An Introduction to Pediatric Orthopedics

When it comes to the skeleton, kids are not just mini adults. The child’s skeleton is a work in progress from conception until the late teen years. By age 14 for girls and 16 for boys, the bones are more akin to an adult’s than they are to a 10-year-old sibling. In children, the bones are morphing from mostly cartilage and softer bones to the denser, harder bones of an adult.


For examples, an adult hand has 27 bones, but an x-ray of a toddler’s hand will have less than half of them. The bones are all there in a 2-year-old, but many of the bones do not have enough calcium yet to be visible on plain x-rays. Hence, making accurate diagnoses in young kids requires intuition and experience.


Fractured bones in a growing child are impacted by the growth plate (aka physis) at the ends of the longer bones that make up the bulk of our arms and legs. This can be a blessing or a curse. A fracture close to, but not involving, the growth plate will heal faster, more reliably and “straighter” than in an adult. A fracture that extends into the growth plate needs much closer observation, as it brings the risk of possible change to the length, contour or shape of a bone. Any of these effects might require a corrective procedure later in life. Fortunately, because kids are still growing they have what we call “remodeling” potential. This means that the need for dramatic surgeries with lots of hardware, such as rods, plates, screws, etc. is much less frequent in kids than in adults. But when the decision to treat with surgery or not is at hand, experience and focus on kids’ bones gives pediatric orthopedic specialists an advantage in making the right call.


Parents often wonder when their child is injured on the playground or in sports if a broken bone has occurred. As an aside, in medicine we always use the term fracture for any break or crack in a bone, whether larger or small, mild or great. Some fractures are very mild and may just need rest and immobilization, while others are very significant and will need surgery.


How do kids fracture a bone? Mostly bad luck, hence the word “accident.” Toddlers for example can simply twist the leg getting a foot caught while running on tile and get a “hairline” fracture. Again, such fractures may be invisible on x-ray, but an experienced pediatric orthopedic specialist will recognize that such “invisible” fractures will require casting.


Playground equipment is another big offender. Trampolines and monkey bars create a lot of work for pediatric orthopedic doctors, as they can often result in complex elbow fractures, fractures to the upper end of the tibia or shin, and of course, the wrist. The American Academy of Orthopaedic Surgeons and the American Academy of Pediatrics recommend adult supervision and only one kid at a time on the home trampoline; that’s a tough safety measure for many households. Please be careful though, as year after year trampolines are top cause of catastrophic head and spine injuries.


Another playground tip for little kids; if a child is too small to go down a playground slide, discourage tandem sliding with bigger kids or adults. Tandem sliding creates a surprising number of tibia fractures, whereas solo sliding does not.


Not surprisingly, sports are another leading cause of childhood bone fractures. Some of the sports with a higher incidence of fractures are gymnastics, soccer, football, BMX, competitive cheer, parkour, and lacrosse.

Is childhood dangerous? Yes and no. I don’t mean to terrify you with the information in this update. We all should encourage kids to explore, play outdoors, and experience or try out different sports. But with our encouragement should also come common sense and boundaries based on the age and ability of the child.

What are 10 things you can do as a parent if you suspect your child might have a fractured bone?

  1. Try to stay cool. Your child is distresses and needs to see you as a source of comfort and tranquility.
  2. If a limb is bent or crooked, apply ice, fashion some sort of a simple splint, and seek emergency care. You may give your child ibuprofen or acetaminophen with water as long as it isn’t prohibited by some other medical condition. Stop any other food or drink until your child has been assessed medically.
  3. If the limb is not deformed, ice it and elevate it, administer an OTC painkiller as above, and if pain does not diminish promptly, call your pediatrician or orthopedic doctor.
  4. Kids should never be sent back into a game or practice with any significant pain.
  5. If a fracture is diagnosed at an urgent care of ER, gather as much information as you can. Do Not leave the building without at least a cell phone photo image of x-rays or other imaging tests; hopefully you get an actual x-ray or disc to bring to the pediatric orthopedic doctor.
  6. Don’t hesitate to call and ask for help if a splint seems too tight or pain is extreme at home. In general, loosening the wrap on a splint or cast to maintain circulation and relieve tightness is a good idea.
  7. Ask plenty of questions at the ER or Urgent Care about who you should see, when, and if they can help you obtain an appointment with a pediatric orthopedic specialist.
  8. Once you get into the specialist ASK QUESTIONS. Our mission is to give you clear information about your child’s injury.
  9. Our common goal is to get your child healed in a safe and efficient manner. Every child deserves to heal and have the best limb for the rest of their life. It’s worth missing the rest of this sport’s season and disappointing coaches and teammates if that’s what’s necessary for your child to heal correctly,
  10. Monitor the Cactus Pediatric Orthopaedics blog, as we’ll be posting regular about topics to keep your kids safe healthy.


drMay your children be safe and healthy!


Dr. Greg Hrasky