Fractures in Children

Aka: Fractures in Children, Pediatric Fractures

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II. Pathophysiology: Anatomical differences in children result in unique Fracture patterns

  1. Pediatric bone is more porous and less dense (more pliable)
    1. Bowing or plastic deformity
    2. Buckle or torus Fracture
    3. Greenstick Fracture
  2. Growth Plates (epiphsyeal plates) are weaker than ligaments, tendons and bone
    1. Growth Plate Fractures (Epiphyseal Fractures) are more common than sprains in children
    2. Periosteal bone is relatively thick by comparison

III. Precautions

  1. See Non-Accidental Trauma related Fractures

IV. Types: Upper extremity Fractures and injuries in children

  1. Shoulder Fracture
    1. Clavicle Fracture
      1. Also see Clavicle Fracture from Birth Trauma
    2. Humerus Fracture
      1. See Proximal Humerus Fracture
      2. See Humerus Shaft Fracture
      3. Consider abuse if Humeral Fracture in small children or spiral Fracture
  2. Elbow Fracture
    1. See Elbow Ossification Centers
    2. Supracondylar Fracture of Humerus
    3. Lateral Condyle Fracture
    4. Olecranon Fracture
    5. Radial Head Fracture
    6. Lateral Epicondyle Fracture
      1. Caused by varus stress to supinated and extended arm
      2. Rare Fracture (typically Salter-Harris Fracture Type 4 requiring ORIF)
    7. Medial Epicondyle Fracture
      1. Apophysis Fracture in older children
      2. Associated with elbow Fracture in 50% of cases
    8. Medial Epicondyle Apophysitis (Little Leaguer's Elbow)
    9. Nursemaid's Elbow (Radial Head Subluxation)
  3. Forearm Fracture
    1. Distal Radius Fracture or Colles Fracture
    2. Proximal Radius and Ulna Fracture
    3. Isolated Ulna Fracture
      1. Rare in children
      2. Confirm radial head not dislocated (Monteggia Fracture), which requires urgent reduction
  4. Wrist and Hand Fracture
    1. Scaphoid Fracture
    2. Tuft Fracture (or distal phalanx crush injury)

V. Types: Lower extremity Fractures and injuries in children

  1. Hip and Pelvis Fracture
    1. Pelvic Fracture
    2. Hip Fracture
    3. Femoral Shaft Fracture
    4. Distal Femoral Fracture
    5. Slipped Capital Femoral Epiphysis
  2. Knee injuries
    1. Patella dislocation
    2. Patella Fracture
  3. Tibia and fibula injuries
    1. Tibial spine Fracture
    2. Tibial tuberosity Fracture
    3. Proximal tibial physis Fracture
    4. Tibia and fibula shaft Fracture
    5. Toddler's Fracture
  4. Ankle injuries
    1. Distal fibula Fracture
    2. Distal tibia Fracture
  5. Foot injuries
    1. Lisfranc Fracture
    2. Fifth Metatarsal Fracture

VI. Imaging

  1. XRay
    1. See Epiphyseal Fracture
  2. Ultrasound
    1. High accuracy in diagnosing upper extremity Fracture (aside from elbow Fractures)
      1. Tsou (2021) Am J Emerg Med 44:383-94 [PubMed]

VII. Management: General

  1. Ibuprofen or Tylenol are typically sufficient for home Analgesics
    1. Opioid Analgesics are not commonly needed for home pediatric Fracture management after Splinting
    2. Ibuprofen does not appear to significantly delay Fracture healing
      1. DePeter (2017) J Emerg Med 52(4): 426-32 +PMID:27751698 [PubMed]

VIII. Management: Fracture Referral Timing

  1. Emergent surgical Consultation indications
    1. Open Fracture
    2. Neurovascular injury (or high risk for neurovascular injury, such as for supracondylar Fracture)
    3. Unreducible joint dislocation (uncommon in children)
  2. Urgent surgical Consultation indications
    1. Unstable Fracture (Radius and Ulna Fracture, tibia and fibula Fracture, displaced tibia Fracture)
    2. Salter Harris III or IV Epiphyseal Fracture (involving joint capsule or cartilage)
    3. Fracture-dislocation (e.g. Galeazzi Fracture)
  3. Routine follow-up care (1-2 weeks)
    1. Small, non-displaced Fractures of non-weight bearing bones
    2. Buckle Fractures (Torus Fractures)
    3. Clavicle Fractures (without tenting or vascular injury)

IX. References

  1. Majoewsky in Herbert (2012) EM:RAP C3 2(7): 3

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