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Emergency And Acute Medicine – Pediatric Fractures
Basics Description
Approximately 20% of children presenting with acute traumatic injuries sustain fractures, with boys affected more frequently than girls. Pediatric bone anatomy differs from adults and includes the diaphysis (shaft between growth plates), metaphysis (rapidly growing trabecular bone adjacent to the growth plate), epiphysis (cartilaginous growth center near the bone end), and the epiphyseal or growth plate, which is cartilaginous and radiolucent on imaging. Children’s bones are more elastic and resilient, allowing unique fracture patterns such as greenstick fractures (incomplete cortical disruption), torus or buckle fractures (compression injury at the metaphyseal–diaphyseal junction), and plastic deformities (bowing without cortical break). Growth plate involvement is common, as ligaments are stronger than physes. The Salter–Harris classification describes physeal fractures, with increasing risk of growth disturbance from type I through type V.
Etiology
Mechanism of injury helps predict fracture type and severity. Risk factors include obesity and rapid growth spurts. Nonaccidental trauma must be considered, particularly in children younger than 1 year with fractures inconsistent with the history. Highly suggestive findings include metaphyseal corner fractures, posterior rib fractures, spiral femur fractures, fractures at different stages of healing, skull fractures crossing suture lines in infants, and concerning child or caregiver behavior.
Diagnosis Signs And Symptoms
Children may present with refusal to use a limb, decreased movement, swelling, tenderness, deformity, ecchymosis, crepitus, limp, or abnormal neurovascular findings. Compartment syndrome should be suspected with severe pain (especially in forearm, calf, or foot), pain on passive stretch, sensory deficits, cool extremity, or absent pulses. Open fractures may be subtle and appear as localized bleeding with fat globules.
History
Obtain a detailed mechanism of injury including fall height, vehicle speed, and events surrounding trauma. Assess for neurologic symptoms and associated injuries, and ensure the history is consistent with findings.
Physical Exam
Perform a thorough secondary survey. Assess deformities, bruising, and associated injuries. Carefully evaluate neurovascular status, including motor function, sensation, distal pulses, capillary refill, and joint range of motion.
Essential Workup
Prompt immobilization followed by appropriate imaging.
Diagnosis Tests And Interpretation
Lab
Laboratory studies are required only when infection, surgery, or multisystem trauma is suspected and may include CBC and inflammatory markers.
Imaging
Obtain AP, lateral, and oblique radiographs as needed, including joints above and below the injury. Comparison views can be helpful when growth plate injury is suspected. Repeat radiographs in 7–10 days may identify occult fractures or Salter–Harris type I injuries. Bone scan, CT, or MRI may be used when plain films are inconclusive or to evaluate infection.
Diagnostic Procedures/Surgery
Arthrocentesis is indicated if joint infection is suspected.
Differential Diagnosis
Sprain, strain, contusion, infection, tumor, neurologic injury, subtle dislocations such as nursemaid’s elbow, and nonaccidental trauma.
Treatment
Prehospital
Immobilization of the affected extremity.
Initial Stabilization/Therapy
Address life-threatening injuries and immobilize fractures.
ED Treatment/Procedures
Provide adequate analgesia and manage concurrent injuries. Dislocations require urgent reduction with careful neurovascular assessment. Alignment is critical, especially for intra-articular fractures. Suspected nonaccidental trauma must be reported appropriately.
Salter–Harris type I and II fractures are treated with immobilization and orthopedic follow-up. Type III, IV, distal femur type II, and type V fractures require urgent orthopedic consultation; even with anatomic reduction, growth disturbance may occur.
Clavicle fractures are treated with a sling or figure-of-eight brace; distal third injuries require referral.
Elbow fractures, especially supracondylar injuries, require orthopedic consultation due to risk of neurovascular compromise and compartment syndrome.
Distal radius and ulna fractures are the most common pediatric fractures; angulated fractures often require reduction and immobilization. Torus fractures require immobilization only, while greenstick fractures may need reduction if angulated.
Tibial and fibular fractures are managed based on displacement, with toddler’s fractures often requiring immobilization despite subtle imaging findings.
Slipped capital femoral epiphysis requires nonweight bearing and urgent orthopedic referral.
Open fractures require irrigation, sterile dressing, immobilization, and early antibiotics in consultation with orthopedics.
Children presenting with limp require evaluation for infection, rheumatologic disease, malignancy, transient synovitis, or septic arthritis.
Medication
Acetaminophen 10–15 mg/kg PO or PR q4–6h.
Ibuprofen 10 mg/kg PO q6–8h as first-line therapy.
Morphine 0.05–0.2 mg/kg IV/IM/SC q2–4h for severe pain.
Cefazolin and gentamicin dosing as indicated for open fractures.
Local hematoma block with 1% lidocaine without epinephrine when appropriate.
Follow Up Disposition
Admission Criteria
Suspected nonaccidental trauma, open fractures, or fractures with neurovascular compromise or compartment syndrome.
Discharge Criteria
Uncomplicated fractures without associated injuries or neurovascular compromise, with reliable caregivers and arranged follow-up.
Issues For Referral
All Salter–Harris fractures and complex injuries require orthopedic follow-up.
Key Practice Insights And Common Pitfalls
A careful history is essential when evaluating for nonaccidental trauma. Fully undress the child when abuse is suspected. Maintain a low threshold for splinting or orthopedic consultation. Adequate pain control is frequently underdosed. Distal radius fractures often coexist with ulna, elbow, or carpal injuries and should be evaluated carefully.
