Treatment

Initial assessment

Initially, the whole patient must be assessed to identify any life-threatening injury that would take precedence over a musculoskeletal injury "A,B,C"). Once assessed and stabilized (if necessary), assessment should focus on the injury to determine whether there are any complicating factors that would influence treatment choices. These include:
  • Skin integrity/open injury
  • Assessment of nerves
  • Assessment of blood vessels
  • Intra-articular fracture extension
  • Associated joint subluxation or dislocation

Reduction

Pediatric fractures, if undisplaced or minimally displaced, may require no reduction. Children can remodel fractures if the displacement is angular (not rotational) and in the plane of motion of the adjacent joint. A rule of thumb is that children can remodel 5 degrees for every year of growth remaining. Generally, girls grow until age 14 and boys until age 16. It is therefore reasonable to expect some pediatric fractures to remodel, reducing the need for "perfect" reduction. One notable exception is intra-articular fractures that need to be anatomically reduced to prevent (or reduce the chance of) post-traumatic arthritis.

Immobilization

Because of the thick periosteum and the intrinsic biomechanical properties of immature bone, pediatric fractures are often relatively stable and are generally quick to heal. Children's fractures are frequently immobilized using casts or splints. Traction was historically the treatment of choice for children's femoral fractures. However, over the past decade, it has fallen out of favour and is used less frequently than in the past.

Fractures requiring open reduction may be stabilized with percutaneous pinning, external or internal fixation with plates/screws. It is important to spare the growth plate when fixing a child's fracture; this consideration influences the choice of internal fixation. Standard long bone (femur, tibia, humerus) intramedullary rods are not used in children because of potential complications including avascular necrosis of the hip. Flexible intramedullary nails that can be inserted without crossing the physis are now used for long bone fractures in older children who require internal fixation.

Rehabilitation

Children are often described as their own "best physiotherapist" and therefore formal physiotherapy is less frequently prescribed than in adults. Nevertheless, especially in situations of return to sports and other activities, it in important to ensure adequate flexibility and strength prior to resuming full activities in order to reduce the chance of future injury.