Pediatric Fractures

Pediatric Bone: Unique Features - Not Just Little Adults

• Thicker Periosteum: Highly osteogenic; promotes rapid healing, increased callus formation, and fracture stability.
• Physis (Growth Plate): Weakest structural component; common site for Salter-Harris fractures. Ligaments are generally stronger than the physis.
• Bone Properties: More porous, less dense, and more elastic than adult bone. Allows for greater plastic deformation before fracturing.
• Unique Fracture Patterns:
  • Greenstick: Incomplete fracture; one side of cortex broken, other side bent.
  • Torus (Buckle): Impaction fracture causing a bulge or buckle in the cortex.
  • Plastic Bowing: Bone bends without a visible cortical disruption.
• Healing & Remodeling Potential:
  • Rapid healing; non-union is rare.
  • Significant remodeling capacity, especially for angular deformities in the plane of joint motion and in younger children.

⭐ The thick, metabolically active periosteum in children is a key factor for faster fracture healing, robust callus formation, and its ability to act as a hinge during fracture reduction, often remaining intact on the concave side of angulated fractures.

Fracture Classification: Physeal & Patterns - Growth Plate Perils

• Physeal (Growth Plate) Injuries: Classified by Salter-Harris (SH). Physis = weakest zone.
  • 📌 Mnemonic: SALTER
    • S (Type I - Slipped): Through physis. Good prognosis.
    • A (Type II - Above): Physis & Metaphysis. Most common. Good prognosis.
    • L (Type III - Lower): Physis & Epiphysis. Intra-articular. Poorer prognosis.
    • T (Type IV - Through/Transverse): Metaphysis, Physis & Epiphysis. Intra-articular. High risk of complications.
    • ER (Type V - Erasure/Rammed): Crush of physis. Worst prognosis; growth arrest common.
  • Risk of growth disturbance: V > IV > III > II > I.

⭐ Salter-Harris Type II is the most common physeal fracture, typically involving the distal radius.

• Common Pediatric Fracture Patterns:
  • Greenstick Fx: Incomplete; one cortex fractured, other bent. Like breaking a young branch.
  • Torus (Buckle) Fx: Compression failure; bulging cortex. Stable.
  • Plastic Bowing Deformity: Bone bends, no visible fracture line. Common in ulna/fibula.
  • Complete Fx: Both cortices broken.

Common Pediatric Fractures: Regional Review - Hotspots & How-Tos

• Clavicle: Most common pediatric fracture. Typically mid-third. Often a birth injury (shoulder dystocia). Tx: Sling or Figure-of-eight bandage for 3-4 weeks.
• Supracondylar Humerus: Most common elbow fracture (~60%). FOOSH mechanism. Gartland classification.
  • Complications: Volkmann's ischemic contracture (brachial artery), nerve injury (Median > Radial > Ulnar). Anterior humeral line, Baumann's angle assessment.
  • Tx: Type I: Cast (~3 wks); Type II/III: Closed reduction & percutaneous pinning (CRPP).

• Lateral Condyle Humerus: Intra-articular (Salter-Harris Type IV). Risk: non-union, malunion (cubitus valgus), AVN. Tx: CRPP or ORIF if displaced >2mm.
• Forearm (Radius/Ulna): Distal radius most common. Greenstick & Torus (buckle) fractures frequent.
  • Remodeling potential: <10 yrs: up to 20-30° angulation acceptable; >10 yrs: <10-15°.
  • 📌 GRIMUS: Galeazzi - Radius fx, Inferior (Distal) radioulnar joint (DRUJ) injury; Monteggia - Ulna fx, Superior (Proximal) radioulnar joint / Radial head dislocation.
• Femur Shaft:
  • <6 months: Pavlik harness.
  • 6 months - 5 years: Hip spica cast.
  • 6-12 years: Flexible intramedullary nails (TENS) or spica.

  • 12 years: Rigid IM nail or plate.

• Tibia: Toddler's fracture (spiral fracture of tibia, typically undisplaced, in children 9 months - 3 years).

⭐ In supracondylar humerus fractures, posteromedial displacement is commonly associated with radial nerve injury, whereas posterolateral displacement often compromises the median nerve and brachial artery.

Fracture Complications & NAI - Red Flags & Responsibilities

• Complications:
  • Early: Compartment syndrome (⚠️ urgent fasciotomy), neurovascular compromise, infection.
  • Late: Malunion, nonunion, physeal arrest (growth issues), Avascular Necrosis (AVN).
• Non-Accidental Injury (NAI):
  • Red Flags: Story-injury mismatch, multiple fractures (varied healing), bruises in pre-ambulatory infants.
    • Highly specific: Metaphyseal corner fx, posterior ribs, sternal fx.
  • Action: High suspicion, document meticulously, report (CWC/POCSO Act), ensure child safety.

    ⭐ Metaphyseal "corner" or "bucket-handle" fractures are virtually pathognomonic for NAI. oka

High‑Yield Points - ⚡ Biggest Takeaways

• Salter-Harris Type II is the most common physeal injury.
• Greenstick and torus (buckle) fractures are unique to pediatric bones.
• Supracondylar humerus fractures: high risk of neurovascular injury and Volkmann's contracture.
• Clavicle fractures are very common, often treated non-operatively with a figure-of-eight bandage.
• Children possess excellent remodeling potential, especially for fractures near growth plates and in the plane of joint motion.
• Suspect non-accidental injury (NAI) with metaphyseal corner fractures, posterior rib fractures, or multiple fractures in varied healing stages.
• Toddler's fracture is typically an undisplaced spiral tibial fracture in young, ambulatory children (9 months to 3 years).