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Musculoskeletal complaints and injuries are some of the most commonly encountered problems in pediatrics. In addition, children have immature musculoskeletal systems that pose particular challenges that are quite different than those of adults.

  • Children have open growth plates, or physes, located between the epiphysis and the metaphysis

  • Fractures most commonly occur near the metaphysis or physis

  • An open growth plate is cartilaginous, and has not yet calcified, which makes it the weakest part of the immature bone

  • Pediatric bones are less brittle than adults leading to some distinct fracture patterns

  • In a buckle fracture, compression force leads to partial failure, but the fracture does not traverse the entire bone

  • A greenstick fracture occurs due to tension or torsion force that leaves the cortex and periosteal sleeve intact of one side of the bone

  • Angulated fractures in children have a much greater potential to remodel back to original shape than fractures in adults. Remodeling potential is greatest in: younger patients, injuries near a growing physis, and those in the plane of motion congruent to an associated joint

  • Open fractures require consultation with Orthopedic Surgery

  • Consider child abuse as a factor in pediatric fractures. Injuries concerning for abuse include: Bucket-handle (metaphyseal corner) fractures, multiple fractures of different ages, posterior rib or scapular fractures, and long bone fractures in children that do not walk


Management of fractures depends on the type, location, and amount of displacement present. Displacement, or loss of normal alignment of the distal fragment, is usually described in terms of translation (repositioning away from but remaining parallel to the long axis), angulation (degrees of bending from a straight line), shortening (overlap) or distraction (increased distance), and rotation (twisting).


Physeal fractures are more common than isolated ligament or tendon injuries in skeletally immature patients because the surrounding connective tissues are stronger than the open physis. Injuries involving the physis are described with the Salter–Harris (SH) classification as shown in Figure 23-1, and described in Table 23-1.

  • Physical exam findings in physeal fractures: Tenderness over long bone physis following an injury, swelling, difficulty bearing weight

  • Diagnosis: Commonly made by plain radiographs

  • SH-I fractures may not be visible on initial films. Look for soft tissue swelling adjacent to the physis in question

  • In equivocal cases, consider imaging the contralateral joint to compare physeal widths

  • Injuries to the physis should be monitored for several months after injury to monitor for growth arrest

  • Injuries that result in some measure of disability, along with tenderness at a physis on exam, should be treated as SH-I fractures even if there is no abnormality demonstrated on the radiographs


Salter–Harris types I–V.

TABLE 23-1

Salter–Harris Classification for Fractures Involving the Physis

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