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Pearls for improving patient outcomes • Children with open growth plates are more likely to fracture through the growth plate than sustain a sprain. • Many buckle fractures of the forearm will only be visible on the lateral film. • Nurse maid ’ s elbow can be diagnosed clinically. If the typical history of being pulled with an outstretched hand, without any other trauma is present a hyperpronation maneuver may be performed without radiographs. • The presence of a posterior fat pad in the setting of traumatic injury to the elbow with otherwise normal radiographs is highly suggestive of occult fracture. • Normal x-rays are common in toddler ’ s fracture. Immobilization of the extremity should be based on clinical suspicion. • A normal white count does not rule out the possibility of septic arthritis. • Children frequently complain of knee pain, when in reality it is the hip that is the cause of the pathology. • Child abuse should always be a consideration when a child has a fracture or bruising in an infant. Rib, metaphyseal fractures, midshaft humeral and femur fractures in infant and non-ambulatory toddlers are high risk for abuse.