suspicion should be maintained if there is a concerning mechanism or presence of a joint effusion in the absence of radiographic abnormalities of the bone These fractures have the worst prognosis for growth disturbance as the compressive force may result in premature closure of the physis Unfortunately, the diagnosis is often made in hindsight after a growth arrest becomes evident Torus Fractures Torus (buckle) fractures are common fractures in young children They most often occur at the junction of metaphysis and diaphysis from a compressive load The cortex of the bone buckles in a small area, resulting in a stable fracture pattern ( Fig 111.3 ) As the child matures, the strength of the metaphyseal region increases, and the incidence of this fracture pattern decreases Greenstick Fractures The composition of pediatric bones makes them less likely to propagate the force of injury into comminuted fragments Thus, with greenstick injuries, the bone bends before it breaks, with the thick and active periosteum remaining intact on one cortex and acting like a hinge: torn on the convex side of the fracture while remaining intact on the concave side The intact cortex thus maintains apposition at the site of fracture; however, to obtain an anatomic reduction, the fracture must often first be completed The emergency clinician must be attuned to this pattern of injury as inadequate reduction of the deformation or bowing of the bone can result in an abnormal growth pattern and loss of function ( Fig 111.4 ) FIGURE 111.3 Anteroposterior (A ) and lateral (B ) radiographs of a distal radius torus fracture (Reprinted with permission from Waters PM, Skaggs DL, Flynn JM Rockwood and Wilkins’ Fractures in Children 9th ed Philadelphia, PA: Wolters Kluwer; 2020.) FIGURE 111.4 Greenstick fracture of the ulna (large arrow ) and a bowing fracture (small arrows ) of the radius The extent of bowing can often be fully appreciated only with comparison views of the opposite extremity Bowing Fractures Bowing fractures occur uniquely in children Evidence suggests that the mechanism is a longitudinal force causing “plastic” deformation (bowing), but stops short of creating a fracture ( Fig 111.4 ) Little remodeling can be expected from the injury, and both cosmetic and functional deficits are common Anatomic reduction produces the most satisfactory result All bowing deformities should be referred to an orthopedic surgeon Avulsion Fractures The frequency of avulsion fractures in pediatrics is a consequence of the strong muscular attachments to relatively weak secondary centers of ossification in the developing skeleton known as apophyses During intense muscular contraction, fractures can occur through the apophyseal plate Common sites include the pelvis, tibial tubercle, and the phalanges Avulsion fractures infrequently require open or closed reduction Conservative care is the mainstay of treatment GENERAL PRINCIPLES OF ACUTE ORTHOPEDIC CARE CLINICAL PEARLS AND PITFALLS Any child with obvious extremity deformity should be made nil per os (NPO) at triage given the potential need for procedural sedation or operative management for fracture reduction and casting Based on the history and mechanism of injury, the possibility of other injuries (e.g., head, chest, intra-abdominal organs) should be considered Physical examination must include inspection, palpation, range of motion (passive and active), and neurovascular examination with careful examination of the joints proximal and distal to the point of maximal tenderness Always carefully remove all splints, bandages, and clothing in order to perform an accurate examination with documentation of breaks in the skin, which may represent an open fracture Splinting the injured extremity immediately after evaluation and before radiographs are taken can decrease the child’s discomfort and prevent further injury Neurovascular status should be assessed before and after any splinting is performed If an orthopedist is not readily available, gentle longitudinal traction and gross realignment may be performed by the emergency clinician for fractures that are grossly displaced, unstable, or if there is vascular compromise Current Evidence Rapid assessment and treatment of pain both in the ED and after discharge are key components of the emergency care of musculoskeletal trauma Increasingly, triage protocols include the administration of appropriate oral analgesics prior to physician care For significantly painful injuries, clinicians should consider intranasal fentanyl, which has the advantage of a relatively fast onset of action (