TOPOGRAPHY AND SYMPTOMATOLOGY We will treat only of those fractures which are especially frequent in children, and in this connection we shall also mention those dislocations which are occasionally observed in children associated with fractures.
1. Fractures of the Skull It requires great force to fracture the very elastic bones of the skull, for as long as the fontanelles are open the cranial hones, owing to their elasticity, give way to the impact of the frequent falls.
We have lately observed a number of intrapartum crania] fractures; in one of these we proved at postmortem that our diagnosis of "separa tion of a cortical lamella of the parietal was correct; in another case we removed a piece of the oeciput which was lying in a suppurating cephallilematoma like a sequestrum.
Falls upon some sharp edge, a blow, etc., on the soft, and sometimes rachitic, skulls of small children will be followed by large lumnatomata, after absorption of which we will observe sometimes more or less deep impressions of the cranial capsule. (Guard against mistaking the bony wall (periosteal swelling) in himnatoma for a fracture.) We were also able to observe at times depressions, the history of which told of their being reeent, which were without reaction, swelling, or pain, and which most resembled a place in a celluloid ball which had been pushed in.
The cranial fractures of older children with the symptoms of coot motio eerebri, and the typical bleeding from the mouth and ears in frac tures of the base, do not differ from the same injuries in adults as to their cause or their symptoms.
2. Fractures of Vertebra' and Ribs The vertebra] and ribs in children are well protected against frac tures owing to their considerable elasticity, and only tremmulous forces will fracture then] when other injuries are to be found.
3. Fracture of the Clavicle This is extremely frequent in children (about 30 per cent. of all fractures), thus taking the same place as dislocation in the shoulder in adults. It is caused by the same mechanism (fall upon the outstretched hand or the shoulder), the impact being transmitted to the clavicle and causing an infraction at the weakest point, usually at the junction of the middle and outer third of the bone.
Sometimes we will have only an infraction, with very little disloca tion. In complete fracture we observe much pain and a lowering of the shoulder; the arm cannot be raised above the horizontal without pain. This is frequently the only symptom in subperiosteal fractures. Palpa tion of the clavicle reveals a place which is especially tender and swollen. Crepitation and abnormal motion may be lacking.
Fracture of the clavicle may also be found in the newborn after difficult labor (differential diagnosis from Parrot's paralysis, birth paralysis). (See Fractures in Infants, Plate 19.) 4. Fractures of the Humerus In rare cases and in older children we will observe (a) FRACTURE AT THE UPPER END OF THE HUMERUS at the surgical neck; this is usually a fracture from abduction from direct force (blow or fall upon the shoulder).
The short upper fragment is rotated outward by the supraspinatus, infraspinatus and tcres minor muscles, while the lower fragment is pulled inward by the pectoralis and latissimus do•si muscles, and elevated by the deltoid muscle, so that the arm appears to be in adduction, the same as in the typical dislocation in the shoulder. But the abnormal motility, crepitation, and palpation in the axilla and of the socket will explain A simple dislocation of the shoulder-joint is extremely rare in chil dren, and in apparent dislocation we must always think of this fracture and look for the torn-off head in the socket.
(b) THE FRACTURES OF TILE DIAPHYSIS OF THE HUMERI These are especially frequent in the new-born and are caused by muscular action and intrapartum manipulations. The fracture is usually transverse, about the middle of the diaphysis (slight dislocation) (Fig, 165a, Plate 19).
Occasionally we observe similar greenstick-fractures in young infants (rickets). In older children we find more frequently the oblique fractures, as in adults.
The most important symptoms are loss of function, well-localized pain, the bending in incomplete fractures, the abnormal motility and crepitation in complete ones (shortening). The amount of dislocation depends upon the the fracture or upon the change in muscular action from the separation.