Paediatric fractures: A general approach

by Anria Horn

Learning Objectives

  1. Understand the differences between adult and paediatric fractures
  2. Identify greenstick, buckle and growth plate fractures.
  3. Understand the basic principles of managing paediatric fractures.
  4. Exclude non-accidental injuries (NAI).

Clinical assessment

  1. History: In very young children, get additional history from parents or caregivers. Determine the time and mechanism of the injury. Be wary of changing stories and an implausible history. Fractures in non-walkers should raise suspicions of NAI.
  2. Examination: Assess the child from head-to-toe using the ‘look, feel and move’ approach. In small children look for pseudo-paralysis (unwillingness to move a limb) and refusal to weight bear. Also look for swelling, deformity and bruising. Feel for tenderness or crepitus.
  3. Special investigations: Start with X-rays of the affected limb or limbs. Also, apply the rule of 2:2 views (AP and lateral), two joints (above and below). In the case of uncertainty, two sides to compare to the normal side.

How are children’s bones different from adult bones?

Children have growth plates that may be confused with fractures; an X-ray of the contralateral side for comparison can assist if you are not sure. Children’s bones are also elastic and can bend without breaking. They also have remodelling potential. The closer the fracture to the growth plate, the greater the remodelling potential.

Growth plate injuries

In children, the weakest point around a joint is the growth plate. In adults, it is usually the ligaments of the joint. Growth plate fractures occur in typical patterns and are described using the Salter-Harris classification. The word SALTER (I – Straight across, II – Above, III – Lower, IV – Trough Everything and V – cRush) is a useful acronym to remember this classification.

Image 22.1
Image 22.2

Greenstick and buckle fractures

Buckle fracture of the distal radius
Buckle fracture of the distal radius
Greenstick fracture of the radius with an associated buckle fracture of the distal ulna
Greenstick fracture of the radius with an associated buckle fracture of the distal ulna

Principles of management


Modified images:

Tib/fib growth plate. Available from: