Children have more fractures than healthy adults [1]. Child and teenage risk assessment skills are lower. Skeletal development is less stable but more elastic than adulthood. These qualities explain why children and teenagers have more fractures and recover faster. The skeleton is a dynamic organ with well-known growth and damage responses [2].

The patient's medical history must provide a sufficient explanation for the fracture. It is especially crucial to distinguish between accidental and non-accidental injuries in young patients (pathological fracture, child abuse). Despite their rarity, pathological fractures (such as in the presence of juvenile bone cysts) must be ruled out when trivial trauma results in shattered bones. Child maltreatment is indicated by delayed presentation, shaft fractures in newborns who are not yet walking, and conflicting or contradictory reports of what occurred. Metaphyseal fractures or bone fragments, subperiosteal hematomas, and fractures of varying ages are typical patterns of injury associated with child maltreatment [3].

Treatment Principles 

The primary objective of treatment is pain relief. Provisional immobilisation of the damaged limb provides pain relief and can be supplemented by medicine (nonsteroidal anti-inflammatory drugs, opiates). The patient must be put to sleep for any painful procedures, such as adjusting the teeth or fixing a misalignment.

Once the decision to anaesthetize a patient has been made, definite care must be administered. Unanticipated procedure modifications and repeated interventions should be considered therapy problems. Fragile vital signs or compromised limb viability necessitate immediate attention [4]. All other measures can be undertaken with less urgency if appropriate pain treatment is commenced [5]. Inadvertently     separating    children   from    their  attachment figures (Parents) can cause emotional pain, hence a parent should be permitted to stay in the hospital with an injured child. Outpatient or brief inpatient treatment facilitates a speedy return to the child's familiar social milieu and reduces family stress. The treatment should promote the child's natural need to be active rather than repress it [6].

Follow Up

Compression fractures do not entail displacement; hence, radiographic follow-up is unnecessary [7]. Therefore, radiographs should be acquired 7 and 28 days after conservative treatment of unstable fractures, as subsequent displacement may occur. Fractures treated with fixation are radiographed four weeks following surgery and prior to planned metal removal. Through clinical examination, bone healing, range of motion, and load-bearing capability are evaluated. As soon as the patient's mobility is nearly normal, he or she can resume athletic activity.       

Distal Upper Arm 

Supracondylar humerus fracture and radial condyle fracture are the distal upper arm fractures most likely to be associated with problems throughout skeletal development [8]. Due to the fact that growth at the plates above and below the elbow joint is minimal, residual malalignments are corrected exclusively in the plane of motion (antecurvatum) until the seventh year of life [9], which can result in significant movement limits [10].

Classification of supracondylar humerus fractures by degree of displacement (grades I–IV) [11]. Up to ten percent of cases are complicated by primary vascular and neurological injury, and twenty percent of these individuals require extra surgical therapy [12]. Reduction is intended to address axial abnormalities that cannot be corrected spontaneously (varus, valgus, and rotational deformities) [13]. Due to the brevity of the joint-bearing fragment, fixation is always recommended for displacements (grades III and IV). K-wire osteosynthesis (more stable crossed than unilateral), descending ESIN, and radial external fixator are the available alternatives [14]. K-wire fixation carries a 10% chance of ulnar nerve damage. Plaster must also be used to immobilise the arm. In contrast, the technically significantly more difficult descending ESIN or, alternatively, the radial external fixator provides the most movement stability [15].

Radiographic evaluation of a decreased supracondylar humerus fracture might be challenging. It is possible to interpret rotational abnormalities inaccurately. Unrecognised, they result in instability and tilting, as well as unsightly varus deformities. Therefore, intraoperative clinical examination of the arm axes with control of elbow joint mobility is essential [16]. A number of operations to treat post traumatic cubitus varus have been documented. During the time of skeletal development, radial condyle fracture is the most frequent intra-articular fracture. This fracture requires open reduction and stable (tension screw) fixation to prevent pseudarthrosis, which can result in valgus deformity and subsequent instability [17]. Correct primary care is crucial since secondary surgical correction gives inferior clinical outcomes. 

Additional diagnostic techniques are required to rule out secondary dislocation in fractures that are predominantly non-displaced. As the peak age for lateral humeral condyle fracture is between 4 and 5 years, magnetic resonance imaging requires anaesthesia and is thus a major intervention. Sonography [18], may be uncomfortable, and instruments of high quality are not universally accessible. The diagnostic criteria for exclusion of subsequent dislocation is consequently plaster-free radiography four to five days following treatment – this follow-up exam is essential.

Avulsion fractures of the epicondyle do not induce development problems. The lateral epicondyle ossific nucleus must not be mistaken as a fracture fragment. If medial epicondyle avulsion occurs in conjunction with elbow dislocation, one must rule out the existence of a fragment in the joint space. In instances when there is a propensity for redislocation, such as when there is substantial displacement, the fragment must be prefixed with a cannulated screw [19].

Proximal Forearm 

Compression fractures heal without any complications. They require plaster cast immobilisation for 2–4 weeks. Radiographic follow-up is unnecessary as clinical examination can evaluate bone repair. 

Both greenstick and complete fractures, especially those extending beyond the metaphysis, have a tendency to angulate and must be radiologically evaluated 7 to 10 days after injury [20]. Studies on the management of these extremely common fractures reveal a high rate of redislocation following conservative therapy and a high rate of complications with K-wire fixation. Some authors recommend casting the entire arm, however this appears to be inferior to a forearm cast. A Cochrane Review demonstrated a trend toward faster recovery following K-wire fixing. The distal radius has a particularly significant capacity for spontaneous repair of post-traumatic abnormalities until the tenth or even twelfth year of life. Up to 50° of corrections have been observed. However, it may not be acceptable to ask the patient and his or her family to endure a bayonet deformity for several months, therefore this decision should be discussed with everyone involved.

This overview of therapeutic principles for long bone fractures, particularly upper limb fractures, throughout bony growth can only give an indication of the amount of understanding of skeletal development physiology needed for paediatric traumatology. We must estimate future growth, taking into account the patient's age, fracture site, direction, and displacement, to do fair to our young patients. Working with each patient and parent to get the best treatment outcome is also crucial. This demands effective communication. Correctly selecting and applying conservative and surgical therapy options is essential. 

The essential needs for treating fractures in children and adolescents are fast pain relief and effective treatment (either in the hospital or outpatient) to achieve the best possible outcome while minimising expenditure and effort. It's also important to get back to full mobility quickly and avoid long-term problems like limited range of motion or growth problems from a broken bone. The treating doctor needs to know about and be able to use all of the right non-surgical and surgical treatments to reach these goals.

1. Landin, L.A. "Epidemiology of children’s fractures." J Peadiatr Orthop B, vol. 6, 1997, pp. 79–83.

2. Beaty, J.H., Kasser J.R., and Skaggs D.L. Rockwood and Wilkins Fractures in Children. 7th ed., Lippincott Williams and Wilkins, 2009.

3. Ravichandiran, N. et al. "Delayed identification of pediatric abuse-related fractures." Pediatrics, vol. 125, 2010, pp. 60–66.

4. Whitesides, T.E. et al."Tissue pressure measurement as a determinant for the need of fasciotomy." Clin Orthop, vol. 113, 1975, pp. 43–51.

5. Mehlman, C.T. et al."The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children." J Bone Joint Surg Am, vol. 83, 2001, pp. 323–327.

6. Slongo, T.F. "The choice of treatment according to the type and location of the fracture and the age of the child." Injury, vol. 36, no. Suppl 1, 2005, pp. A12–A9.

7. May, G., and Grayson A. "Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Bet 3: Do buckle fractures of the paediatric wrist require follow up?" Emerg Med J, vol. 26, 2009, pp. 819–822.

8. Shrader, M.W. "Pediatric supracondylar fractures and pediatric physeal elbow fractures." Orthop Clin North Am, vol. 39, no. 2, 2008, pp. 163–171.

9. Wessel, L.M. et al. "Wie lässt sich die Wachstumsprognose nach kindlicher suprakondylärer Humerusfraktur erfassen?" Orthopäde, vol. 32, 2003, pp. 824–832.

10. Devnani, A.S. "Late presentation of supracondylar fracture of the humerus in children." Clin Orthop Relat Res, vol. 431, 2005, pp. 36–41.

11. Weinberg, A.M. et al. "Die suprakondyläre Oberarmfraktur im Kindesalter - eine Effizienzstudie. Ergebnisse der multizentrischen Studie der Sektion Kindertraumatologie der Deutschen Gesellschaft für Unfallchirurgie - Teil I: Epidemiologie, Effektivitätsprüfung und Klassifikation." Unfallchirurg, vol. 105, 2002, pp. 208–216.

12. Ay, S. et al. "Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach." J Pediatr Orthop, vol. 25, 2005, pp. 149–155.

13. v. Laer, L. et al.Frakturen und Luxationen im Wachstumsalter. 5th ed., Thieme, 2007.

14. Hasler, C., and v. Laer L. "Screw osteosynthesis in dislocated fractures of the radial condyle of the humerus in the growth period: A prospective long-term study." Unfallchirurg, vol. 101, 1998, pp. 280–286.

15. Handelsman, J.E. et al."Corrective supracondylar humeral osteotomies using the small AO external fixator." J Pediatr Orthop B, vol. 15, 2006, pp. 194–197.

16. Wessel, L. "Diagnostik der supracondylären Oberarmfraktur." Hefte zur Zeitschrift Der Unfallchirurg, vol. 272, 1998, pp. 598–607.

17. Thomas, D.P. et al."Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children." J Pediatr Orthop, vol. 21, 2001, pp. 565–569.

18. Vocke-Hell, A.K., and Schmid A. "Sonographic differentiation of stable and unstable lateral condyle fractures of the humerus in children." J Pediatr Orthop, vol. B10, 2001, pp. 138–141.

19. Ngom, G. et al. "Fractures of the medial humeral epicondyle in child: Preliminary study about 18 cases." Dakar Med, vol. 48, 2003, pp. 199–201.

20. Randsborg, P.H., and Sivertsen E.A. "Distal radius fractures in children: Substantial difference in stability between buckle and greenstick fractures." Acta Orthop, vol. 80, 2009, pp. 585–589.