paediatric limb fractures and dislocations

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Paediatric
limb fractures
& dislocations
Evaluation
Managing
upper-limb
fractures
Managing
lower-limb
fractures
Joint dislocations
Non-accidental
injury
The author
DR HELEN J MEAD,
paediatrician and emergency
physician, Princess Margaret
Hospital for Children, Perth; and
senior clinical lecturer; school of
paediatrics and child health,
University of WA.
Background
MUSCULOSKELETAL injuries in
children are common, with fractures
accounting for about 20% of presentations with injury. About 42% of
boys and 27% of girls sustain at least
one fracture during childhood. The
paediatric musculoskeletal system differs from the adult in its anatomy, biomechanics and physiology, leading to
injury patterns unique to the child.
High-energy forces may cause mul-
tiple injuries that require stabilisation
of the patient (airway, cervical spine,
breathing, circulation and neurological function), analgesia and transfer to
a centre for definitive care. Imaging of
the spine, chest and pelvis takes precedence over limb injuries. Management
of these injuries is beyond the scope
of this article.
Most paediatric fractures are due
to relatively low-velocity impacts
during play and recreation. Fractures
and dislocations may be caused by a
direct blow or, more commonly,
result from indirect forces.
The upper limbs are especially vulnerable. The age of the child will
affect whether a fall on an outstretched hand is more likely to cause
a fracture of the scaphoid, distal
radius, supracondylar region of the
elbow or clavicle.
Stress fractures are uncommon until
adolescence.Pathological fractures
may occur through areas of weakness
such as a benign bone cyst. Child
abuse must always be considered if
fractures occur without adequate
explanation.
This article discusses the role of the
GP in managing bony injuries commonly encountered in children.
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How to treat – paediatric limb fractures and dislocations
from previous page
Figure 1: Normal anatomy of immature (growing) long bones. Adapted from
Student BMJ April 2004, p 148; with permission from BMJ Publishing.
Unique aspects of the
growing bone
The immature bone comprises the
diaphysis (shaft of a long bone),
metaphysis (the expanded ends of
the shaft), physis (epiphyseal or
growth plate) and epiphysis (ends
of a long bone) (figure 1).
Children’s bones are resilient
due to the high cartilage content,
so substantial energy is required,
and substantial soft tissue damage
will occur, before the bone breaks.
Unossified bone and numerous
epiphyses makes X-ray interpretation challenging.
The high collagen content
causes the immature bone to be
more porous, with lower tensile
strength than adult bone. It is
prone to incomplete fractures,
buckling (‘torus’ fracture) when
compressed and bowing when
bent (plastic deformation).
A ‘greenstick’ fracture occurs
when the limit of bending leads to
a fracture on the tension side and
plastic deformity or buckle with
intact periosteum on the compression side.
All fractures may be described
according to the side (eg, dominant
or right-hand), anatomical site or
position on the bone (eg, proximal,
mid-shaft, distal). Complete fractures can be described as follows:
■ Open or closed.
■ Simple (two bone fragments) or
comminuted (multiple fragments
— unusual in children).
■ Direction of the fracture line:
— spiral: encircling a portion of
the shaft
— transverse: at a 90° angle to
the long axis of the shaft
— oblique: 30-40° to the long
axis.
■ The relationship of the bone
fragments to each other (com-
Figure 2: Salter-Harris classification of epiphyseal injuries. Type I: slips or
separates through the physis. Type II: above-fracture through the physis and
metaphysis. Type III: lower-fracture through physis and epiphysis. Type IV:
through-fracture through the physis, metaphysis and epiphysis. Type V: Ram
(a crushing fracture). Adapted from Student BMJ April 2004, p 149; with
permission from BMJ Publishing.
(physis)
pared with anatomical position):
— angulation: the angle of the
distal fragment relative to the
proximal fragment
— displacement: may be
volar/dorsal, lateral/medial or
radial/ulnar offset, measured
as a distance or percentage
of the width of the proximal
fragment, eg, 50%
— length: separation or shortening (due to impaction or
over-riding)
— rotation.
