What is the initial management of a pediatric plastic fracture?

Initial Management of Pediatric Plastic Fractures

For pediatric plastic fractures, the initial management should involve immobilization with a posterior splint (back-slab) rather than collar and cuff immobilization, as this provides better pain relief during the first two weeks after injury. 1

Understanding Plastic Fractures in Children

Plastic fractures represent one of the five common types of pediatric fractures, characterized by:

• Bowing deformity without visible fracture lines on radiographs 2
• Absence of periosteal new bone formation during healing 2
• Unique to children due to the higher elasticity of their bones 3
• Typically seen in long bones following trauma 2

Initial Assessment and Management Algorithm

Step 1: Radiographic Confirmation

• Obtain appropriate radiographs to confirm the diagnosis of a plastic fracture 2
• Look for bowing deformity without visible fracture lines 2

Step 2: Immobilization

• Apply a posterior splint (back-slab) for immobilization 1
• Avoid collar and cuff immobilization as studies show inferior pain control compared to posterior splinting 1
• Ensure proper splint application techniques to prevent complications:
  • Avoid applying elastic bandage directly to the skin 4
  • Ensure appropriate splint length 4
  • Position the extremity in functional position 4

Common Pitfalls in Splint Application

Improper splint application can lead to significant complications:

• 93% of splints are improperly placed in emergency/urgent care settings 4
• 40% of patients experience skin and soft tissue complications from improper splinting 4
• Most common complications include:
  • Excessive edema (28% of cases) 4
  • Direct injury to skin and soft tissue (6% of cases) 4
  • Poor immobilization leading to inadequate fracture healing 4

Follow-up Care

The AAOS guidelines do not provide specific recommendations regarding:

• Optimal time for removal of immobilization 1
• Need for supervised physical or occupational therapy 1
• Optimal timing for allowing unrestricted activity 1

Special Considerations

• The thick periosteum in children contributes to rapid fracture healing and helps maintain reduction 3
• Nearly all fractures in children can be treated in a cast without concerns about joint stiffness 3
• For more complex fractures or in polytrauma cases, external fixation may be considered, though this is not typically necessary for simple plastic fractures 5

Evidence Quality Note

The evidence specifically addressing plastic fractures is limited. The AAOS guidelines primarily focus on supracondylar humerus fractures, with moderate-strength evidence supporting posterior splinting for nondisplaced fractures 1. The recommendation for posterior splinting is based on two moderate quality studies that demonstrated better pain relief with posterior splint/back-slab immobilization compared to collar and cuff immobilization 1.