DDX of spectrum of pediatric fractures

Approach to the DDX of the spectrum of pediatric fractures / Rules of pediatric fractures:

  • Don’t panic because the patient is a child
  • Obtain 3 views (AP, lateral, oblique) of the suspected fracture site because you want to see the fracture on 2 views to be sure it is real
  • Image the joint above and the joint below the suspected fracture site to look for associated dislocations
  • When you see one fracture in paired bones (radius/ulna, tibia/fibula) look for second fracture in the other bone
  • Correlate point tenderness on physical exam to radiograph findings as if the patient has point tenderness at an area of lucency on the radiograph which is suspicious for a non-displaced fracture (especially if it is only seen on one view), this lucency most likely represents a fracture
  • Image the opposite side of the body as a control when in doubt as to whether a bone is fractured or is a normal variant
  • If what you are seeing on a radiograph can be found in Keats’ Atlas of Normal Roentgen Variants That May Simulate Disease, it most likely does not represent a fracture
  • If you are still not sure if a bone is broken, treat it as a fracture and have the child return in 2 weeks for a repeat exam, as if there is a fracture, healing callus will be present at 2 weeks on the follow-up radiograph