D. INJURIES TO THE SKELETON OF THE CHILD (FRACTURES) These are usually caused by tumbles and falls. The external force, either the weight of the tinny in hitting or a force acting from outside (uterine nuiscles, obstetrical operations, muscular strength of others at play), will meet many conditions in the ehild's skeleton which differ materially from t hose met with in adults.
Tlw bone is soft and elastic and it carries, especially in its end.:, cartilaginous discs which give way to traction and bending. This is most likely the reason why we hardly ever observe luxations in children and why fractures are also rarer than in adults.
Falls down a whole flight of stairs, in which an adult would surely bleak several bones, can be sustained by the child often without suffering any damage.
The rigid lever of the adult is lifted and pushed more easily out of its socket by certain forces, while the young 1)011' will bend and finally break at the place of the severest strain rather than being loosened from its joint.
Intraperiosteal fractures take the place of dislocations in children.
Another peculiarity of injuries to bones in children deserves special mention here, concerning which many erroneous views prevail in the text-books, namely, epiphyseolysis (loosening of the epiphyses).
As soon as a child had a break in the continuity of a bone near a joint we used to speak of epiphyseolysis. We flint minute directions how to diagnose these; for instance, cartilaginous crepitation was said to indicate an epiphyseolysis. Still this was a mistake in the majority of cases, as among 1000 fractures which we had occasion to examine in the last ten years we were able to find only two true eases of epiphyseolysis.
One was in a girl of four years, whose leg had been caught in the wheel of a heavy truck, by which it was dragged. The leg was twisted out, we may say, and finally almost severed in the middle of the thigh by being run over by a heavily loaded wagon. After amputating, this being indispensable, we found besides the fracture in the diaphysis a loosening of the lower epiphysis of the femur.
The second case, in which we made a tentative diagnosis of loosening of the same epiphysis, happened in the following manlier: A boy was caught up to his knee in a pile of logs and fell forwards. We made the
diagnosis of epiphyseolysis because we were not able to find a line of fracture in the skiagram, but the nucleus of ossification in the epiphysis of the femur appeared to be dislocated and we noticed crepitation.
We will see from these two cases that it always requires tremendous force to produce this separation, and that it is more a tearing-off than a fracture. The anatomical conditions also favor this. The periosteum is especially thick around the epiphyseal cartilages, so thick that Reiner has to cut it first to get a separation in the epiphyseal line in his opera tive epiphyseolysis.
We have personally gained the impression in more than one hundred epiphyseotomies (see Germ valguni) that the cuff of periosteum around the epiphysis is very strong and solid. From this it follows that when certain forces hit the bone it will break much sooner in the nearest weaker tissues, and these we find in the last formed osseous tissue of the metaphysis, which is still soft. We find the fractures in the neck of the humerus, the end of the radius, and the end of the femur as in adults, and skiagraphic diagnosis shows us that a piece of the metaphysis will always be united with the broken-off epiphysis, as has been stated before by French authors (Broca, Curtillier).
We can frequently observe hemorrhages into the epiphyseal zone without any the periosteum; and Trumpp reports one such case in which inflammatory processes followed the trauma.
Kirmisson, who wants to call every epiphyscolysis in and near the cartilaginous border "d6collement 6piphysaires," can give only very few clear eases. Ile observed that separation of the lower epiphysis of the femur happens in the same as we have described above "when children steal a ride on the back of a wagon or get their foot in a wheel, also when they fall forwards or sideways with the leg caught up to the condyles." Epiphyseolysis at the upper end of the humerus is very rare in children. Only in pathologic conditions of the epiphyseal line, syphilis or suppura tion in the joint, were these observed. In other cases of suspected epi physeolysis the skiagram showed a fracture near the surgical or ana tomical neck.