A child's skeleton is still growing. Bones are more porous and flexible, the periosteum is thick, and each long bone has a growth plate (physis) at its ends. These features explain why children have fracture patterns adults do not, why their fractures heal faster, and why an injury to the growth plate can shorten or angle a limb later.

Fractures

• Pain, swelling, deformity, refusal to use the limb or bear weight
• Neurovascular status distal to the injury: color, temperature, capillary refill, pulses, sensation, movement
• Suspect abuse with: fractures in a non-walking infant, posterior rib fractures, metaphyseal corner fractures, multiple fractures in different healing stages, or a history that does not fit the injury or development

Compartment syndrome — the classic "Ps" are pain out of proportion, pain on passive stretch (early), paresthesia, pallor, poikilothermia, pulselessness and paralysis (late). In children, watch for the "3 As": increasing anxiety, agitation, and analgesic requirement. Supracondylar humerus and forearm fractures carry high risk.

DDH

• Newborn: positive Ortolani (reduction "clunk") and Barlow (dislocation) maneuvers
• After about 3 months: limited hip abduction, asymmetric thigh and gluteal folds, apparent shortening of the femur (Galeazzi sign)
• Walking child: limp, toe walking, waddling gait (bilateral)

Clubfoot — rigid foot that cannot be manipulated to neutral; visible at birth and often on prenatal ultrasound.

Scoliosis — uneven shoulders, scapulae, or waist; one hip higher; rib hump on the Adams forward bend test; usually painless (pain needs further evaluation).

Osteomyelitis — fever, localized bone pain and tenderness, limp or refusal to bear weight, warmth and swelling.

DMD — delayed walking, frequent falls, waddling gait, difficulty climbing stairs, Gowers sign (uses hands to "climb up" the legs to stand), calf pseudohypertrophy.

• X-ray for fractures (compare with the other side when growth plates confuse the picture); skeletal survey when abuse is suspected
• DDH: hip ultrasound before about 4–6 months (femoral head not yet ossified); X-ray after that age
• Scoliosis: standing spine X-ray to measure the Cobb angle and assess skeletal maturity (Risser sign); scoliometer during screening
• Osteomyelitis: CBC, ESR and CRP (CRP is used to track response), blood culture before antibiotics, MRI (most sensitive); bone aspirate or biopsy for culture
• DMD: markedly elevated creatine kinase (CK), genetic testing of the dystrophin gene; echocardiogram or cardiac MRI and pulmonary function tests for monitoring
• JIA: clinical diagnosis; ANA (identifies uveitis risk); regular slit-lamp eye examinations

Fractures: reduction and casting or splinting; surgery for displaced or physeal fractures. Femoral shaft fractures are managed by age — Pavlik harness in young infants, spica cast in toddlers and preschoolers, and flexible intramedullary nails or other fixation in school-age children. Traction (skin or skeletal) is used less often but still appears in care.

DDH

• Pavlik harness for infants under about 6 months: holds hips flexed and abducted; worn continuously (often 23 hours a day) for several weeks as prescribed; straps are adjusted only by the provider
• Older infants or harness failure: closed or open reduction and hip spica cast

Clubfoot — Ponseti method

1. Gentle manipulation and long-leg casts changed weekly (usually about 5–7 casts)
2. Most infants need a percutaneous Achilles tenotomy before the last cast
3. Foot abduction brace (shoes on a bar) full time for about 3 months, then at night and naps until about age 4 — poor brace adherence is the main cause of relapse

Scoliosis

• 10–25° in a growing child: observation with repeat X-rays
• About 25–40° while still growing: bracing (skeletally immature — Risser 0–2; also 20–25° curves with documented progression) (thoracolumbosacral orthosis, such as the Boston brace), commonly prescribed for about 18 hours or more a day; benefit rises with hours worn. The older Milwaukee brace is now rarely used
• Curves beyond about 45–50°: posterior spinal fusion with instrumentation

Osteomyelitis: empiric IV antibiotics covering S. aureus (and MRSA according to local rates), switched early to oral therapy once fever and pain improve and CRP falls, for a total course of several weeks; surgical drainage for abscess. Vancomycin — levels and kidney function; clindamycin — diarrhea and Clostridioides difficile; cephalexin or cefazolin — allergy history.

DMD

• Corticosteroids (prednisone, deflazacort, or vamorolone) slow loss of strength. Monitor weight, BP, glucose, growth, bone density, cataracts, behavior; give stress dosing and never stop abruptly
• Cardiac medications (ACE inhibitor or ARB), respiratory support (cough assist, noninvasive ventilation), physical therapy, bracing
• Anesthesia alert: avoid succinylcholine and volatile anesthetics (risk of hyperkalemia and rhabdomyolysis)

JIA

• NSAIDs (GI upset, kidney effects — give with food)
• Methotrexate — given once a week (oral or subcutaneous; accidental daily dosing has been fatal); folic acid supplement; CBC and liver tests; no alcohol in adolescents; teratogenic; avoid live vaccines
• Biologics (e.g., TNF inhibitors) — TB screening before starting, serious infection risk, no live vaccines
• Corticosteroids — intra-articular preferred; systemic courses kept short (growth suppression, Cushingoid features, osteoporosis, hyperglycemia, infection)

Listed in priority order.

