The lost art of conservative management of paediatric fractures

The orthopaedic surgeon practising general trauma will invariably encounter fractures in children. Mercer Rang points out in the opening chapter of his textbook, “children are not just small adults”.1 The paediatric skeleton is more forgiving, demonstrates greater rapidity of healing and has an unrivalled capacity to remodel. Greater angulation, translation, and shortening can be accepted and reliably expected to remodel without clinical, functional or radiological shortcomings. Despite the fact that the outcomes following paediatric fractures are predictable and the healing potential offers considerable latitude for restoration of normality, there has been a global paradoxical shift from conservative treatment to early fracture fixation. This has perhaps been driven by the desire for immediate correction of clinical deformities or by financial incentives to minimise hospital costs accrued with prolonged admissions during periods of immobilisation. This review examines the evidence and indications for conservative treatment, and describes our preferences for the management of some commonly encountered paediatric fractures. The ability of the paediatric skeleton to remodel lies at the heart of non-operative management. Semantically, this process is called modeling; remodeling being the constant homeostatic cycling of calcium and phosphate from bone stores. Everyone understands remodeling so we use it now even though it’s wrong! It is the process by which angulation and translation are corrected to restore acceptable alignment. The potential for remodeling is influenced by a number of factors: