Resident Guidelines - PEDS 5


FRACTURES:   Link here to a pdf of Simplified PEDS Fracture Guide



A. General Principles

  • You may accept more angulation once callus has begun to bridge.
  • All other situations not covered in this guide: use literature or consult an attending or chief.
  • Pediatric service cares for operative fractures before the 16th birthday.
  • Call attending whenever you have admitted a fracture which requires surgery, even if it is not an emergency. This allows for timely planning.
  • Not all casts need to be bivalved: if the mechanism is low-energy and the swelling is minimal, this should not be necessary
  • Splints should be made of fiberglass. Plaster bends at the joint.
  • Fracture follow-ups generally at 1 week except buckle/toddler fractures. These are stable fractures and just need to come back at a month for cast removal.
  • Make follow-up instructions as specific as possible: give specific name and number for clinic; give specific date of follow up. This avoids a lot of secretarial effort trying to figure out what we meant.  Make sure you are aware of clinic cancellations and holidays.
  • Fractures taken care of by Pediatric service or involving unusual growth issues can be followed up in Pediatric Chief clinic. Phone number is 5-3870. Others can go to Fracture clinic (5-1796).
  • Children of Faculty and Staff should generally go to an attending clinic for TLC and continuity.



    • Physeal Fractures
      Accept up to 10 degrees of angulation in either plane, and up to 25% translation. Use well-molded long arm cast if reduction was necessary; well-molded short arm cast if it was not.
    • Metaphyseal Fractures
      Accept up to 10 degrees angulation. Well-molded short arm cast is all that is needed (flatten it out in dorsal and palmar surfaces). Cast should not extend all the way up to the elbow. If forearm is very chubby could use a Munster cast (around olecranon, analogous to PTB) or long arm cast, at surgeon's discretion.
    • Buckle Fractures (one cortex intact, one cortex compressed)
      Generally are intrinsically stable. No reduction is needed unless the angulation exceeds 10-15 degrees. Can be treated by short arm cast for 3-4 weeks.
    • Greenstick Fractures
      Less stable than buckle fractures, but accept up to 10 degrees angulation.
    • Plastic Deformation
      Accept up to 20 degrees angulation compared to other side. If greater, then need to sedate and crack the concave cortex and reduce.
    • Type I: no reduction; long arm splint made of fiberglass.
    • Type II: OK to reduce pure extension of 10-20 degrees, but any varus or valgus >10degrees (difference in Baumann angle from other side) should be reduced and pinned in the OR.
    • Type III: no reduction attempt in ER unless dysvascular and OR is delayed.

    • < 2mm displaced: Fiberglass splint, follow-up in one week.
    • >2 mm displaced: to OR for CRIF/ORIF.
    • >2 years of growth remaining: accept anything; sling and swathe.
    • <2 years of growth remaining: accept if angulation <40 degrees and head is reduced. Pin if greater displacement.
    • Accept any displacement; Sling.

    • May be treated in ER with spica cast if child under 6 and shortening at rest <2.5 cm. Need adequate sedation and skilled assistant.
    • Accept up to 10 degrees varus/valgus or flexion/extension.
    • Proximal metaphysis: anatomic reduction, cast in extension.
    • Diaphysis: accept 10 degrees in any plane. Can be PTB cast if undisplaced fracture not requiring reduction.
    • Toddler's fracture (undisplaced buckle or spiral); short leg walking cast; do not bivalve.
    • Physeal fractures involving distal tibia: ORIF if displacement >2mm and > 2 yrs growth remaining.




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