Children break bones more easily than adults - so pediatric fractures are very common. There are several unique features of the pediatric musculoskeletal system that need to be considered in management decisions of all of these injuries - growth plates, plasticity, callus formation, remodeling potential, and partial breaks are some of the key ones. Recognition and appropriate management of pediatric fractures by ED providers is critical. While some common minor wrist and ankle fractures can be treated with a less conservative approach encouraging an early return to activities, other fractures if not treated properly can result in long term functional problems for the child and/or be a sign of child maltreatment.



Bottom Line Recommendations

Bottom Line Recommendations: Fractures


Boutis K, Camp M & TREKK Network

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of fractures in children. Original (version 1.0) published online: November 2015. Updated (version 2.0) published online: February 2018.

Recommandations de Base: Fractures chez l'enfant


Boutis, K & TREKK Network

Recommandations de base pour le diagnostic et le traitement des fractures chez les enfants. Original (version 1.0) publié en ligne en décembre 2016. Mise à jour (version 2.0) publiée en ligne février 2018.


Clinical guidelines

Clinical Practice Guideline: Paediatric fracture guidelines


Victorian Paediatric Orthopaedic Network

Summary of paediatric fracture types, emergency department management, and information for fracture clinics.

Clinical Practice Guideline: Peripheral neurovascular checklist


SicKids Division of Orthopaedic Surgery

Peripheral Neurovascular Checklist.

Clinical Practice Guideline: Management of fractures in adolescents


Parikh, SN, Wells, L, Mehlman, CT & Scherl, SA

Summary of classifications, imaging, and treatments of fractures.

Clinical Practice Guideline: AboutKidsHealth: Tools for measuring pain


Stinson, J

Objectives: To assess the level of pain felt by children through the use of pain scales and other measurement tools such as behavioural and composite measures.

Clinical Practice Guideline: Splinting ABCs: upper and lower extremity splinting in the emergency department


Sarwark, JF, Maizels, M, Adler, MD & Nicholson, D

This guideline describes preparation and application of plaster and fiberglass short arm splints and short leg splints. Materials and set up for each type of splint are discussed in detail and the advantages and disadvantages of using fiberglass splints are outlined.

Summaries of systematic reviews

Cochrane Summary: Antibiotics for preventing infection in open limb fractures


Gosselin, RA, Roberts, I & Gillespie, WJ

Objective: To review the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

Systematic reviews

Systematic Review: Which radiological investigations should be performed to identify fractures in suspected child abuse? (2006)


Kemp, AM, Butler, A, Morris, S, Mann, M, Kemp, KW, Rolfe, K, Sibert, JR, &...

Objectives: To determine which radiological investigations should be performed and which children should be investigated.

Cochrane Systematic Review: Antibiotics for preventing infection in open limb fractures


Gosselin, RA, Roberts, I, & Gillespie, WJ

Objective: To quantify the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

Key studies

Key Study: Cost-effectiveness analysis of cast versus splint in children with acceptably angulated wrist fractures (2011)


von Keyserlingk, C, Boutis, K, Willan, AR, Hopkins, RB, & Goeree, R

Objective: to assess the cost-effectiveness of wrist splints compared with routine casting in children with acceptably angulated distal radius greenstick or transverse fractures in a practice setting where casting is considered the standard of care.

Key Study: Femur fractures in the pediatric population: abuse or accidental trauma? (2010)


Baldwin, K, Pandya, NK, Wolfgruber, H, Drummond, DS, & Hosalkar, HS

Objective: to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.

Key Study: Pediatric distal radial fractures treated by emergency physicians (2009)


Pershad, J, Williams, S, Wan, J, & Sawyer, JR

Objective: To assess short-term outcomes after distal forearm fracture reductions performed by emergency physicians.

