Fractures, Pediatric

Fractures, Pediatric is a topic covered in the 5-Minute Emergency Consult.

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  • 20% of pediatric patients with acute traumatic injuries will have a fracture
  • Boys have fractures more commonly than girls
  • Anatomy:
    • Diaphysis: Physis to physis; bone shaft
    • Epiphysis: Cartilaginous center at or near end of bone that is site of bone growth
    • Epiphyseal (growth) plate: Radiolucent line between epiphysis and metaphysis; cartilaginous
    • Metaphysis: Region of rapidly growing trabecular bone underlying base of cartilaginous growth plate; between diaphysis and epiphysis
    • Most long bones are ossified by the end of puberty
  • Bones are highly resilient, elastic, and springy
  • Allow for fractures not seen in adults:
    • Greenstick fracture:
      • Incomplete fracture through cortex on opposite side of impact
    • Torus (buckle) fracture:
      • Usually at junction of metaphysis and diaphysis
      • Compression of bone of 1 cortex
    • Plastic deformity:
      • Bowing without disruption of cortex
    • Fractures involving the physis
  • Cartilaginous growth plates are potential areas of injury.
  • Ligaments more resistant to injury than growth plates
  • Salter–Harris classification:
    • Risk of growth disturbance increases from type I to type V.
    • Type I:
      • Separation of epiphysis from metaphysis without displacement or injury to the growth plate
      • Tenderness and pain at point of growth plate
      • Radiograph typically normal
      • Growth disturbance is rare.
    • Type II:
      • Metaphyseal fracture extending to physis
      • Most common
      • Growth disturbance is rare.
    • Type III:
      • Intra-articular fracture extending through the epiphysis into the physis
      • Most common site is distal tibial epiphysis.
      • Growth disturbance possible
    • Type IV:
      • Epiphyseal, physeal, and metaphyseal fracture
      • Lateral condyle of humerus is the most common site.
      • Growth disturbance highly likely
    • Type V:
      • Crush injury to epiphyseal plate, producing growth arrest
      • Usually occurs in joints that move in only 1 plane such as knee
  • Fractures often accompany dislocations.
  • Nonaccidental trauma (NAT) if history inconsistent with findings


  • Mechanism is useful in defining the potential and type of injury
  • Obesity and rapid growth spurts are risk factors.
  • NAT:
    • Any fracture in a child younger than 1 yr of age in whom history is not consistent with injury
    • Metaphyseal “corner” fractures are pathognomonic.
    • Posterior rib fractures
    • Spiral femur fracture
    • Fractures at different stages of healing
    • Skull fractures crossing suture lines, especially in children younger than 1 yr
    • Unusual behavior in child or parent

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