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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 from 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 because of tension or torsion force that leaves the cortex and periosteal sleeve intact on one side of the bone.

  • Angulated fractures in children have a much greater potential to remodel back to their original shape than do 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 nonaccidental trauma (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 who do not walk. Refer to Chapter 7 for details.


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).

Fractures of the Physis

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 classification as shown in Figure 24-1 and described in Table 24-1.

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

Figure 24-1

Salter–Harris Types I–V.

Table 24-1Salter–Harris Classification for Fractures Involving the Physis

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