Paeds · rheumatology-musculoskeletal-and-sports
Common paediatric fractures and growth-plate injury
Also known as Salter-Harris classification · growth plate fracture · physeal injury · buckle fracture · torus fracture · greenstick fracture · supracondylar fracture · Gartland classification
A fellowship approach to the common fractures of children's long bones and the growth-plate injuries they carry: the Salter-Harris classification of physeal injury and its prognosis, the greenstick, buckle and plastic-bowing patterns that come from the pliable paediatric bone, the Gartland classification and emergency percutaneous pinning of the displaced supracondylar humerus fracture with lateral-entry pins, the soft-bandage evidence for the torus fracture, the remodelling potential that accepts certain malunion, and the growth-arrest complications of physeal injury.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A child with a supracondylar humerus fracture and a cold, pulseless, white hand has a vascular emergency that needs immediate reduction and often brachial artery exploration — a pulseless white hand is never sent to the ward to wait
- The anterior interosseous nerve is the commonest nerve injured in an extension-type supracondylar fracture — test the OK sign, because a normal grip, a normal pulse and a grossly normal hand do not exclude an anterior interosseous nerve palsy
- A growth-plate injury can look deceptively normal on the first radiograph — Salter-Harris type V is a crush injury with a normal initial film, and a normal radiograph never rules out later premature physeal closure, so the child is followed up
- A femoral fracture or a classic metaphyseal lesion in a non-walking infant is inflicted injury until proven otherwise — take the safeguarding pathway, not just the plaster room
Life stages
Care settings
Clinical exam formats
Board mappings
- Musculoskeletal medicine - recognise and manage common fractures and growth-plate injuries in children
- Acute presentations - the injured child's limb and the threatened hand
- Orthopaedics and musculoskeletal medicine - apply the Salter-Harris and Gartland classifications and plan reduction and immobilisation
- Acute presentations - the displaced supracondylar fracture and the neurovascularly threatened limb
- Child protection - recognise inflicted-injury fracture patterns
- Rheumatology and orthopaedics 10-12
- Acute presentations 10-12
- Short Cases
- Long Cases
- 9. Musculoskeletal medicine - fractures and growth-plate injuries in children
- 3. Safeguarding - inflicted-injury fracture patterns
- 4. Professional skills and knowledge: Patient management
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline - Musculoskeletal disorders
- General Pediatrics Content Outline - Universal Task 4: Management and Treatment
- General Pediatrics Content Outline - Child Abuse and Neglect
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 1: Musculoskeletal disorders and trauma
- Medical Expert
- Pediatrics: Orthopaedics and musculoskeletal applied domain
A five-year-old falls off the monkey bars onto an outstretched hand and arrives with a swollen, S-shaped elbow held guarded and a hand that is pale and pulseless; or a toddler is brought in with a mildly sore wrist used normally, whose radiograph shows a tiny buckle of the dorsal distal radius cortex; or a non-walking infant presents not moving the leg and a radiograph shows a corner fracture at the distal femur. In each, the question is the same — what pattern is this, what does it threaten, and what is the right immobilisation. [7] [9]
Run the paediatric fracture through five patterns. Plate injuries cross the growth plate and are labelled Salter-Harris I to V. Bend is plastic bowing, a gradual curve with no break. Kink is the buckle or torus, a cortex that crumples without breaking through. Snap is the greenstick, one cortex broken and the opposite cortex intact and bent. Crush is Salter-Harris V, the physis squashed. Naming the pattern names the management. [1] [7]
Overview & Definition
A paediatric fracture is a break in a bone that is still growing, and the growth is what changes everything. The growth plate or physis is the cartilage layer at each end of a child's long bone, and it is weaker than the surrounding bone and ligament, so the forces that sprain or strain an adult instead fracture the child's growth plate. Because the bone is also more plastic and wrapped in a thicker periosteum, it bends, kinks and cracks in patterns that adult bone cannot reproduce. [1] [7]
The growth plate is the reason a child's fracture is a paediatric problem and not an orthopaedic aside. Injury to the physis can arrest growth, producing a leg-length discrepancy or an angular deformity months or years after the fracture has healed, and the pattern of the injury across the plate — captured by the Salter-Harris classification — predicts this risk. The fellowship skill is therefore not only to heal the bone but to read the growth plate and to follow the child long enough to catch a physeal bar. [1] [6]
The clinical importance comes from the handful of fractures that are not benign. The displaced supracondylar humerus fracture threatens the brachial artery and the nerves of the arm and is the commonest reason a child's hand becomes pulseless, and the high-energy physeal fracture of the distal femur or proximal tibia carries a high rate of growth arrest. Around these sit the common and forgiving fractures — the distal radius buckle, the greenstick forearm — which heal well and demand only the right immobilisation and a short follow-up. [7] [5]
References11ShowHide
- [1]Peterson HA. Physeal fractures: Part 3. Classification. J Pediatr Orthop, 1994.PMID 8077424
- [2]Pakarinen O, Saarinen AJ, Ponkilainen VT, Uimonen M, Helenius I, Kuitunen I. Soft bandage, splint or cast as the treatment of distal forearm torus fracture in children: a systematic review and meta-analysis. Sci Rep, 2024.PMID 39251716
- [3]Perry DC, Achten J, Knight R, Dutton SJ, Dritsaki M, Mason JM, Appelbe DE, Roland DT, Messahel S, Widnall J, Gibson P, Costa ML. Offer of a bandage versus rigid immobilisation in 4- to 15-year-olds with distal radius torus fractures: the FORCE equivalence RCT. Health Technol Assess, 2022.PMID 35904496
- [4]Kwok SM, Clayworth C, Nara N. Lateral versus cross pinning in paediatric supracondylar humerus fractures: a meta-analysis of randomized control trials. ANZ J Surg, 2021.PMID 33792121
- [5]Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am, 2001.PMID 11379744
- [6]Peterson HA, Shaughnessy WJ, Stans AA. Physeal bar equivalent. J Pediatr Orthop B, 2017.PMID 27748675
- [7]Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg, 1998.PMID 9689186
- [8]Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop, 1990.PMID 2250053
- [9]Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol, 2011.PMID 21940592
- [10]Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop, 1993.PMID 8370784
- [11]Jeroense KT, America T, Witbreuk MM, van der Sluijs JA. Malunion of distal radius fractures in children. Acta Orthop, 2015.PMID 25355309