What is the treatment for pediatric plastic fractures?

Treatment of Pediatric Plastic Fractures

Posterior splinting is the recommended treatment for pediatric plastic fractures, as it provides superior pain relief compared to collar and cuff immobilization during the first two weeks after injury. 1

Understanding Plastic Fractures in Children

• Pediatric plastic fractures occur due to the unique properties of children's bones, which have lower mineral content than adult bones, allowing them to absorb more energy before fracturing but potentially resulting in persistent deformity 2
• These fractures represent incomplete breaks where the bone has bent but not completely fractured, maintaining some structural integrity 2

Initial Management

• The American Academy of Orthopaedic Surgeons (AAOS) recommends nonsurgical immobilization for acute or nondisplaced pediatric fractures 3
• Posterior splinting (back-slab) is preferred over collar and cuff immobilization based on moderate-quality evidence 1
• Two moderate-quality studies have demonstrated better pain control with posterior splinting compared to collar and cuff immobilization 3

Proper Splinting Technique

• Correct splint application is crucial as improper technique can lead to complications 4
• Key elements of proper splinting include:
  • Appropriate functional positioning of the extremity 4
  • Correct splint length to adequately immobilize the fracture 4
  • Avoiding direct application of elastic bandage to the skin (a common error seen in 77% of cases) 4

Common Pitfalls and Complications

• Improper splinting can lead to:
  • Excessive edema (most common complication, seen in 28% of cases) 4
  • Skin breakdown and soft tissue injury (6% of cases) 4
  • Inadequate immobilization leading to poor healing 4
• Overall, studies have found that 93% of splints are improperly placed, with 40% resulting in skin and soft tissue complications 4

Follow-up Care

• The AAOS does not provide specific recommendations on:
  • Optimal time for removal of immobilization
  • Need for supervised physical or occupational therapy
  • Timing for allowing unrestricted activity 1
• Close follow-up is essential to monitor healing and ensure proper alignment 5

Special Considerations

• While most pediatric fractures can be treated with closed reduction and immobilization, certain cases may require surgical management, particularly when anatomic realignment of the growth plate (physis) or articular surface is necessary 5
• For some specific pediatric fractures (like toddler's fractures), studies suggest that minimal intervention may be sufficient, with some patients doing well with removable splints or even no immobilization 6, 7
• The treatment approach should consider the specific fracture type, location, and degree of displacement 3