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  • Pediatric patients have unique patterns of injuries and fractures due to the immaturity of bone and the dynamic nature of skeletal growth. Fractures account for 10% to 15% of all childhood injuries.
  • Fractures are more common than ligamentous injuries or sprains in children due to the relative weakness of the physis or growth plate.
  • Injuries to the physis may lead to long-term growth abnormalities or growth arrest. Injuries to the physis occur in up to 18% of all pediatric fractures.
  • Radiographs are more difficult to interpret and findings can be much more subtle in children than adults, as the physis is radiolucent and there are secondary ossification centers. Comparison views of the uninjured extremity can be helpful.
  • The majority (75%) of physis fractures are Salter II fractures, and most of these are found after the age of 10 years.
  • Up to 50% of fractures in children younger than 1 year are the result of nonaccidental trauma.

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Orthopedic injuries are one of the most common reasons for pediatric visits to the emergency department (ED) with more than 40% of boys and 25% of girls experiencing a fracture before the age of 16. These injuries are often the result of either falls, recreation, sports, or motor vehicle accidents, but unfortunately situations like child abuse must also be considered with pediatric injuries.1 Children with orthopedic injuries are often seen as diagnostic dilemmas because of the various injury patterns seen with growing bones and the challenges of interpreting pediatric x-rays. The better clinicians understand the growing skeleton, the more accurate the diagnosis and management of these injuries. Proper diagnosis allows for better outcomes and better anticipation of possible complications.

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The immature skeleton has unique characteristics to understand when comparing it to mature, adult bone. First, growing bone is much more porous and flexible leading to unique fracture patterns such as the greenstick, torus (buckle), and bowing (plastic deformation). Much of the immature skeleton consists of radiolucent cartilage that ossifies at different stages making some fractures difficult to visualize on radiographs. Growing bone is surrounded by a thick and active periosteum, which promotes faster healing and better remodeling than in adults. The most obvious characteristic on radiographs is the presence of the physis or “growth plate” at the end of growing bones. The radiolucent physis often leads to confusion and presents many challenges when interpreting radiographs.

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The porous character and greater flexibility of the pediatric skeleton allows it to bend much further and absorb much more force before a fracture occurs. This “bending” characteristic is why incomplete fractures like the greenstick, torus, and bowing exist. These incomplete fractures occur when the bone “bends” without resulting in a complete, transverse fracture. The porous character is also why there is less comminution and less propagation seen with fractures of the immature skeleton.2

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The largest obstacle to overcome when assessing pediatric orthopedic injuries is an understanding of the physis and the ...

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