General principles of fracture management: Fracture patterns and description in

children

Authors:
David J Mathison, MD, MBA
Dewesh Agrawal, MD
Section Editor:
Richard G Bachur, MD
Deputy Editor:
James F Wiley, II, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: May 2018. | This topic last updated: Jul 17,
2017.

INTRODUCTION — This topic discusses the unique properties of pediatric fractures

and illustrates different classification systems that exist to identify and describe them.
Management of specific fractures is discussed separately and can be found by
searching for the anatomic region of interest.

Common fracture patterns (eg, transverse, oblique, spiral) seen in both children and
adults and general principles of fracture management are discussed in detail
separately.

●(See "General principles of fracture management: Bone healing and fracture

description", section on 'Orientation: Transverse, oblique, and spiral'.)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

BACKGROUND — Musculoskeletal injuries comprise approximately 12 percent of the

10 million annual visits to United States pediatric emergency departments [1]. Skeletal
fractures account for a significant proportion of these injuries and cause considerable
cost and morbidity to children. Despite aggressive campaigns for injury prevention, the
overall rate of fractures has been increasing [2-5].

Fractures in children exhibit unique patterns. Because of the distinctive properties of

the growing bone, special attention is required to differentiate normal variants and, for
the physeal fracture, to guarantee adequate healing while avoiding growth disturbance.
(See 'Physeal fracture description' below.)

FRACTURE DESCRIPTION IN CHILDREN — Describing a fracture entails a thorough

explanation of both the clinical scenario and the radiographic findings (table 1).

The clinical narrative should include:

 ●Age

●Gender

●Mechanism of injury

●Anatomic location

●Soft tissue involvement (eg, open or closed)

●Key physical examination findings, especially neurovascular status

The initial imaging study is usually a plain radiograph. The radiologic interpretation of
the fracture encompasses the following:

●Type of imaging (including modality and view selection)

●Anatomic location

●Fracture pattern

●Relationship of fragments

●Physeal involvement (ie, Salter-Harris classification)

●Apophyseal disruption

●Joint or soft tissue involvement

A more detailed discussion of how to describe a fracture based on the plain radiograph
is provided separately. (See "General principles of fracture management: Bone healing
and fracture description", section on 'Fracture description'.)

PLAIN RADIOGRAPH VIEWS — An accurate radiologic evaluation begins with

obtaining the appropriate imaging study which is usually a plain radiograph. Standard
radiographic series in fracture evaluations of the extremities are often two or three
views and vary by the anatomic region of interest (table 2).

The assessment of a child with suspected fracture, especially of the long bone
diaphysis, requires physical examination of the joint both above and below the site of
injury. In some instances, radiographs of these areas are also needed. As an example,
the Monteggia fracture is a well described fracture of the proximal one-third of the ulna
with dislocation of the radial head. If the clinician visualizes a radial head dislocation on
an elbow series, it would be important to also image the entire forearm to evaluate for a
Monteggia fracture, a well-described pattern that is associated with a mid-to-proximal
shaft ulna fracture that may be missed on a dedicated elbow series. (See "Proximal
fractures of the forearm in children", section on 'Monteggia fractures'.)

FRACTURE PATTERNS — The periosteum of pediatric bone has significant

osteogenic potential and is comparatively more metabolically active than the adult
periosteum. This active periosteum promotes callus formation, union of fractures, and
remodeling during the healing process. The periosteum is also thicker and stronger in
children, which limits fracture displacement, reduces the likelihood of open fractures,
and maintains fracture stability in comparison to adult fractures [6,7]. The qualities and
function of the pediatric periosteum are responsible for some of the unique fracture
patterns seen in children [6,8,9]. Examples of these fractures include buckle,
greenstick, and plastic deformation (or bowing).

A bone fails when the loading forces exceed the load bearing capacity. Depending
upon both the force of the injury and the properties of the bone involved, load failure
results in a fracture in several unique patterns. Three fundamental forces cause
fractures: shear, compressive, and tensile. Bone is least able to withstand shear forces,
followed by tension, then compression [10].

Tensile bone failure causes fractures perpendicular to the direction of loading

(transverse), whereas compression forces cause oblique stresses in a plane
approximately 45 degrees to the bone's long axis [11]. Bending forces result in a
tensile stress to the convex side and a compressive stress to the concave side,
resulting in transverse and oblique fractures on the tensile and compressive sides
respectively. This tensile-compressive pattern from bending can cause a resultant bone
wedge referred to as a butterfly fragment or the characteristic greenstick fracture.
Torsion (rotational) forces lead to more complex fractures by causing a small crack to
extend into a spiral pattern (figure 1). Many fractures, however, involve combinations of
forces and therefore develop complex fracture patterns (figure 2).