Key Study: Evidence into practice: pediatric orthopaedic surgeon use of removable splints for common pediatric fractures


Boutis, K, Howard, A, Constantine, E, Cuomo, A, Somji, Z, & Narayanan, UG

Removable splints when compared with circumferential casts in randomized trials have been shown to be a safe and cost-effective method of managing many common minor distal radius and fibular fractures. This study estimated the extent to which this evidence is being implemented in clinical practice, and determined the perceived barriers to the adoption of this evidence.

Key Study: Epidemiology of pediatric fractures presenting to emergency departments in the United States


Naranje, SM, Erali, RA, Warner, WC Jr, Sawyer, JR, & Kelly, DM

Objective: To identify the most frequent pediatric fractures per 1000 population at risk in the United States using the 2010 National Electronic Injury Surveillance System database and 2010 Census information.

Key Study: Management of toddler's fractures in the pediatric emergency department


Schuh, AM, Whitlock, KB, & Klein, EJ

Objectives: To evaluate current practice in treatment of toddler's fractures, as well as subsequent healthcare utilization and complications.

Key Study: Evidence into practice: emergency physician management of common pediatric fractures


Boutis, K, Howard, A, Constantine, E, Cuomo, A, & Narayanan, U

Objectives: To determine the proportion of emergency physicians who prescribe removable devices for distal radius buckle fractures and/or nondisplaced distal fibular Salter-Harris I fractures. The investigators also examined follow-up referral patterns for these injuries.

Key Study: Paediatrician office follow-up of common minor fractures


Koelink, E, & Boutis, K

Objectives: To determine paediatricians opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office.

Key Study: Bone fractures in children: is there an association with obesity?


Sabhaney, V, Boutis, K, Yang, G, Barra, L, Tripathi, R, Tran, TT, & Doan, Q

Objective: To determine the relationship between body mass index (BMI) and odds of extremity bone fractures in children.

Key Study: Who are we missing? Too few skeletal surveys for children with humeral and femoral fractures


Shelmerdine, SC, Das, R, Ingram, MD, & Negus, S

Objective: To determine the potential shortfall in skeletal survey referral for children presenting with an acute non-supracondylar humeral or femoral fracture.

Key Study: Emergency ultrasound in the detection of pediatric long-bone fractures


Barata, I, Spencer, R, Suppiah, A, Raio, C, Ward, MF, & Sama, A

Objective: The goal of this study was to assess the agreement between emergency physicians' and radiologists' final assessments of suspected long-bone fractures using emergency ultrasound and radiography, respectively, in the pediatric population.

Key Study: Extremity fracture pain after emergency department reduction and casting: predictors of pain after discharge


Thompson, RW, Krauss, B, Kim, YJ, Monuteaux, MC, Zerriny, S, & Lee, LK

Objectives: To determine the prevalence of pediatric extremity fracture pain after emergency department (ED) discharge, compare pain severity between fractures requiring simple casting versus sedated reduction and casting, and explore predictors of postdischarge pain.

Key Study: Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients


Sinha, TP, Bhoi, S, Kumar, S, Ramchandani, R, Goswami, A, Kurrey, L, & Ga...

Objective: To assess the diagnostic accuracy of bedside ultrasound for fractures in pediatric trauma patients.

Key Study: Emergency room visits by pediatric fracture patients treated with cast immobilization


Sawyer, JR, Ivie, CB, Huff, AL, Wheeler, C, Kelly, DM, Beaty, JH, & Canal...

Objectives: To determine when and why pediatric patients with cast complaints return to the emergency room (ER). If this could be determined, educational and treatment strategies may help decrease the number of these visits and the cost of care.

Key Study: Sonographic detection of radiographically occult fractures in pediatric ankle and wrist injuries


Simanovsky, N, Lamdan, R, Hiller, N, Simanovsky, N,

Objective: To determine the effectiveness of high-resolution ultrasound (US) in differentiating radiographically occult fractures from sprains.

Key Study: A randomized prospective study of music therapy for reducing anxiety during cast room procedures


Liu, RW, Mehta, P, Fortuna, S, Armstrong, DG, Cooperman, DR, Thompson, GH, &a...

Objective: To decrease anxiety through the use of music therapy.