X-rays

• Include the joint above and below the fracture to avoid missing an associated dislocation.
• Pediatric patients often are unable to localize pain; another reason for imaging joints above and below area of concern.
• X-rays should be taken in two planes; i.e. AP and lateral.
• When diagnosing epiphyseal separation or fractures of unossified epiphyses, obtain comparison limb views.

Treatment Pearls

• A child’s healing and remodeling capabilities can compensate for imperfect alignment to a much greater degree than an adult.
• Rapid fracture healing: femur fracture in infant - 3 weeks; 8 year old - 8 weeks.
• To prevent physical injury, growth plate fractures should be reduced only once. Splint and refer to an orthopedist on an urgent basis.
• Rotational malalignment and lateral angulation do not self correct. Bayonet apposition and anteroposterior angulation in place of joint motion do tend to correct.
• Open fracture – use advanced trauma life support (ATLS) guidelines.
• Be aware of child abuse. If the story does not fit the injury, consider doing entire long bone/body x-rays if child abuse is suspected.

Complications

• Growth disturbances after epiphyseal plate injuries.
• Osteomyelitis.
• Volkmann's ischemia of nerves and muscles.
• Post-traumatic myositis ossificans.
• Refracture, deformities.

Reviewed by CDR Wendy Bailey, MC, USN, Pediatric Specialty Leader, Naval Medical Center San Diego, San Diego, CA (1999).