Basics Description
Approximately 20% of children presenting with acute traumatic injuries sustain fractures, with boys affected more frequently than girls. Pediatric bone anatomy differs from adults and includes the diaphysis (shaft between growth plates), metaphysis (rapidly growing trabecular bone adjacent to the growth plate), epiphysis (cartilaginous growth center near the bone end), and the epiphyseal or growth plate, which is cartilaginous and radiolucent on imaging. Children’s bones are more elastic and resilient, allowing unique fracture patterns such as greenstick fractures (incomplete cortical disruption), torus or buckle fractures (compression injury at the metaphyseal–diaphyseal junction), and plastic deformities (bowing without cortical break). Growth plate involvement is common, as ligaments are stronger than physes. The Salter–Harris classification describes physeal fractures, with increasing risk of growth disturbance from type I through type V.
Etiology
Mechanism of injury helps predict fracture type and severity. Risk factors include obesity and rapid growth spurts. Nonaccidental trauma must be considered, particularly in children younger than 1 year with fractures inconsistent with the history. Highly suggestive findings include metaphyseal corner fractures, posterior rib fractures, spiral femur fractures, fractures at different stages of healing, skull fractures crossing suture lines in infants, and concerning child or caregiver behavior.
Diagnosis Signs And Symptoms
Children may present with refusal to use a limb, decreased movement, swelling, tenderness, deformity, ecchymosis, crepitus, limp, or abnormal neurovascular findings. Compartment syndrome should be suspected with severe pain (especially in forearm, calf, or foot), pain on passive stretch, sensory deficits, cool extremity, or absent pulses. Open fractures may be subtle and appear as localized bleeding with fat globules.
History
Obtain a detailed mechanism of injury including fall height, vehicle speed, and events surrounding trauma. Assess for neurologic symptoms and associated injuries, and ensure the history is consistent with findings.
Physical Exam
Perform a thorough secondary survey. Assess deformities, bruising, and associated injuries. Carefully evaluate neurovascular status, including motor function, sensation, distal pulses, capillary refill, and joint range of motion.
Essential Workup
Prompt immobilization followed by appropriate imaging.
Diagnosis Tests And Interpretation
Lab
Laboratory studies are required only when infection, surgery, or multisystem trauma is suspected and may include CBC and inflammatory markers.
Imaging
Obtain AP, lateral, and oblique radiographs as needed, including joints above and below the injury. Comparison views can be helpful when growth plate injury is suspected. Repeat radiographs in 7–10 days may identify occult fractures or Salter–Harris type I injuries. Bone scan, CT, or MRI may be used when plain films are inconclusive or to evaluate infection.
Diagnostic Procedures/Surgery
Arthrocentesis is indicated if joint infection is suspected.
Differential Diagnosis
Sprain, strain, contusion, infection, tumor, neurologic injury, subtle dislocations such as nursemaid’s elbow, and nonaccidental trauma.
Treatment
Prehospital
Immobilization of the affected extremity.
Initial Stabilization/Therapy
Address life-threatening injuries and immobilize fractures.
ED Treatment/Procedures
Provide adequate analgesia and manage concurrent injuries. Dislocations require urgent reduction with careful neurovascular assessment. Alignment is critical, especially for intra-articular fractures. Suspected nonaccidental trauma must be reported appropriately.
Salter–Harris type I and II fractures are treated with immobilization and orthopedic follow-up. Type III, IV, distal femur type II, and type V fractures require urgent orthopedic consultation; even with anatomic reduction, growth disturbance may occur.
Clavicle fractures are treated with a sling or figure-of-eight brace; distal third injuries require referral.
Elbow fractures, especially supracondylar injuries, require orthopedic consultation due to risk of neurovascular compromise and compartment syndrome.
Distal radius and ulna fractures are the most common pediatric fractures; angulated fractures often require reduction and immobilization. Torus fractures require immobilization only, while greenstick fractures may need reduction if angulated.
Tibial and fibular fractures are managed based on displacement, with toddler’s fractures often requiring immobilization despite subtle imaging findings.
Slipped capital femoral epiphysis requires nonweight bearing and urgent orthopedic referral.
Open fractures require irrigation, sterile dressing, immobilization, and early antibiotics in consultation with orthopedics.
Children presenting with limp require evaluation for infection, rheumatologic disease, malignancy, transient synovitis, or septic arthritis.
Medication
Acetaminophen 10–15 mg/kg PO or PR q4–6h.
Ibuprofen 10 mg/kg PO q6–8h as first-line therapy.
Morphine 0.05–0.2 mg/kg IV/IM/SC q2–4h for severe pain.
Cefazolin and gentamicin dosing as indicated for open fractures.
Local hematoma block with 1% lidocaine without epinephrine when appropriate.
Follow Up Disposition
Admission Criteria
Suspected nonaccidental trauma, open fractures, or fractures with neurovascular compromise or compartment syndrome.
Discharge Criteria
Uncomplicated fractures without associated injuries or neurovascular compromise, with reliable caregivers and arranged follow-up.
Issues For Referral
All Salter–Harris fractures and complex injuries require orthopedic follow-up.
Key Practice Insights And Common Pitfalls
A careful history is essential when evaluating for nonaccidental trauma. Fully undress the child when abuse is suspected. Maintain a low threshold for splinting or orthopedic consultation. Adequate pain control is frequently underdosed. Distal radius fractures often coexist with ulna, elbow, or carpal injuries and should be evaluated carefully.
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