General principles
Children's fractures differ from adult fractures because of:
- thick periosteum
- remodelling potential
- open physes
- growth-related complications
- age-specific patterns
Always consider non-accidental injury when the history, developmental stage or fracture pattern is inconsistent.
Femoral shaft fractures
Treatment depends on age, weight, fracture pattern and social circumstances.
Options include:
- harness or spica in infants/young children
- early spica casting
- elastic intramedullary nails in appropriately sized school-age children
- submuscular plating
- rigid trochanteric-entry nails in selected adolescents
- external fixation in selected severe soft-tissue or polytrauma situations
Complications include malunion, overgrowth/shortening, infection and implant irritation.
Supracondylar humerus fracture
Assess urgently for:
- brachial artery perfusion
- median/AIN, radial and ulnar nerve function
- compartment syndrome
Displaced extension-type fractures commonly require closed reduction and percutaneous pinning.
A pulseless pale hand is a vascular emergency. A pink perfused hand without a palpable pulse requires close senior-led assessment and treatment according to perfusion after reduction.
Late complications include cubitus varus and stiffness.
Lateral condyle fracture
This is an intra-articular physeal injury with a risk of displacement and nonunion. Stable minimally displaced fractures require close radiographic follow-up; displaced/rotated fragments need anatomical reduction and fixation.
Paediatric Monteggia injury
Always check radiocapitellar alignment in an ulna fracture or plastic bowing injury. Restoration of ulnar alignment usually restores the radial head.
Physeal injuries
Salter-Harris classification describes relationship to physis, metaphysis and epiphysis. Risk of growth arrest depends on more than the classification alone; injury energy, location and vascular damage are important.
Why children are different
Children have:
- open physes
- thick active periosteum
- greater remodelling potential
- different ligament-bone strength relationships
- age-dependent tolerance of deformity
These features influence both fracture pattern and treatment.
Remodelling
Remodelling is greatest:
- in younger children
- near an active physis
- in the plane of joint motion
Rotational deformity remodels poorly. Coronal or sagittal deformity far from a physis also remodels less reliably.
Therefore “children remodel” is not a justification for accepting any displacement.
Physeal injury
Physeal fractures require assessment of:
- fracture pattern
- displacement
- joint congruity
- age/growth remaining
- risk to the germinal layer
Growth arrest can produce:
- angular deformity
- length discrepancy
- partial physeal bar
Higher-energy injuries and some anatomical sites have greater arrest risk.
Reduction
Repeated forceful reduction attempts should be avoided because they can further injure the physis.
When reduction is required, aim for gentle accurate restoration, particularly for intra-articular physeal fractures.
Supracondylar humerus
Important complications include:
- brachial artery injury
- median/AIN injury
- compartment syndrome
- malunion/cubitus varus
Document pulse, perfusion and nerve function before and after reduction/fixation.
A well-perfused but pulseless hand requires careful specialist decision-making and monitoring rather than a simplistic pulse-only rule.
Lateral condyle
Lateral condyle fractures are intra-articular and can displace because of muscle pull. Missed displacement risks non-union and deformity.
Forearm fractures
Plastic deformation and greenstick patterns are characteristic. Alignment and rotation require assessment; refracture can occur after return to activity before full remodelling.
Non-accidental injury
Consider safeguarding concerns when:
- history is inconsistent
- injury is unexplained
- fracture pattern/age is unusual
- there are multiple injuries of different ages
FRCS synthesis
A paediatric-fracture answer should always mention physis, remodelling potential, neurovascular status and safeguarding where appropriate.