Marilyn W. Edmunds, PhD, NP


January 08, 2004


What are the most important criteria for evaluating fractures in children?

Response From the Expert

Laurie Scudder, MS, RN-C, PNP
Adjunct Assistant Professor, School of Health Sciences, George Washington University, Washington, DC, and Pediatric Nurse Practitioner in a primary care pediatric practice, Columbia, Md.


Kids are kids, and in the process of being kids they will invariably hurt themselves. Injury evaluations are a primary part of pediatric practice. Almost 20% of children who present to a pediatric setting with an injury will have sustained a fracture.[1] While it may sound simplistic, the most important point to remember when evaluating children with potential musculoskeletal injuries is that they are not little adults! Children's bodies are a growing system, and injuries to little bones are very different.

There are several biological differences between adult and pediatric bone that should be noted. First, bones in children are more porous and less dense. Therefore, pediatric bony tissue may sustain injury with less significant amounts of trauma compared with in an adult.

Second, due to the immaturity and plasticity of children's bones, bony injury may result in bowing or bending, rather than an actual break. Commonly, a force to one side of a long bone may result in bending that leads to a torus or buckle fracture on the opposite side. Very young children may not sustain any actual disruption of the bony cortex, but rather may sustain a plastic deformation (a deformity that changes the shape of the bone without actually fracturing the bony cortex) that results in a change in the bone's shape or alignment.

The third major difference that must always be considered in children is the presence of the physis or growth plate. The point of attachment of the physis to the metaphysis is the weak link in a child's skeletal system; ligaments and tendons are stronger than this growing area of bone. Thus the types of trauma that could lead to a strain or sprain in an adult may result in a growth plate fracture in a child.

Injuries to the physis are classified using the Salter-Harris system, which grades injury from type I, a separation of the epiphysis from the metaphysis, to type V, a crush injury to the growth plate.[2] Injuries to the physis may result in a disruption of future growth; recognition and appropriate management are therefore essential.

The fourth point is that the periosteum, the vascular outer layer of the bone, is often thicker in children and may remain intact despite a fracture to the remainder of the bone's structure. The periosteum lessens the amount of displacement that may occur during a fracture and leads to more rapid healing.

The final critical point in evaluation of children is the consideration of abuse within the context of the child's age and developmental stage. A sizable percentage of fractures in very young children are the result of abuse. There is no fracture pattern that is diagnostic of abuse, nor is there a pattern that is completely inconsistent with this possibility. A thorough history, focused on the plausibility of the event, the concordance between the reported injury and the trauma sustained, and the previous history of injuries must be obtained in order to rule out the possibility of nonaccidental injury.

A full discussion of this topic is well beyond the scope of this response, but readers are referred to several excellent resources. The November 2003 issue of Contemporary Pediatrics contains an excellent review written by M. Patrice Eiff and Robert L. Hatch.[1] Perhaps the most well-regarded textbooks in this field are those by Dr. Lynn Staheli, who in 2001 published Practice of Pediatric Orthopaedics.[3] This thorough, extensively illustrated text may be more than the average primary care NP wants to digest, but it is an essential reference for most pediatric offices. Another wonderful option is Primary Orthopedic Care written by Christy Crowther, a nurse practitioner in private practice.[4]


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