Fractures specific to the pediatric patient are discussed here. Common fracture
patterns (eg, transverse, oblique, spiral) seen in both children and adults are discussed
in detail separately. (See "General principles of fracture management: Bone healing
and fracture description", section on 'Orientation: Transverse, oblique, and spiral'.)

Buckle (torus) — Buckle fractures follow compression injury, often at the junction

between the porous metaphysis and the denser diaphysis (image 1). With buckle
fractures, the cortical compression may be associated with an intact or disrupted
periosteum, depending upon the extent of the fracture. These injuries typically occur in
the distal radius after longitudinal trauma directed along the shaft of the bone (eg, fall
on an outstretched hand), but are also seen in the distal tibia, fibula, and femur. Buckle
fractures are also known as torus fractures (derived from the Greek "tora," meaning
ring and referring to the radiologic resemblance to the raised band around the base of
a Greek column, and also from the Latin "tori," for swelling or protuberance). Buckle
fractures are by definition stable and can often be managed with splinting by a
knowledgeable clinician and a single follow-up visit [12]. (See "Distal forearm fractures
in children: Diagnosis and assessment", section on 'Torus (buckle)
fractures' and "Distal forearm fractures in children: Initial management", section on
'Torus (buckle) fracture'.)

Plastic deformation — A plastic deformity (or bowing fracture) occurs when a

longitudinal force directed along the shaft of the bone exceeds the bone's ability to
recoil to its normal position leading to accentuation of the curvature of the bone which
indicate microscopic fractures within the periosteum of the bone (image 2). Plastic
deformities are most commonly seen in the ulna, the radius, and occasionally in the
fibula. If the deformation is less than 20 degrees or if the deformity occurs in a young
child (<4 years of age), the angulation often corrects itself [13]. Otherwise, urgent
referral to an orthopedist with pediatric expertise for closed reduction or operative
intervention is necessary to ensure proper healing. (See"Midshaft forearm fractures in
children", section on 'Plastic deformation'.)

Greenstick — A greenstick fracture describes a bone that is bent with a fracture line
that does not extend completely through the width of the bone (image 3). With these
injuries, one side has a visible, complete fracture (sometimes referred to as the
"tension side") and the opposite side has a plastic deformation or buckling due to
compression. The greenstick fracture is at high risk for repeat fracture. For example,
primary greenstick fractures account for 84 to 100 percent of forearm recurrent
fractures [14-16]. All greenstick fractures warrant immobilization followed by casting
within a few days of injury. The need for orthopedic referral at the initial visit depends
upon the age of the child and the degree of angulation as discussed separately.
(See "Distal forearm fractures in children: Initial management", section on 'Greenstick
fracture' and "Midshaft forearm fractures in children", section on 'Greenstick fracture'.)

Physeal (growth plate) — The diagnosis and management of specific types of

physeal fractures is discussed separately and can be found by searching on the long
bone of interest.

The anatomy of the growth plate leads to a special susceptibility to fractures and long
term complications in children:

●Normal long bone physis anatomy and growth – The growth plate or physis
represents a major anatomical difference between adult and pediatric bone.
Growing long bones in children are composed of the following segments:
diaphysis (shaft), metaphysis (where the bone flares), physis (growth plate), and
epiphysis (secondary ossification center) (figure 3).

The longitudinal growth of long bones occurs primarily at the physis. The germinal
area of the physis borders the epiphysis. The epiphyseal cartilage cells grow
toward the metaphysis and form columns of cells. These columns degenerate,
undergo hypertrophy, and then calcify at the metaphysis to form new bone (figure
3) [17]. The epiphyseal cartilage cells stop duplicating at the end of puberty. The
entire cartilage is eventually replaced by bone and epiphyseal lines remain at the
site [17]. The contribution of specific physes to longitudinal growth in the
extremities varies by site (figure 4).

In infancy and early childhood, the physis is relatively thick and the epiphysis is
mostly cartilaginous, serving as a shock absorber and transmitting forces to the
metaphysis. During adolescence, when the epiphysis begins to ossify, these
forces are less absorbed and consequently transmitted to the physis.
 Once the physis closes, then adult patterns of fracture are seen. The timing of
physeal closure varies in individual patients and by bone and patient sex (figure
5).

●Physeal fractures – Growth plates are susceptible to fracture and represent a

weak point in pediatric bone. Histologically, the weakest part of the physis is the
third zone (zone of hypertrophic cartilage), and is the most common site for
physeal fractures (figure 3). Because the tensile strength of pediatric bone is less
than that of the ligaments, the same injury mechanism causing a ligamentous
injury in adults (sprain or strain) may be more likely to cause a bone injury in
children: the physis will separate or fracture before disruption or "spraining" of an
adjacent strong and flexible ligament [6-8,18].

The growth and change that occur at a growth plate promotes rapid healing of
fractures in children. However, injury to the physis itself can lead to asymmetric
growth and subsequent deformity [6,19,20]. Displaced physeal fractures require
prompt consultation with an orthopedist with pediatric expertise. Thus, accurate
description of these pediatric fractures is essential to communicating the
seriousness of bone injury and the potential for growth disturbance. (See 'Physeal
fracture description' below.)

Physeal injuries occur in 21 to 30 percent of pediatric long bone fractures [21,22],

more commonly involving the distal growth plates of the radius and ulna [23]. In
girls, growth plate injuries occur between ages 9 and 12, while in boys they
typically occur later, between ages 12 and 15 [24]. Although a majority of these
fractures heal without incident, approximately 30 percent of these physeal
fractures cause a growth disturbance (premature closure and unilateral long bone
shortening) [6]. Appropriate anatomic alignment is critical for optimal growth and
minimal deformity following physeal fractures [7].

Apophyseal avulsion — Certain physes contain fibrocartilage instead of columnar

cartilage (eg, tibial tuberosity or the inferior pole of the patella) and are called
apophyses. These apophyseal centers are prone to overuse traction and inflammation,
termed apophysitis. Characteristic apophyseal overuse injuries include Osgood-
Schlatter disease (tibial tuberosity), Sever disease (calcaneus), pelvis (iliac crest,
anterior superior iliac spine, anterior inferior iliac spine, symphysis pubis, and ischial
tuberosity) and Sinding-Larsen-Johansson syndrome (inferior pole of the patella).
Unlike physeal injuries, apophysitis and mild apophyseal avulsions do not interfere with
growth and are mostly self-limited in adolescents. However, significant apophyseal
avulsions may require more aggressive management as discussed separately.
(See "Osgood-Schlatter disease (tibial tuberosity avulsion)" and "Heel pain in the active
child or skeletally immature adolescent: Overview of causes", section on 'Calcaneal
apophysitis (Sever disease)' and "Radiologic evaluation of the hip in infants, children,
and adolescents", section on 'Pelvic apophyseal avulsions' and "Approach to chronic
knee pain or injury in children or skeletally immature adolescents", section on 'Sinding-
Larsen-Johansson disease (patellar apophysitis)'.)
SPECIAL CIRCUMSTANCES

Potentially occult fractures — The following pediatric fractures may not be evident on

initial plain radiographs and often require diagnosis based upon physical findings and
follow-up imaging:

●Toddler's fracture (nondisplaced spiral fracture of the distal tibia) – The

toddler's fracture is a nondisplaced fracture of the distal tibial shaft in patients in
the age group from nine months to three years, when weightbearing is just
beginning. AP and lateral radiographs of the affected leg may show a faint hairline
fracture that can be easily missed, mistaken for a nutrient vessel, or inapparent on
initial films in almost a third of patients. The AP view is the best view for observing
the nondisplaced spiral fracture coursing along the distal tibia (image 4). Oblique
views of the tibia can aid diagnosis when the AP and lateral plain radiographs are
not revealing. In patients with clinical findings suggestive of a toddler's fracture but
negative plain radiographs, repeat plain radiographs in seven days will show
evidence of a fracture line that was not apparent on initial radiograph or new bone
growth suggesting a fracture. (See "Tibial and fibular shaft fractures in children",
section on 'Toddler's fractures'.)

●Nondisplaced Salter-Harris I fracture – Type I Salter-Harris fractures can have

normal plain radiographs. In these patients, the diagnosis is clinically suspected
when focal tenderness is found over the growth plate and confirmed later when
bone healing is found on repeat radiographs obtained seven days after injury.
(See 'Salter I (Ogden IA-C)'below.)

●Nondisplaced type I supracondylar fractures of the elbow – With Gartland

type I supracondylar fractures of the elbow, a fracture line is usually not seen on
plain radiographs but elbow effusion indicated by anterior sail and/or posterior fat
pad signs is appreciated (figure 6 and image 5). (See "Elbow anatomy and
radiographic diagnosis of elbow fracture in children", section on 'Fat
pads' and "Evaluation and management of supracondylar fractures in children",
section on 'Supracondylar fracture classification'.)

●Stress fractures — These fractures represent overuse injuries that arise from
accumulated microtrauma after repetitive strain. The loads from stress fractures
are less than what the bone can withstand, but cumulative fatigue damage can
cause small but progressive cracks in the periosteum. Stress fractures are more
commonly seen in adolescents than younger children and more frequently affect
females. The common sites of stress fracture vary depending upon the sport
(table 3). However, the most common sites of stress fracture, in decreasing order
of frequency, are the tibia, fibula, pars interarticularis (ie, spondylolysis), and
femur. (See "Overview of the causes of limp in children", section on 'Stress
fractures' and "Overview of stress fractures".)

Plain radiographic findings usually are not apparent until one to two weeks after
the onset of symptoms. They include lucency or periosteal reaction with new bone
formation in cortical bone; callus does not appear until four weeks after the onset
 of symptoms. Magnetic resonance imaging (MRI) has become the preferred test
when plain films are negative and the diagnosis is essential. It is extremely
sensitive and defines the anatomy and extent of injury more precisely than
scintigraphy. (See "Overview of the causes of limp in children", section on 'Stress
fractures' and "Overview of stress fractures", section on 'Approach to stress
fracture imaging'.)

Child abuse — Clinicians should be cognizant of certain fracture patterns that are

associated with child abuse. Fractures that are highly suggestive of intentional injury
include (see"Orthopedic aspects of child abuse", section on 'Fracture patterns'):

●Long bone fractures in non-ambulatory children

●Metaphyseal corner(or bucket handle) fractures (image 6 and image 7 and figure

7)

●Rib fractures (image 8)

●Fractures of the sternum, scapula, or spinous processes

●Multiple fractures in various stages of healing (image 9) (see "Orthopedic

aspects of child abuse", section on 'Fracture age')

●Bilateral acute long-bone fractures

●Vertebral body fractures and subluxations in the absence of a history of high

force trauma

●Digital fractures in children younger than 36 months of age or without a

corresponding history

●Displaced physeal fractures

●Complex skull fractures in children younger than 18 months of age, particularly

without a corresponding history

Furthermore any fracture in children with other red flags for child abuse on history or
physical examination should raise suspicion for abuse (table 4 and table 5).
(See "Physical child abuse: Recognition", section on 'Approach'.)

Any suspicion of child abuse should prompt involvement of an experienced child

protection team (eg, child abuse specialist, social worker, and nurse), if available. In
many parts of the world (including the United States, United Kingdom, and Australia), a
mandatory report to appropriate governmental authorities is also required. (See "Child
abuse: Social and medicolegal issues", section on 'Reporting suspected
abuse' and "Physical child abuse: Diagnostic evaluation and management".)

Pathologic fracture — A fracture in a bone that is weakened by an underlying

abnormality is termed a pathologic fracture. Patients with bone tumors, rickets,
McCune-Albright syndrome, juvenile osteoporosis, chronic renal insufficiency,
osteogenesis imperfecta (OI), and osteopetrosis are all at greater risk for fractures. The
proximal femur and humerus are the most frequent sites for pathologic fractures and
unicameral (simple) bone cysts, aneurysmal bone cysts, and nonossifying fibromas are
the most common tumors [25]. (See"Benign bone tumors in children and adolescents".)

OI is the most common metabolic bone disorder that causes pathologic fractures [26].
Features of OI include multiple fractures, a suggestive family history, and clinical
manifestations that can include short stature, scoliosis, basilar skull deformities,
hearing loss, blue sclerae, opalescent teeth, ligamentous laxity, and easy bruisability.
(See "Osteogenesis imperfecta: Clinical features and diagnosis".)

Repeat fracture — Refractures characterize repeat or recurrent fractures at the initial

site of injury. Refractures make up only 1 in 1000 of all children's fractures, occurring
frequently in the forearm and complicating 5 to 13 percent of forearm fractures
[14,16,27]. Risk factors for refracture include incomplete bony union, residual
angulation, early cast removal, radial or ulnar diaphyseal fracture, and greenstick
fracture pattern [15,16,28-31]. (See "Midshaft forearm fractures in children", section on
'Complications' and "Distal forearm fractures in children: Initial management", section
on 'Complications'.)

PHYSEAL FRACTURE DESCRIPTION — Several classification schemes for physeal

fractures have been devised, including the Salter-Harris, Ogden, Peterson, and many
others, most of which are specific to certain anatomical locations [32-34]. Of these, the
Salter-Harris classification is easily applied and appropriate for the majority of physeal
fractures. It is also the most widely used system, and represents as much a means of
communication between healthcare professionals as a method of classification.

The Salter-Harris classification system grades physeal fractures as types I through V.

While controversial and joint dependent, the severity of injury to the growth plate
generally increases with each Salter-Harris grade [35-37]. Complications of physeal
injury include growth arrest, permanent decreased range of motion, and angular
deformity [38]. The following mnemonic can be helpful to remember the different Salter-
Harris types when the long bone is in a vertical orientation with the epiphysis at the
bottom. The mnemonic refers to the fracture line and its relationship to the growth plate
(figure 8) [39]:

●S ("Straight across") – Type I (low risk for growth plate injury)

●A ("Above") – Type II, fracture through the physis and the metaphysis

●L ("Lower" or "BeLow") – Type III, fracture through the physis and the epiphysis

●T ("Two" or "Through") – Type IV, fracture through the physis and both the
metaphysis and the epiphysis

●E ("End") or ER ("ERasure of the growth plate") – Type V (high risk for growth
plate injury)

●R
Several modifications and additions have been made to the Salter-Harris schematic
[40,41], including Ogden's system that includes injuries to surrounding elements such
as the periosteum, zone of Ranvier, and perichondrium (figure 3 and figure 9) [42].
While the five Salter-Harris types (with Ogden's elaboration) encompass the mainstay
for physeal injuries, additional types have been described. (See 'Ogden Type VI' below
and 'Ogden Type VII' below.)

Physeal injuries are more common during times of rapid growth, such as adolescence,
and generally occur through the hypertrophic zone of the physis [5]. (See 'Physeal
(growth plate)' above.)

Salter I (Ogden IA-C) — The fracture line extends through the zone of hypertrophic
cartilage (zone 3), causing the epiphysis and physeal elements to separate from the
metaphysis (figure 3 and image 10).

Subclasses of Salter I fractures are described by the Ogden classification:

●A type IA Ogden fracture is characterized by a non-displaced fracture through

the physis without further extension of the fracture line.

●A type IB Ogden fracture is characterized by the fracture line extending through

the primary spongiosa bone layer resulting in a thin line of bone displaced with the
epiphysis. Type IB fractures usually occur in children with systemic diseases such
as myeloproliferative disorders. Subsequent growth is usually normal with Type IA
and IB fractures (figure 9).

●A Type IC Ogden fracture has an associated injury to the germinal portion of the
physis. Type IC fractures can cause growth arrest and rarely occur after three
years of age (figure 9).

Salter II (Ogden IIA-D) — The fracture line passes through the physis and then
extends across the physeal-metaphyseal junction into the metaphysis (figure 8). Type II
fractures are the most common physeal fractures.

The Ogden classification subdivides Salter II fractures as follows:

●An Ogden Type IIA fracture is characterized by a metaphyseal wedge, also

known as the Thurston Holland fragment (image 11).

●A type IIB involves further extension of the fracture line bidirectionally through
the metaphysis creating a free metaphyseal fragment or multiple fragments (figure
9).

●A type IIC fracture is a transverse physeal fracture that includes a thin layer of
metaphysis along with the metaphyseal triangular corner segment (figure 9).

●A type IID fracture is characterized by the angulation of the two segments

resulting in the metaphyseal segment compressing the physis and creating an
osseous bridge that leads to permanent growth arrest (figure 9).
Salter III (Ogden IIIA-D) — The fracture line extends through the physis and then
spreads through the epiphysis into the intraarticular space (image 12). If the transverse
fracture extends across the complete width of the physis, two epiphyseal segments
may be formed.

●A Type IIIB fracture, similar to type IB, courses through the primary spongiosa
physeal layer resulting in a thin bony metaphyseal line displaced with the
epiphyseal segment (figure 9).

●Type IIIC injuries involve epiphyses in mostly nonarticular areas.

●Type IIID fractures penetrate the germinal zone and interrupt the blood supply to
the avulsed segment. These fractures are difficult to visualize on traditional
radiographs.

Salter IV (Ogden IVA-C) — The fracture line spreads from the articular surface,
through the epiphysis, across the physis, and through a segment of the metaphysis
(image 13).

●A Type IVB fracture is characterized by further transverse extension of the

fracture through part or all of the physis creating additional epiphyseal fragments
(figure 9).

●Type IVC fractures involve damage to the adjacent cartilage, and type IVD
fractures have multiple metaphyseal-physeal-epiphyseal fragments, usually from
severe trauma.

Salter V (Ogden V) — This fracture is thought to be caused by a force transmitted

through the epiphysis and physis. The resultant disruption of the germinal matrix,
hypertrophic regions, and vascular supply causes a severe injury with growth arrest
and poor prognosis (figure 9). Type V injuries usually occur in joints that only move in
one plane, such as the knee or ankle. Causes of type V injuries include electric shock,
frostbite, and irradiation [43]. The mechanism for this growth arrest is unknown but
most theorize that compression, vascular insult, or an otherwise unrecognized direct
injury are the most likely mechanisms [44]. Because displacement of the epiphysis can
be minimal, this fracture pattern may go unrecognized on initial radiographs although
physeal injury can be demonstrated on magnetic resonance imaging (MRI).

Ogden Type VI — This fracture is typically a result of glancing trauma that involves the
peripheral perichondral area including the zone of Ranvier (figure 3 and figure 9)
[40,42].

Ogden Type VII — The fracture line is completely intraepiphyseal, from the epiphyseal
cartilage into the secondary ossification center. These fractures classically occur as
avulsions of fibrocartilaginous complexes at ossification centers, such as the tibial
tuberosity (figure 9).

Peterson fractures — The Peterson classification system was developed based upon

the epidemiologic results of 951 physeal fractures [24,45]. It describes two unique
patterns not reflected in the Salter-Harris and Ogden systems; Peterson type I and VI
fractures:

●Peterson type I – A Peterson type I fracture is a complete transverse

metaphyseal disruption with an additional extension that extends longitudinally to
the physis. This injury typically does not cause significant growth disturbance.

●Peterson type VI – A Peterson type VI fracture is a partial physeal loss usually

including the epiphysis. This injury occurs largely from lawn mower trauma which
is frequently associated with neurovascular injury and soft tissue damage.

AO pediatric classification — The Arbeitsgemeinschaft fur Osteosynthesefragen or

AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) is an
adaptation of a similar system used in adult orthopedic trauma [46]. This elaborate tool
uses body location (bone, segment) and morphology (severity, displacement) to more
distinctly identify the breadth of physeal and non-physeal pediatric long-bone fractures.
Because there are more than 200 different categorizations according to the AO
framework, this classification system may be better used for research purposes rather
than routine clinical documentation.

SUMMARY

●Describing a fracture entails a thorough explanation of both the clinical scenario

and the radiographic findings (table 1). (See 'Fracture description in
children' above and"General principles of fracture management: Bone healing and
fracture description", section on 'Fracture description'.)

●An accurate radiologic evaluation begins with obtaining the appropriate imaging
study. Plain radiographs are usually the first study in children with suspected
fractures. Standard radiographic series in fracture evaluations are often two or
three views and vary by the anatomic region of interest (table 2). (See 'Plain
radiograph views' above.)

●Children exhibit unique fracture patterns because of the relative compressibility

of their bone, the increased fibrous strength of the periosteum, and the presence
of the physis (growth plate). Examples of these fractures include buckle (image 1),
greenstick (image 3), and plastic deformation (or bowing) (image 2).
(See 'Fracture patterns' above.)

●Clinicians should be cognizant of certain fracture patterns that are associated

with child abuse, especially when other red flags for child abuse are present on
history (table 4) or physical examination (table 5). (See 'Child abuse' above
and "Orthopedic aspects of child abuse", section on 'Fracture patterns'.)

●The physis is susceptible to fracture and therefore similar forces that cause
ligamentous injuries in adults may lead to physeal bone fractures in children. The
Salter-Harris classification system has become the most widely accepted method
for describing physeal fractures. Physeal fractures are graded as types I through V
(figure 8). Special attention is needed for physeal injuries because growth arrest
can occur. (See 'Physeal fracture description' above.)

●Once the physis closes, then adult patterns of fracture are seen. The timing of
physeal closure in the extremities varies in individual patients and by bone and
patient sex (figure 5). (See 'Physeal (growth plate)' above.)

●Some pediatric fractures may not be evident on initial plain radiographs and

often require diagnosis based upon physical findings and follow-up imaging.
Common examples include toddler's fractures (nondisplaced spiral fracture of the
tibia) (image 4), Salter-Harris I fractures, Gartland type I supracondylar fractures
of the elbow (figure 6 and image 5), and stress fractures (table 3).
(See 'Potentially occult fractures' above.)