Pediatric Fractures in the ED

Introduction to Pediatric Fractures

Fractures are common injuries in pediatric patients, often seen in the emergency department. Children’s bones are more flexible and have active growth plates, making them prone to specific fracture patterns and remodelling. Recognising fracture types, red flags and appropriate disposition is crucial for safe management.

Common Pediatric Fractures

Below are some of the most common fracture patterns in children:

Fracture Type	Features
Greenstick Fracture	One side of the cortex is broken, while the other side is bent. Typical in younger children due to bone plasticity.
Torus (Buckle) Fracture	Compression injury causing a bulge or buckle in the cortex. Stable, with intact periosteum.
Supracondylar Humeral Fracture	Fracture of the distal humerus just above the elbow joint. High risk of neurovascular compromise and compartment syndrome.
Clavicle Fracture	Common fracture of the collarbone, often after a fall on an outstretched hand or shoulder. Usually managed with a sling.
Toddler's Fracture	Low-energy spiral fracture of the tibia in toddlers. May follow minor trauma and can be subtle on initial X-rays.

Salter-Harris Fractures

Salter-Harris fractures involve the growth plate (physis) and can impact future bone growth. Classification helps guide prognosis and management:

Type	Description	Treatment
Type I	Fracture through the physis only, separating epiphysis from metaphysis.	Immobilisation; usually good prognosis. Ortho review if displaced.
Type II	Fracture through physis and metaphysis, sparing epiphysis. Most common type.	Closed reduction and immobilisation; orthopedic referral if significantly displaced.
Type III	Fracture through physis and epiphysis, involving the joint surface.	Orthopedic consultation; often needs anatomical reduction and sometimes surgery.
Type IV	Fracture through metaphysis, physis and epiphysis.	Urgent orthopedic consultation; usually surgical fixation to preserve the joint and growth plate.
Type V	Crush injury to the physis, often subtle initially on X-ray.	Orthopedic follow-up; high risk of growth arrest, long-term monitoring needed.

Pediatric Hip and Leg Injuries

Various hip and leg injuries can affect pediatric patients. Important conditions to recognise:

Injury	Features	Treatment
Slipped Capital Femoral Epiphysis (SCFE)	Occurs in adolescents during growth spurts, often overweight. Epiphysis slips off the femoral neck → hip, thigh or knee pain and limp. Limited internal rotation; leg may be externally rotated. X-ray: “Ice cream slipping off the cone”.	Immediate non–weight-bearing. Urgent orthopaedic referral. Surgical fixation to prevent further slippage.
Legg-Calvé-Perthes Disease	Avascular necrosis of the femoral head in children. Gradual onset of limp, hip or referred knee pain. Reduced range of motion, especially abduction and internal rotation. X-ray: Flattened, fragmented femoral head. Most common in boys aged 4–8 years.	Orthopedic consultation for staging and management. Activity modification and non–weight-bearing as advised. Bracing, casting or surgery depending on severity and age.
Developmental Dysplasia of the Hip (DDH)	Abnormal development of the hip joint → instability or dislocation. Uneven skin folds, leg length discrepancy, limited hip abduction. More common in females and breech-position infants. Diagnosed through physical exam and ultrasound in infants.	Early detection via newborn and infant hip screening. Pavlik harness or spica cast in infants. Surgical intervention for older children or late diagnosis.

Pediatric Fracture Red Flags in the ED

These findings should prompt urgent senior/orthopaedic review and often admission:

Neurovascular Assessment & Compartment Syndrome

Always document a full neurovascular examination before and after any manipulation or casting:

• Circulation: distal pulses (e.g. radial, dorsalis pedis), capillary refill time, limb temperature and colour.
• Sensation: light touch and pinprick over nerve territories (e.g. median, radial, ulnar; peroneal, tibial).
• Motor: ask the child to move fingers/toes; check key muscle groups (e.g. wrist/finger extension, ankle dorsiflexion/plantarflexion).

Compartment syndrome – think of it especially in:

• Supracondylar fractures, tibial shaft fractures, high-energy injuries, tight casts/bandages.
• Increasing pain not relieved by analgesia, pain on passive stretch, tense compartments.
• Agitation, anxiety or “pain out of proportion” in a child who cannot verbalise well.

Compartment syndrome is a surgical emergency – urgent orthopedic review and fasciotomy where indicated.

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General Disposition of Pediatric Patients with Fractures

Disposition is based on fracture type, stability, associated injuries and social/safeguarding factors:

• Outpatient Management
  Stable simple fractures (e.g. buckle fractures, undisplaced distal radius, uncomplicated clavicle fractures). Provide:
  • Appropriate immobilisation (sling, splint or cast).
  • Analgesia plan and cast/splint care advice.
  • Written safety-netting and fracture clinic/orthopaedic follow-up.
• Short-term Observation / Day Case
  Fractures requiring reduction/sedation or early monitoring (e.g. some supracondylar fractures without NV compromise).
• Admission and Possible Surgery
  
  • Open fractures, neurovascular compromise, suspected compartment syndrome.
  • Unstable or markedly displaced fractures requiring operative fixation.
  • SCFE, complex pelvic or hip fractures, polytrauma.
  • Concerns for non-accidental injury or unsafe home environment.
• Follow-up Care
  All pediatric fractures need follow-up to:
  • Confirm healing clinically and radiologically.
  • Monitor growth plate function and alignment where relevant.
  • Detect complications such as malunion, stiffness, or growth arrest.

A multidisciplinary approach involving orthopedics, paediatrics, physiotherapy, nursing and social services (when indicated) helps optimise outcomes.