About 15-25% of extremity
fractures in children involve the
physis, which is a radiolucent cartilaginous structure providing longitudinal and circumferential
growth. It is weaker than the adjacent ligaments, so fractures are
more likely than sprains or dislocations.
The Salter-Harris classification
of physeal injuries is widely used
and has therapeutic and prognostic implications (figure 2). Most
of these injuries heal well but
some have the potential for
growth arrest or asymmetrical
bone growth, leading to deformity
and permanent disability.
Type II is the most common,
often occurring at the ankle or
wrist. Both types I and II have
excellent prognosis, as the germinal layer is left intact. Undisplaced
fractures simply require immobilisation in a plaster of Paris cast.
Types III and IV require precise
reduction, usually under a general
anaesthetic. Type V is a crushing
injury, especially of the knee or
ankle, often only diagnosed in retrospect, and has a poor prognosis.
The periosteum surrounding
immature bones is thicker and
stronger than in the adult, limiting displacement, contributing to
stability and reducing the possibility of open fractures. The child’s
periosteum responds to injury with
vigorous callus formation. Healing is rapid and non-union is rare.
Children have a remarkable
potential for remodelling, especially if the injury is adjacent to a
hinged joint, but this potential
declines with age (eg, up to 30° in
the plane of motion in the young
child or 10° in the older child).
Injury stimulates physeal blood
flow and longitudinal bone
growth, so overriding of the fracture fragments with shortening
may be desirable in certain cir-
cumstances such as fractured
femur. Fractures not involving the
growth plate will generally heal in
an acceptable position if the general alignment of the limb is maintained.
Displacement of a single long
bone remodels efficiently and even
100% displacement is acceptable
for a humeral shaft fracture. Rotational deformity remodels poorly
and must be correctly reduced.
Evaluation
WHEN high-energy forces are
involved in injury, the need
for resuscitation is the first priority. Only then should you
examine for other injuries,
including spinal injury.
History may be vague and
often limited by the child’s
pain, fear and developmental
stage. Being unable to bear
weight or use a limb is a
common presentation. Information about the mechanism
of injury supports the examination and is helpful in
requesting appropriate X-rays.
Figure 3: Examination of the ‘finger cascade’ — fingernails in
a straight plane in extension, partial flexion and as the fist
closes excludes rotation.
Figure 4: Examination of motor function of the hand (test against resistance if possible).
A
A: ‘High five’ — radial extension of wrist
and fingers (radial nerve).
B
B: ‘Thumbs-up’ — thumb extension (posterior
interosseous branch of median nerve).
Examination
A calm and gentle approach
aided by adequate analgesia
will usually reap rewards.
Analgesia should be given as
soon as possible. Assessment
is not altered by analgesia; in
fact, in children it will nearly
always make assessment
easier, as the child will be
more co-operative.
Limb-threatening injuries
Identify any limb-threatening
injuries such as:
■ Dislocations
■ Vascular injury
■ Skin ischaemia
36
C
■
■
Compartment syndrome
Open fractures
Neurovascular assessment
of the limb
Test the sensation over the
thumb web space on the
dorsum of the hand (radial
nerve), thumb side of the
index finger (median nerve)
and ulnar side of little finger
(ulnar nerve) using a cocktail
pick. Another test involves five
minutes immersion in warm
water — skin that has lost its
| Australian Doctor | 26 October 2007
D
nerve supply will not show the
characteristic wrinkling.
Classic fracture features
Look for classic features of a
fracture: deformity, swelling
and bruising, as well as posture, spontaneous movement
and skin integrity (any puncture wound over a fracture
site should be regarded as a
potential open fracture).
Exclude rotational deformity of the phalanges and
metacarpals by ensuring all
C: ‘OK’ — active opposition of thumb and
forefinger and flexion at interphalangeal joints
of thumb and index finger (median nerve).
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D: ‘Show me a starfish’ — abduction of
fingers (ulnar nerve).
AD_037a___OCT26_07 Page 3 18/10/07 4:12 PM
fingernails of the flexed hand
are in the same plane and
pointing towards the thenar
eminence (figure 3).
Feel the limb
Palpate the entire limb (including clavicle and snuff-box tenderness). Assess warmth, capillary refill, pulses, tenderness
(localise the point of maximal
tenderness), and any obvious
step.
Axial compression (including weight-bearing) may
localise pain at the fracture
site. Do not attempt to test for
crepitus, as this causes unnecessary pain and does not contribute to the clinical assessment.
Movement
Move the joint above and
below the injury if pain
allows. If the child is co-operative, use active movement,
ideally testing against resistance (figure 4). If not, use
passive movement, but avoid
this if there is an obvious fracture or dislocation around the
joint.
Analgesia
Analgesia provides comfort
and facilitates examination
and positioning for X-ray.
Age-appropriate explanation
may allay anxiety. Elevating
the limb on pillows or in a
high arm sling and splinting
the joint above and below the
injury greatly improves patient
comfort.
Oral paracetamol 15mg/kg,
ibuprofen 10mg/kg or paracetamol-codeine mixture are
options for a child with minimal discomfort. Opioids given
IM are a practical option for
more significant distress, but
the effect is delayed and
unpredictable.
Titration of IV morphine
(0.1-0.2mg/kg) is desirable for
displaced fractures or dislocations. A digital nerve block for
finger injuries, and femoral
nerve block for femur fractures, are particularly effective
and easy to learn.
Needle-free alternatives
such as inhaled nitrous oxide
and intranasal fentanyl are
available in some centres.
Non-pharmacological
adjuncts such as distraction
can help reduce focus on the
injury.
Consultation and referral
Early communication with an
orthopaedic service ensures
the most appropriate management and best outcome. Most
epiphyseal injuries angulated
beyond acceptable limits can
be treated with gentle closed
reduction. Teleradiology facilities in many regional centres
have enhanced orthopaedic
consultation and permit many
children to be managed locally
by their GP.
Immediate referral to hos-
Analgesia
provides
comfort and
facilitates
examination and
positioning for
X-ray.
pital is indicated for:
Amputations.
■ Significant skin loss.
■ Compound fractures.
■ Clinically deformed fractures.
■ Fractures with axial rotation, significant angulation
or displacement.
■ Actual, or high risk of, vascular complications.
■ Neurological compromise.
■ Compartment syndrome,
indicated by:
— increasing pain in the
first few hours
— tightness of the muscle
compartment (forearm
and calf particularly vulnerable)
— pain on passive extension
— impaired capillary refill
— absence of pulses (occurs
late).
■ Suspicion of non-accidental
injury.
■ All dislocations requiring
reduction under anaesthesia.
■
Radiography tips
Children tend to fracture rather than sprain; therefore have a low threshold for imaging children.
Avoid X-raying an entire limb by considering the mechanism of injury and age of the child and
localising the point of maximum swelling and tenderness.
■ Aim to have TWO views at 90° (a single view is appropriate for a clavicle), TWO joints, often TWO
times (a follow-up film at 7-10 days may show periosteal reaction and sclerosis of a fracture not
seen on initial films). In selected cases TWO sides (a comparison view) may aid interpretation.
■ Assess:
— alignment; for example, the anterior humeral line, drawn along the anterior surface of the
humerus on a true lateral view of the elbow, should pass through the middle third of the
capitellum. The radiocapitellar line through the long axis of the radius passes through the
centre of the capitellum (regardless of the position of the elbow) if the radial head is
correctly located.
— bones: fracture lines are lucent (black) or sclerotic (white) if overlapping. Look for a
cortical step, buckle or bulge, or interruption of the bony trabeculae pattern. Is the bone
you are looking at a fracture or an ossification centre? Ossification centres are usually
rounded. Interpreting radiographs of the elbow and the wrist can be particularly
challenging. In the elbow the appearance of ossification centres occurs in a predictable
sequence in about a two-year progression.
■
■
Ossification centres in the elbow
Age (years)
C = capitellum
1
R = radial head
3
I = (internal) medial epicondyle
5
T = trochlear
7
O = olecranon
9
E = (external) lateral epicondyle
11
— cartilage; for example, at the elbow a displaced ossification centre indicates a significant
fracture
— soft tissues; for example, at the elbow an exaggerated anterior fat pad (‘sail sign’) or any
visible posterior fat pad implies a joint effusion, suggestive of an intra-articular fracture,
even if no fracture line is visualised (most commonly an undisplaced supracondylar
fracture).
■ Avoid under-interpretation — radiological signs are often subtle.
■ Avoid over-interpretation — developing epiphyses and anatomical variations may mimic
fractures.
■ If in doubt, treat presumptively for a fracture and arrange follow-up (clinical review or repeat
X-ray in one week).
■ Accurate description of the X-ray facilitates phone consultation regarding management.
Upper-limb fractures
Clavicle
Humerus
FRACTURE of the clavicle — usually mid-shaft — after a fall on the
outstretched hand or onto the shoulder tip is the most common fracture
in children of all ages. Many are
greenstick. If the fracture is complete, the unsupported shoulder
droops and a tender lump is easily
palpable.
Birth trauma may result in a pop
being heard at delivery, or an asymmetric Moro or an expanding lump
may be noted in the first few weeks.
A sling worn under clothes for 2-3
weeks in young children or 3-4
weeks in the older child provides support and comfort. Repeat X-rays are
not required.
Acromioclavicular injuries in the
older child are usually managed in
the same way. Even grossly displaced
fractures remodel well in young children, although a lump due to abundant callus will be noticeable for up
to 12 months.
Epiphyseal or metaphyseal injuries
of the proximal humerus are treated
with a collar and cuff and remodel
well even if displaced; gravity and
growth correct the deformity.
Supracondylar fracture of the
distal humerus is the most common
paediatric elbow fracture, with a
peak at age 4-8 years. It is usually
due to a fall onto the outstretched
hand or, less commonly, a direct
blow to the flexed elbow. Pain is
often severe and swelling may be
mild or severe.
The injury is a transverse metaphyseal fracture. Radiographic
appearances range from undisplaced
or minimally displaced greenstick to
‘off-ending’, with backward displacement of the distal fragment. A
fracture line may not be visible but a
visible posterior fat pad or anterior
sail sign indicate joint effusion, highly
suggestive of an occult fracture.
In a lateral view of the normal
elbow the distal humerus is tilted
30-40° anterior to the longitudinal
axis of the distal humeral metaphysis. A posteriorly displaced fracture is associated with a loss of this
angle and the anterior humeral line
will intersect the capitellum more
anteriorly or not at all. Immediate
referral is indicated for marked
swelling or significant displacement,
as there is a risk of vascular impairment and compartment syndrome.
Undisplaced fractures can be managed by immobilising in a collar and
cuff, initially at no more than 90°
elbow flexion, and advising the parents to watch carefully for signs of
vascular compromise. The collar and
cuff can be further elevated within
the limits of comfort after a couple of
days. Arrange follow-up in a fracture clinic in seven days.
Lateral condylar fractures are the
second most common elbow fracture and the most common physeal
elbow fracture, occurring after a fall
on the outstretched hand. There is
localised swelling on the lateral
distal humerus (radial side) and the
X-ray may show a deceptively thin
sliver of ossified bone. The injury
involves a large fragment of cartilaginous tissue and extends into the
joint (Salter-Harris IV fracture).
Refer for immediate orthopaedic
opinion.
