What is the management approach for pediatric fractures?

Management of Pediatric Fractures

Most pediatric fractures should be managed conservatively with immobilization, accepting greater initial deformity than traditionally tolerated, because children's exceptional remodeling capacity mitigates long-term deformity risk and non-union is rare. 1

Initial Assessment and Evaluation

Clinical Examination

• Perform thorough neurovascular assessment documenting pulses, capillary refill, sensation, and motor function in all injured extremities 2
• Examine the entire limb, not just the obvious injury site, as children may have multiple fractures 3
• Complete skin examination for bruising patterns, particularly in non-mobile infants where bruising in unusual locations (ears, neck, trunk) raises concern for non-accidental trauma 4
• Document point tenderness, deformity, and any open wounds 4

Imaging Strategy

• Obtain orthogonal radiographs (AP and lateral views) of the injured area 2
• Minimize postoperative imaging—avoid routine follow-up radiographs unless clinically indicated, as immediate postoperative imaging identifies complications in only 0.22% of cases 4
• For stable, non-displaced fractures healing appropriately, serial radiographs are unnecessary; repeat imaging only for new trauma, increased pain, loss of range of motion, or neurovascular symptoms 5

Screening for Non-Accidental Trauma

• Perform skeletal survey in all children <12 months with fractures, with few exceptions (ambulatory children with toddler fractures or buckle fractures of radius/ulna or tibia/fibula) 4
• For children 12-23 months, skeletal survey appropriateness depends more on fracture type and mechanism 4
• Always obtain skeletal survey when fracture is attributed to abuse, domestic violence, or being hit by objects 4
• Universal skeletal survey for rib fractures and fractures without trauma history in non-ambulatory children 4
• Repeat skeletal survey at 2-3 weeks improves sensitivity and may identify 13 of 19 fractures missed initially 4

Conservative Management Principles

General Approach

• Accept more initial deformity than previously tolerated—pediatric remodeling potential is exceptional, and corrective procedures remain highly successful options if needed later 4
• Immobilize with removable casts and splints whenever possible to facilitate hygiene and monitoring 4
• Most upper limb fractures can be managed conservatively 4

Specific Fracture Management

Upper Extremity:

• Forearm fractures: Manipulation with intranasal opiates in emergency department, followed by plaster immobilization for fractures within acceptable displacement parameters 2
• Obtain orthogonal radiographs post-manipulation and repeat neurovascular assessment 2
• Review in fracture clinic within one week of injury 2

Lower Extremity:

• Non-displaced great toe fractures: Buddy taping with rigid-sole shoe, though conservative management without rigid immobilization may be equally effective with fewer complications 5
• Avoid prolonged immobilization causing unnecessary stiffness, muscle atrophy, and delayed return to activities 5

Surgical Indications

Absolute indications for surgical treatment: 1

• Multiple injuries requiring mobilization
• Open fractures
• Fractures with coexisting vascular injuries
• Failed initial conservative treatment
• Femoral neck fractures
• Displaced extension and flexion type supracondylar humerus fractures
• Displaced lateral condyle humerus fractures
• Femur, tibia, and forearm shaft fractures in older children and adolescents
• Unstable pelvis and acetabulum fractures
• Some physeal fractures

Vascular Compromise Management

• For displaced supracondylar fractures with decreased hand perfusion, perform emergent closed reduction 4
• Practitioner judgment is critical—degree of vascular compromise varies from absent pulses with some perfusion to completely pale hand with nerve deficits 4
• Consider skill level, time from injury, and consultant availability when deciding between immediate manipulation versus transfer 4

Open Reduction Considerations

• Open reduction may be necessary when closed technique fails due to fracture pattern, soft-tissue interposition, or patient characteristics 4
• Mixed evidence on timing: 12-hour cutoff shows statistically significant benefit for early surgery to avoid open reduction 4
• No significant evidence that reasonable delays increase other complications 4

Special Populations and Circumstances

Open Fractures

• Perform washout and apply windowed cast 4
• Open fractures in children have better prognoses than adult equivalents but still risk healing complications and infection 6
• Consider PICC line placement at time of surgery for ongoing management 4
• Minimize procedures and imaging to single most useful modality 4
• Consider at-home intravenous antibiotic treatment where possible 4

Laboratory Evaluation for Suspected Abuse

• Check serum calcium, phosphorus, and alkaline phosphatase (noting alkaline phosphatase may be elevated with healing fractures) 4
• Consider parathyroid hormone, 25-hydroxyvitamin D, and urinary calcium/creatinine ratio in all young children with concerning fractures 4
• Screen for abdominal trauma with liver function studies, amylase, and lipase when severe or multiple injuries identified 4
• Urinalysis for occult blood 4

Follow-Up and Monitoring

Telehealth Utilization

• Maximize video or teleconferencing for follow-ups when clinically appropriate to minimize viral transmission and healthcare contacts 4
• Perform imaging only if it will change treatment plan 4
• Ensure patients are not lost to follow-up and parents have adequate support 4

Pain Management in Toddlers

• At 19 months, communication of pain is limited—monitor for behavioral changes including anxiety, agitation, and increased analgesic requirements 5
• Provide oral analgesia and safety-netting information on discharge 2

Critical Pitfalls to Avoid

• Do not miss non-accidental trauma in infants <12 months—skeletal survey is nearly universal in this age group 4
• Avoid routine postoperative imaging that does not change management 4
• Do not perform prolonged immobilization unnecessarily 5
• Never replant avulsed primary teeth—risk of damage to permanent tooth germ 4
• Recognize that most pediatric fractures heal rapidly with minimal intervention, but maintain high suspicion for growth plate injuries that may cause growth arrest if unrecognized 7