Orthopaedic assessments of impairment in minors pose significant challenges. It is rare that children come to impairment assessments, but they are significantly affected by trauma and are often involved as passengers in motor vehicle accidents. Children have a greater capacity for recuperation following injury, as they have a significant ability to compensate for quite serious injuries that would debilitate adult patients.
They also have from a skeletal perspective an ability to remodel fractures and outgrow deformity due to the presence of growth plates, and the legs can grow at up to 24 mm/year. Young children can outgrow severe bone deformity (such as fracture malunions) of over 30-40degrees, which would normally require corrective surgery in adults.
When assessing orthopaedic injuries in children, stability is important to assess, and whilst children may outgrow their injuries over a long period of time, it is unlikely that they would change by more than 3% within a 12-month period, as they grow quite slowly. However, when considering if they are stabilised and they have reached maximal medical improvement, this may not occur until skeletal maturity. In girls this normally happens at around the age of 14 when they are 2 years post menarche (first menstrual cycle), and in boys this happens at around 16 years of age.
When assessing injuries in children which involve growth plates, deformities can be initially minimal, but with progressive growth, an affected growth plate can cause significant deformity and predispose a joint to early arthritis. In particular, intra articular fractures or fractures which cause early growth arrest cause major joint problems, and deformity. When considering such patients for stabilisation, stabilisation would normally occur once the joint has reached skeletal maturity, and appropriate treatment has been undertaken. This may not occur until a patient is skeletally mature.
Similarly, children are often affected by a leg length discrepancy from lower limb fractures, as bones can become shortened due to growth plate arrest, or they can overgrow due to remodelling post fracture. When considering if a leg length discrepancy is stable, using table 35, this may not occur until skeletal maturity, as most children with growth plate abnormalities and leg length discrepancies are candidates for limb length corrective surgery either by way of selective physeal growth arrest, or limb lengthening procedures. The aim of corrective surgery for this is to obtain lower limbs which are within around 1 cm of each other, and this would not rate as an impairment using the guides.
For patients who have suffered from complex neurological problems, such as cerebral palsy, it is unlikely that their condition would be stabilised for the purposes of impairment assessment until they have reached skeletal maturity, as they may have significant soft tissue contractures and these can progress over time as the underlying bones grow. Also, they would likely be candidates for soft tissue release surgery or reconstruction, and they would not have reached maximal medical improvement until close to skeletal maturity.
Overall, paediatric patients pose significant impairment assessment challenges, and it is appropriate that when considering a skeletally immature patient, that an appropriate expert is sought, who has training in paediatrics. Otherwise, there is a real risk that an injury will not be assessed adequately or thoroughly.