Medial epicondyle fractures occur,
especially in adolescent boys, when a
valgus force is combined with contraction of the forearm muscles, for
example, while throwing.
Ensure the avulsed epicondyle is not
trapped in the joint — if the medial
epicondyle is not visible on an anteroposterior view of the elbow of a child
over six years of age, assume the epicondyle has been displaced into the
joint and urgent refferal is required.
Undisplaced or minimally displaced
fractures (<5mm) can be immobilised
for 1-2 weeks in an above-elbow
backslab with 90° flexion.
Effective pain relief
Olecranon fractures are rare, usually occurring in teenagers with direct
trauma to the elbow. The normal
elbow epiphysis is frequently confused for a fracture, and examination reveals localised tenderness
rather than the generalised swelling
seen with a fracture.
Radius and ulna
Radial head fractures do not occur
until adolescence. Fractures of the
neck and physis are often subtle and
may be greenstick in a young child. In
the skeletally immature child a fall on
the outstretched hand causes force to
be transmitted to the physis and metaphysis, so check for an associated posterior dislocation of the elbow.
Compare the ability to extend the
elbow to that of the other side and
check the function of the posterior
interosseous nerve (‘thumbs up’).
Minimally angulated fractures can
be immobilised for one week in a
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How to treat – paediatric limb fractures and dislocations
from previous page
sling or above-elbow backslab.
Forearm fracture with an
associated dislocation requires
immediate referral. The Monteggia injury is an uncommon
fracture (or bowing deformity
in young children) of the ulna,
with dislocation of the radial
head. Also rare is the Galeazzi
injury, a fracture of the shaft
of the radius and dislocation
of the distal ulna.
Fractures of the radius and
ulna are common and range
from a torus (buckle) fracture
of the distal radius, SalterHarris epiphyseal injury or
greenstick fracture of the
distal radius, to severely angulated fractures of the distal
radius and ulna.
Greenstick and torus fractures of the distal radius are
inherently stable and frequently managed by GPs.
Conversely, mid-shaft injuries
are likely to be displaced or
angulated, requiring reduction.
Even undisplaced fractures
of the mid-shaft and bowing
injuries require close monitoring to ensure alignment is
maintained, as muscle action
and inadequate immobilisation make them more prone
to slipping position, and inadequate reduction may lead to
long-term disability.
Fractures of the wrist
and hand
Scaphoid fracture can only
occur after the scaphoid has
ossified at about age nine and
may occur after a high-impact
fall onto the outstretched
hand. Apply a scaphoid plaster slab for confirmed fractures or patients with point
tenderness in the anatomic
snuffbox and pain to compression of the first
metacarpal.
Examine all hand and
finger injuries for rotation
deformity (figure 3). Metacarpal fractures may be due
to a punch, a fall on the hand
or a crushing injury. Distal
phalanx fractures are of less
importance than the associated fingertip or nailbed soft
tissue injury which may
require an expert opinion.
Phalangeal fractures commonly occur during ball
games. Reduction is required
for >50% displacement or
angulation >20°. A volar plate
injury is suggested by a history of hyperextension of the
finger (‘bent back’) and a
small avulsed fragment at the
proximal interphalangeal
joint. Consult a hand specialist
early, because a fixed flexion
deformity may occur if the
injury is not appropriately
managed.
An inability to extend the
distal interphalangeal joint
indicates a mallet finger
injury, which must be treated
continuously in a splint maintaining extension.
Most hand injuries benefit
from elevation in a high arm
sling for a couple of days and
encouragement of finger
movement. Buddy-strapping
allows movement of the interphalangeal joints but a volar
plaster slab may provide
better initial comfort for more
extensive injuries.
Undisplaced or minimally
displaced thumb injuries may
initially be managed by the
GP in a plaster that immobilises the thumb (eg, plaster
spica or scaphoid-type slab).
Summary of management of upper-limb fractures
Fracture
Immediate referral and precautions
Management of undisplaced
fracture
Clavicle
Prominent lump may persist up to one year.
