Injuries Unique to Children

Injuries unique to children include the following:

Pulled elbow

A straight pull on the arm of a child under the age of 4 years, if forceful enough, is likely to result in a ‘pulled elbow’.

• This is unique to children because the relatively small, immature radial head is able to sublux under the relatively lax annular ligament
• Classic presentation is with the arm usually held straight or slightly flexed and resisting passive movements of flexion but particularly pronation and supination
• A simple manoeuvre reduces the subluxation without the need for any investigation
• If x-rayed, the elbow will appear normal. A large gap is apparent between the epiphyses of the proximal radius and the capitellum, normally because they are not fully ossified
• Children grow out of this condition as the radial head develops and it is said to be very unusual after the age of 4 years, and not to be seen at all after the age of 6 years

Toddlers fracture

This is unique to children due to the mechanism of injury and soft malleable bone. The toddler, still learning to walk, is relatively unsteady on the feet. A fall with the foot planted firmly on the floor will lead to a rotational force as the child falls. Management of toddler fracture would not necessarily require a POP – mostly indicated for pain relief/mobility, can often be managed conservatively.

• An undisplaced spiral or oblique distal tibial fracture is characteristic
• These are often very difficult to see on initial x-ray. Sometimes they’re even invisible
• X-ray at 10 days often shows the healing fracture, soft tissue swelling and/or periosteal reaction. Management is then simple, with long leg POP for 2-3 weeks sufficient if required for pain control.
• These are a differential diagnosis to consider in the presentation of the ‘limping child’

Tillaux fracture

This is an uncommon fracture, unique to adolescents because the distal tibial physis fuses from the lateral to the medial side. Beyond 16 years, the physis is closed and these injuries are not seen.

It occurs in the ankle of the young person (between a narrow window of 14-16 years only) when a forced hyper-flexion and/or supination occurs at the ankle.

The fracture extends from the tibial diaphysis through the distal tibial physis anteriorly (SH II), but also medially out through the physis (SH II) and inferiorly through the epiphysis (SH III). This component is therefore intra-articular.

Caution is required with Tillaux fractures because the Ottawa ankle rules applied to these injuries can miss them. This is because it is not uncommon for the patient to be able to weight bear and the defined bony points are non-tender. The tenderness is usually elicited at the anterior ankle joint line which Ottawa does not describe.