We rarely see an epiphyseolysis in injuries to the elbow. Here we usually get multiple fractures with overlapping of the lines of fracture, which may follow once in a while the complicated epiphyseal line in the elbow, at least partially.
Most frequently epiphyseolysis is reported in the lower end of the radius. Careful examination of the skiagrams in all our cases showed that we always had to deal with one of those typical fractures of the radius which are so frequent in adults; from falls upon the bent or stretched hand, in the shorter bone of the child the line of fracture will naturally be much nearer the epiphyseal line.
A true of the upper end of the femur is also very rare. In most cases the skiagram will show us a fracture in the neck of the femur, which may at times be near the epiphyseal line. Kirmisson collected some cases from the literature. Royal Whitman claims that coxa vary is often due to injuries in the epiphyseal Taking all cases together, we will see that epiphyseolysis is of very rare occurrence and that only the skiagram gives us a right to speak of a true epiphyseolysis (two cases in 1000 fractures in our series).
In the cases of which we know, tremendous forces were always in action, and it was more of the nature of a pulling out or tearing off of the ligaments, which are closely united with the periosteum at the ends of the joints and which will sooner cause an avulsion of the epiphysis in the nietaphysis than that its own elastic tissue should tear.
The treatment of epiphyseolysis is identical with that of intra articular fractures.
We must now mention still another peculiarity of the bones of chil dren, namely, the incomplete and subprriosteal fractures. The bone may break or crack inside the thick tight periosteum like a willow-switch cracks without tearing its bark (en boil vest) (Fig. 151a, Plate 16).
In some cases only one of two parallel bones (tibia and fibula) may be cracked without being bent or in the least displaced. Inside the periosteal tube of, let us say, the tibia may be an oblique fracture and still we will not be able to observe any displacement because the fibula is intact. Only a skiagram taken in different planes will show us the line of fracture and will explain why the child complained of pain at every step (Fig. 151b, Plate 16).
Hemorrhages into the very vascular epiphyseal zone are still more frequent; these we recognize by their dark shadow on the skiagram.
These peculiarities of the bones of children make the diagnosis quite difficult, the more so as all other signs may be lacking as long as the periosteum is intact—such as changes in shape, displacement, and crepitation. Only skiagraphy will enable us to recognize such injuries
to the bones, which we were formerly only able to suspect from the pain and swelling.
We must always think of this as a possibility when children refuse for any length of time to use a limb, especially if they do not use it when we distract their attention from the injury or even when they are at play.
The treatment of these fractures does not differ in any way from that of the complete ones, for the simple reason that we usually change the incomplete fractures into complete ones when we correct the bend in order to avoid bad positions.
We do not advise to make this last a rule: if we should, for instance, be able to reduce the infracted bones in the forearm without tearing the periostcum, then we must naturally do so, because it will surely hasten recovery and keep down the formation of callus.
The subperiosteal fractures without dislocation and the epiphyseal hemorrhages require nothing more than fixation or keeping off the weight.
The treatment of fractures is in general much simpler and easier in children than it is in adults. The thick periosteum which is usually partially intact prevents any considerable dislocations, nor are the muscular tractions quite as strong and are, therefore, easier overcome than in adults. The tendency to heal is also much more intense in the child, so that we can as a rule count the time of union and of treatment one-third less than that of the adult. Only a simultaneous rachitis may interfere, and in its Horid stage it may either shorten the time of healing or it may prevent healing altogether. The scar in the hone remains soft until the rachitis is cured, then only will it heroine solid.
The majority of the very angular rachitie deformities are most likely due to this and arc the results of injuries to the bones which we call "spontaneous fractures." The less the power of resistance of the bone the smaller will be the force which is requir'd to produce an infraction or a fracture (Fig. 152 and Fig. 153, Plate 14). A slight push, a jump, even a sudden strung contraction of a muscle will suffice to break completely the bone which is already bent.
Any process which softens the bone will have this effect: rachitis, osteopsathyrosis, osteomalaeia, atrophy of the bone through disuse (in paralyses and inflammations), and finally that condition of brittleness of the bones which we call osteogenesis imperfecta and by which the number of fractures in one individual may mount up to incredible figures.