Fractures in children: buckle, greenstick and the growth plate (Salter–Harris)
- Finding
Children's bones bend and buckle before they snap, and the growth plate is their weak spot, so their fractures look different from adults'.
What it is
A child's bone is more elastic and porous, with a thick, strong periosteum and an open growth plate (physis) that is weaker than the ligaments around it. So children get fracture types adults rarely do. In a buckle (torus) fracture the cortex is compressed and bulges, usually in the distal radius metaphysis, with no visible line through the bone. In a greenstick fracture the cortex on the tension side breaks and the opposite cortex only bends. A plastic bowing deformity bends the whole shaft without a line. Injuries through the growth plate are graded by Salter–Harris (types I to V): the higher the type, the more likely the joint surface and future growth are affected. Some fracture patterns in young children, especially those who cannot yet walk, raise concern for abuse and need a careful, documented work-up.
What it looks like
- Buckle (torus): a smooth bulge or small step in the cortex of the metaphysis, often only on one view; no line crosses the bone.
- Greenstick: a break through one cortex (the convex, tension side) with the other cortex intact but bent.
- Plastic bowing: the whole shaft is curved with no line; compare with the other forearm bone or the other side.
- Salter–Harris I: through the physis only; the X-ray may be normal or show a widened plate.
- Salter–Harris II (the commonest): through the physis and up into the metaphysis, leaving a metaphyseal corner fragment.
- Salter–Harris III: physis and down through the epiphysis into the joint; IV: across metaphysis, physis and epiphysis; V: crush of the physis, often recognized only later.
Why it looks that way
- The thick periosteum often stays intact on one side, which keeps fragments together and helps reduction.
- The physis is cartilage: it is weaker than ligament, so a child's «sprain» near a joint may be a physeal fracture.
- Remodelling is strong in young children near the growth plate, so some angulation can correct itself with growth.
| Salter–Harris | Where the line runs | What it means |
|---|---|---|
| I | Straight through the physis | X-ray may be normal; good outlook |
| II | Physis + metaphysis (above) | Commonest; usually good outlook |
| III | Physis + epiphysis (below), into the joint | Intra-articular; often needs exact reduction |
| IV | Through metaphysis, physis and epiphysis | Intra-articular; high risk of growth disturbance |
| V | Crush of the physis | Easy to miss at first; worst growth outlook |
Differential and pitfalls
- A tender growth plate with a normal X-ray: treat as a Salter–Harris I injury.
- Types III and IV cross the joint surface and the growing plate: risk of growth arrest, limb-length difference and angular deformity.
- A buckle fracture is stable; a greenstick fracture can angulate and may need reduction.
- Concern for abuse: fractures in a child who does not yet walk, metaphyseal corner («bucket-handle») fractures, posterior rib fractures, several fractures of different ages, or a story that does not match the injury.
- Normal ossification centres and growth plates can mimic fractures; a view of the other side or an atlas of normal variants helps.
Next step
- Buckle fracture: a removable splint for a short period is usually enough; a repeat X-ray is not routinely needed.
- Greenstick with angulation, or any displaced or Salter–Harris III–IV fracture: refer to paediatric orthopaedics.
- Suspected Salter–Harris I with normal X-ray: immobilize and re-examine in one to two weeks.
- Suspected abuse: a full skeletal survey (and head imaging in infants), detailed records, and the local child-protection pathway; ask a senior and the radiologist.
- Complex intra-articular or physeal injuries: CT or MRI as advised by orthopaedics or the radiologist.
Test yourself
Think of the answer, then tap the question to see it.
What is the difference between a buckle and a greenstick fracture?
In a buckle fracture the cortex is compressed and bulges without breaking through; in a greenstick fracture one cortex breaks and the opposite one bends.
Which Salter–Harris type is the most common, and where does its line run?
Type II: through the growth plate and up into the metaphysis, leaving a metaphyseal fragment.
Why can a Salter–Harris type I fracture be missed on X-ray?
The line runs only through the cartilage of the growth plate, so the film may look normal or show only slight widening of the plate.
Which fracture patterns in a young child should raise concern for abuse?
Fractures in a child who is not yet walking, metaphyseal corner fractures, posterior rib fractures, multiple fractures of different ages, or an injury that does not fit the story.
Elsewhere in DurgiPedia
Connections
Educational content; it does not replace a radiologist's report and is not a clinical instruction. Each study is ordered on the patient's assessment and your institution's protocols.
Sources: Pediatric Physeal Injuries Overview (StatPearls (NCBI Bookshelf), 2024); Salter-Harris Fracture (StatPearls (NCBI Bookshelf), 2023); Greenstick Fracture (StatPearls (NCBI Bookshelf), 2026); Pediatric Torus Buckle Fracture (StatPearls (NCBI Bookshelf), 2023); Child Abuse and Neglect (StatPearls (NCBI Bookshelf), 2025).
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