Advancing Pediatric Fracture Care Through Research

Pediatric fractures require different treatment from adult injuries, yet many clinical decisions are based on adult protocols. In addition, many pediatric fractures are more serious than they appear due to the unique anatomy and physiology of children’s growing bones.

Within the Pediatric Orthopedic Clinic at UCSF Benioff Children’s Hospitals, specialists are conducting rigorous research on best practices for diagnosing and treating pediatric fractures and educating patients and families. Led by Ishaan Swarup, MD, chief of pediatric orthopedic surgery, the team is establishing the clinical frameworks that drive the standards of care.

Research insights address both immediate clinical needs and long-term developmental considerations. These include treatment timing for femoral shaft fractures, recognition of easily missed injuries such as Seymour fractures and guidance on when urgent specialist consultation is needed.

Timely intervention for femoral shaft fractures

Treatment delays for femoral shaft fractures in children can lead to poor outcomes. In a 2025 study, Swarup and colleagues examined factors contributing to treatment delays and identified strategies to prevent them.

“We found that patients who are typically 10 and older and those with higher injury severity scores are at greater risk for delayed treatment,” Swarup explains. “Delayed fracture fixation poses a higher risk of complications in young patients.”

The group’s findings support national recommendations to treat femoral shaft fractures within 18 to 24 hours when possible. At UCSF, a multidisciplinary team, including trauma surgeons, neurosurgeons, orthopedic surgeons and plastic surgeons, determines the best timing for surgery when it’s needed.

“The data from this research helps us stratify risk and raise our awareness about reasons for and implications of delays,” Swarup notes. “This is the first study using a large national database to look at the timing of thigh bone fracture surgery in children and how that timing affects outcomes.”

Recognizing the subtle: Seymour fractures

Some potentially serious pediatric fractures masquerade as minor issues. Seymour fractures – growth plate fractures of the great toe – are an important example. Swarup and his colleagues authored a 2025 study that examined key treatment guidelines.

“In Seymour fractures, the bone breaks at the growth plate and comes through the nail bed of the big toe,” Swarup explains. “It's technically an open fracture, which puts it at risk for infection.”

Missed or inadequately treated Seymour fractures can lead to persistent pain, nail deformity, growth plate disturbance and chronic functional impairment. These outcomes may not become evident until months or years after the initial injury.

“If you see a distal phalanx fracture of the great toe, look for changes in the skin around the nail fold and a hematoma under the nail,” Swarup advises. “Swelling around the nail fold is also an important clue. These signs require urgent referral or presentation to the emergency room for evaluation by a pediatric orthopedic clinician.”

Providing a primer on casting and splinting

Proper immobilization techniques are crucial to optimal healing and recovery, yet finding accurate information can be challenging for physicians. To address this gap, Swarup served as co-editor for a primer in the Journal of the Pediatric Orthopaedic Society of North America (JPOSNA) focused on casting and splinting considerations.

“We created step-by-step guides to help clinicians understand best practices to follow and pitfalls to avoid for splinting and casting pediatric patients,” Swarup says. “The primer includes techniques from thought leaders across the country, providing both technical guidance and historical perspectives on pediatric orthopedic care.”

Supporting families beyond the clinic

Swarup's recent research also extends to patient education. His work has examined where patients get information about their health and recovery and how they prefer to receive it.

“We’ve learned that it's important to direct patients to reliable resources online,” Swarup explains. Through this work, Swarup led an effort to revamp the trauma-specific resources available through OrthoKids. This POSNA website features a robust library of materials written at appropriate reading levels and available in multiple languages.

The benefits of pediatric orthopedic expertise

Growth plates present unique considerations that pediatric orthopedic specialists are trained to address. “These injuries demand immediate specialized care and long-term monitoring,” Swarup explains. “We must ensure the bone doesn't deform or stop growing as the injury heals and the child grows.”

Children often require special surgical considerations as well. “Growth plates allow bones to grow and remodel after injury, so surgery is not always indicated,” Swarup says. “In adults, similar fractures often require surgical fixation. Our knowledge of which bones heal well without surgery helps us avoid unnecessary intervention. After all, children are not little adults!”

Guiding referral decisions

Knowing which fractures warrant urgent pediatric orthopedic consultation is an important part of care. Pediatric orthopedic fractures typically fall into one of three categories of referral need.

1. Request urgent care (same-day or next-day) for fractures involving:

• Femoral shaft
• Growth plates
• Large joints
• Multiple bones
• Neurovascular structures
• Skin or nail involvement (open fracture)

2. Request early consultation (within 48 to 72 hours) for:

• Clavicle fractures
• Complex fracture patterns
• Fractures where growth plate involvement is uncertain

3. Treat in primary or urgent care and then refer to pediatric orthopedic follow-up for:

• Incomplete (buckle or greenstick) fractures
• Simple, non-displaced metaphyseal fractures

“If you have questions or concerns about orthopedic issues, call our team,” says Swarup. “We can work with you to find the best path forward for your patient.” Physicians may call the UCSF Pediatric Access Center 24/7 at (877) 822-4453.

Partnership with referring providers

UCSF Benioff Children's Hospitals offer same-day and next-day fracture care at the San Francisco, San Ramon, Oakland and Walnut Creek locations. The team sees referred patients and those in need of urgent care at every location.

With more than 10 fellowship-trained pediatric orthopedic surgeons and eight advanced practice providers (APPs) on staff, UCSF treats a high volume of pediatric fractures in the region. “We're a large group, and we're growing,” Swarup says. “We’re constantly innovating and evolving by listening to our community physicians.”

As clinicians and researchers, the UCSF team strives to advance pediatric orthopedic care. “There's something very special about caring for children with orthopedic injuries,” Swarup says. “We love what we do.”

To refer a patient to the Pediatric Orthopedic Clinic at UCSF Benioff Children’s Hospitals, visit our referral page or call (877) 822-4453 (877-UC-CHILD). Patients can schedule an appointment online while we await your referral.