. Or in the case of severe malpositioning in the fracture area, fractures with opening of the skin or fractures with additional injury to nerves or vessels. «The worst thing parents can do on the way to the emergency ward is to stop at the drive-in,» says the head paediatric orthopaedic surgeon. «Because general anaesthesia is simply not well tolerated on a full stomach.»

Sometimes a short anaesthetic is also necessary when applying the plaster cast in order to get the bones back into shape. However, the child does not necessarily have to be fasting. «Nitrous oxide can also be used to relieve anxiety. We have had good experiences with this,» says Dreher. If surgery is required, metal implants are usually used. «These are usually wires, screws, nails or plates,» he says. These are removed again after three to twelve months.

Special features: Green wood fracture and growth joint fracture

What often occurs in children are so-called greenstick fractures. «These are incomplete fractures that are typical at this age,» explains Dreher. «Children's bones are very soft and flexible and are surrounded by an elastic periosteum. The bone may therefore only break.» The conservative method, i.e. plaster or a plaster splint, is also used for treatment.

Another speciality can be the growth plate fracture. In childhood, the growth plates, which are primarily responsible for the longitudinal growth of the bones, are not yet closed. If the bone breaks in this area, this can lead to deformities. But Thomas Dreher gives the all-clear: «If you keep a close eye on a growth plate fracture, you can recognise permanent misalignments at an early stage and intervene if necessary or correct them before adulthood. The aim is to achieve as normal a situation as possible at the end of growth.» Paediatricians are very important for follow-up care, he says.

Paediatrician Corina Wilhelm pays particular attention to the children's motor skills. «After a wrist or elbow fracture, I check how the child uses the affected limb. I also check the mobility in the affected joints and the axes. After a leg fracture, it is very important to check the gait pattern, the leg axes and also the leg lengths. A side-by-side comparison of the muscles and skin is also always included.» Wilhelm also removes the plaster cast after a fracture has healed. «Depending on the age of the child and the location of the fracture, this usually takes three to six weeks. It's quicker for younger children, but takes a little longer for adolescents.»

Children's bones heal very quickly

«Children's bones are very well supplied with blood,» explains Dreher. «This is one of the main reasons why fractures usually heal quickly. In adults, the healing process often takes twice as long.» In the case of more severe fractures, it can also happen that a longer period of rest or physiotherapy is required after the plaster cast has been removed, says Dreher. However, this is rare. While the plaster cast is still on, children should not go into the water with it on, says Dreher. And one more thing is important: never play in the sandpit. «The small grains of sand and the dirt can cause wounds and infections.»

Lina's time has come after just three weeks. The plaster cast comes off today. What began with a big shock has healed quickly. Once again, she looks at all the little drawings of her friends that have been immortalised on the plaster. Finally, the paediatrician cuts open the plaster cast. Lina is beaming. «At last I can go back to the swimming pool,» she says and laughs.