1. Neurovascular checks after injury, casting, surgery, or traction — color, warmth, capillary refill, pulses, sensation, movement, and pain with passive stretch; hourly at first, then per protocol. Report changes immediately; for suspected compartment syndrome, elevate to heart level (not above), loosen or bivalve the cast per order, and notify the provider — do not apply ice
2. Pain control with weight-based analgesics, positioning, and distraction; rising analgesic need is a warning sign
3. Cast care
   • Elevate the limb above heart level for the first 24–48 hours to reduce swelling (unless compartment syndrome is suspected)
   • Handle a wet plaster cast with palms, not fingertips; keep casts dry
   • Itching: blow cool air from a hair dryer into the cast; never insert objects, powder, or lotion
   • Petal rough edges; check skin at edges; report a foul odor, drainage, hot spot, or a child who keeps complaining under one area
   • Hip spica: tuck diaper edges under the cast, keep the perineal opening clean, turn every 2 hours (never lift or turn by the abduction bar), use a spica-compatible car seat
4. Traction — weights hang freely and are never removed or lifted; keep ropes in pulleys and the child aligned; pin-site care per protocol (e.g., chlorhexidine); watch for pin infection, skin breakdown, constipation, and complications of immobility
5. Pavlik harness — do not remove or adjust straps unless instructed; change diapers without removing the harness, placing the diaper under the straps; check skin in creases daily, with no lotions or powders under straps; report if the infant stops kicking or extending the knee (femoral nerve palsy); wear a thin undershirt and knee socks under straps; sponge-bathe unless the provider permits brief removal
6. Scoliosis brace — wear a snug, seamless cotton T-shirt under the brace; inspect skin over pressure points daily; no lotions or powder; encourage peer support and body-image discussions
7. After spinal fusion — log roll; neuro checks of the legs (movement and sensation); PCA or multimodal analgesia; incentive spirometry; monitor for ileus, urinary retention, and blood loss; early mobilization per protocol
8. Osteomyelitis — obtain cultures before the first antibiotic dose; maintain IV access; monitor fever and CRP trend; protect the limb from weight-bearing if ordered
9. DMD — breathing exercises, coughing, incentive spirometry, and cough-assist devices; position upright; safety for falls (non-slip floors, clear paths, handrails); keep the child as active as possible — avoid prolonged bed rest; weight management
10. Immobilized children (spinal cord injury, spica cast, traction) — reposition regularly and inspect skin to prevent pressure injury, bowel program, age-appropriate play and schooling

• Cast at home: report numbness, tingling, inability to move fingers or toes, pale or cold digits, increasing pain, or odor; keep dry; no objects inside
• DDH: harness wear exactly as prescribed; do not adjust straps; hip-healthy swaddling — legs free to bend up and out at the hips
• Clubfoot: weekly visits are essential; wear the brace as prescribed for years to prevent relapse
• Scoliosis: brace hours matter most; brace can be removed for bathing and sports as allowed
• Osteomyelitis: complete the full antibiotic course even if pain is gone; return for fever, new pain, or swelling
• JIA: warm bath or shower for morning stiffness; regular exercise and swimming; eye examinations even without eye symptoms; do not stop corticosteroids suddenly
• DMD: annual influenza and recommended pneumococcal vaccines; tell every anesthesia provider about the diagnosis; genetic counseling for female relatives (possible carriers)
• Injury prevention: helmets, trampoline safety, car seats, window guards

• Children's fractures: greenstick and buckle are incomplete; physeal injuries can disturb growth; children heal faster
• First assessment after injury, cast, surgery, or traction = neurovascular status
• Itching under a cast: cool air from a hair dryer — nothing inside the cast
• Suspect abuse with posterior rib fractures, metaphyseal corner fractures, or fractures in non-walking infants
• DDH: Ortolani and Barlow in newborns; limited abduction later; Pavlik harness under 6 months, continuous wear, diaper change without removal
• Clubfoot: Ponseti — weekly casts, Achilles tenotomy, then abduction brace
• Scoliosis: Adams forward bend test; brace about 25–40° in a growing child; cotton shirt under the brace, check skin daily; surgery beyond about 45–50°
• Osteomyelitis: S. aureus; cultures before antibiotics; finish the full course
• DMD: X-linked, Gowers sign, high CK; deep breathing and coughing prevent respiratory complications; avoid bed rest
• JIA: slit-lamp eye exams; methotrexate needs CBC and liver tests