Epidemiology
- Trauma is the leading cause of death in children beyond infancy
- Most deaths are from head injury
- Blunt mechanisms predominate
- Greater energy per unit mass makes multiple injuries common
Anatomy
- Large occiput flexes the neck supine, so pad under the shoulders
- Large tongue, floppy epiglottis and higher anterior larynx make intubation harder
- Short trachea predisposes to right main bronchus intubation and tube displacement
- Larger surface area relative to mass predisposes to hypothermia
- Compliant chest wall allows pulmonary contusion and cardiac injury without rib fractures
- Liver and spleen are exposed below a less protective rib cage
- Elastic pelvis makes pelvic fractures less common, but they indicate high energy and visceral injury
Clinical Features
- Blood pressure is maintained despite major blood loss
- Tachycardia and poor perfusion are early signs, hypotension a late sign of decompensation
- Head injury determines outcome, with diffuse swelling more common than focal lesions
- Rib fractures imply high energy and, in infants, suggest NAI
- Lap belt sign suggests a Chance fracture with hollow viscus injury
- Under 8 years, upper cervical and ligamentous injuries and SCIWORA occur
- Compartment syndrome shows as rising anxiety, agitation and analgesic requirement
- NAI features are delay, changing history, injury inconsistent with development and injuries of different ages
- Metaphyseal corner fractures, posterior rib fractures and patterned bruising suggest NAI
Investigations
- Skeletal survey for suspected abuse under 2 years
Management
- ATLS and APLS primary survey with a coordinated trauma team
- Weight and doses from age-based formulae or length-based tapes
- Needle cricothyroidotomy preferred over surgical in young children
- Weight-based fluid and blood boluses, intraosseous if IV access fails
- Most stable solid organ injuries managed non-operatively
- Early long bone stabilisation aids nursing, analgesia and mobilisation
- Femoral fractures, Pavlik or spica when young, flexible nails, plates or lateral entry nails when older
- Open fractures need early antibiotics, tetanus prophylaxis, debridement and soft tissue cover
- Child protection referral is mandatory for Australian medical practitioners
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.