Paediatric Fractures

Overview

Fractures in children are different to fractures in adults as the child’s bones are still growing. Special considerations are taken into account when a child has a bone fracture due to the implications on their growth.

Bones in children tend to be softer and less rigid compared to adult bone, therefore, children are more susceptible to certain fracture types.

Fracture Red Flags in Children

Non-accidental injury

It is important to remember that non-accidental injury may be a possibility. General features suggesting non-accidental injury may include:

• A history or mechanism that is incompatible with the injury seen.
• Delayed presentation
• Fractures inconsistent with the developmental age of the child (e.g. toddler’s fracture in a child that cannot yet walk’
• Multiple injuries
• Injuries at sites not usually susceptible to trauma
• A child that is known to be at risk

More specific fracture types associated with non-accidental injury may include:

• Fractures in immobile children – toddler’s fractures can only happen if the child ‘can toddle’
• Rib fractures in the absence of major trauma
• Multiple fractures – falling down stairs rarely causes multiple injuries
• Fractures at different stages of healing
• ‘Corner’ or bucket handle fractures
• Transphyseal fractures of the distal humerus or proximal femur
• Femoral and humeral fractures in <18 months old

Paediatric Fractures

Greenstick fracture

A greenstick fracture is where the bone is breached on one side but uninterrupted on the other. Its name comes from the fact when a fresh wooden stick is bent, it breaks similarly from the outside.

Greenstick fractures most commonly occur after a fall on an outstretched arm.

Buckle (torus) fracture

A buckle (or torus) fracture is where one side of the bone is compressed but does not break, leading to the bulging of the cortex resembling the torus of a pillar (the round part a pillar stands on that sticks out). The bone ‘buckles’ under pressure.

Buckle fractures usually occur due to axial loading (such as falling on an outstretched hand).

Toddler’s fracture

A Toddler’s fracture is a minimally displaced or undisplaced spiral fracture of the tibia seen in toddlers (around 9 months to 3 years of age).

Toddler’s fractures can occur due to twisting the leg while the child is running or walking. 

Corner (bucket-handle) fracture

A corner (or bucket-handle) fracture describes fractures in the distal end of one or both femurs with wide loose bone at the distal end appearing similar to a bucket handle.

Corner fractures are associated with non-accidental injury.

Bowing fractures

Bowing fractures are incomplete fractures of long bones where the bone becomes curved along its length.

Bowing fractures usually occur after falling on an outstretched hand.

Growth plate fractures

Salter-Harris fractures are fractures that involve the physis (growth plate) of a bone. They are classified using the Salter-Harris system:

The SALTER mnemonic can be used to remember these types. For this mnemonic, the bone should be imaging as a long bone with the epiphysis at the bottom:

• I – Straight across – fracture straight across the physis
• II – Above – fracture above the physis (physis and metaphysis)
• III – Lower – fracture below the physis (epiphysis)
• IV – TE (through everything) – metaphysis, physis, and epiphysis
• V – Rammed – compression (crush) fracture of the physis)