Refer if brachial plexus palsy, acromioclavicular
ligament injury or tenting of skin
Gravity corrects even gross angulation.
Refer for review if >50% displacement
Refer if radial nerve deficit, comminuted or transverse.
Consider non-accidental injury if spiral fracture
Triangular sling for 2-4 weeks.
Repeat X-ray not required.
Avoid contact sports for six weeks
Collar and cuff with elbow in full
flexion for three weeks
U-slab for 2-3 weeks to avoid knocks
and limit movement, then collar and cuff,
with elbow in full flexion until comfortable
Collar and cuff under clothing for 3-4
weeks, with elbow initially flexed at 90°
but gradually elevated higher
Proximal humerus
Humeral shaft
Supracondylar
region of elbow
Lateral condyle
Medial epicondyle
avulsion
Olecranon
Shaft radius/ulna
Distal radius
torus fracture
Distal radius
(greenstick and
complete fractures)
with/without ulna
Scaphoid
Metacarpals
Phalanges (hand)
Thumb metacarpal
or phalanx
Risk of vascular compromise and compartment
syndrome, injury to ulnar, radial or median nerve.
Refer if angulated, displaced or comminuted or
associated fracture of lateral condyle or radial
head dislocation
Refer for assessment
Refer if displaced or associated with elbow dislocation
Exclude associated radial head/neck
fracture or dislocation.
Apophysis or ossification centre often mistaken
for fracture
Refer if angulated, displaced, deformed or
associated dislocation of radial head or distal ulna.
Unstable fractures require close monitoring
of position
Above-elbow backslab for 1-2 weeks
Above-elbow backslab
Above-elbow backslab for 4-6 weeks
X-ray at one week then every 1-2 weeks
to check position
Short arm volar slab for 2-3 weeks
Check median and ulnar nerve. Refer if arm appears
deformed or angulation >15°
Above-elbow backslab for 4-6 weeks.
X-ray at one week then every 1-2 weeks
to check position
Rare if <12 years old.
Presume fracture if ‘snuff-box’ tenderness
Immobilise in scaphoid slab, consider
repeat X-ray at 7-10 days if initial one is
negative
Volar slab in ‘position of function’ for
three weeks
Ensure full extension of fingers and exclude rotation.
Acceptable angulation of neck fractures (20°
for second; 30° for third; 40° for fourth,
50° for fifth)
Refer if displaced, angulated >15° or
intra-articular.
Exclude rotation, mallet deformity, volar plate injury
Refer if displaced or angulated
Buddy-strap or volar slab.
Mallet finger: continuous splint for three
weeks
Thumb spica
Lower-limb fractures
Femur
FRACTURE of the mid-shaft
femur usually results from motor
vehicle trauma in the school-age
child. Significant shortening occurs
from the pull of the quadriceps
muscle. Administer parenteral
opioid and immobilise by strapping
to the other leg. A femoral nerve
block is effective for these injuries.
Young children are usually treated
in traction but there is increasing
use of intramedullary nails in adolescents.
Tibia and fibula
Mid-shaft or distal tibia fractures
are the most common leg fracture
and may be an isolated injury or
combined with fracture or bowing
of the fibula.
The ‘toddler’s fracture’, a hairline spiral fracture of the tibia, is
common in children aged 1-2
years, who often present with failure to bear weight after minimal
or no known trauma.
Swelling and tenderness may be
absent and the fracture may be
radiographically subtle or not seen
at all. Septic arthritis and
osteomyelitis must be considered
in the differential diagnosis but an
X-ray at 7-10 days will reveal the
periosteal new bone growth.
38
| Australian Doctor | 26 October 2007
Summary of management of lower-limb fractures
Fracture
Immediate referral and precautions
Femur
Suspect non-accidental injury if no
history of significant trauma. Refer all for
further management
Tibia
Refer if displaced, angulated or significant
swelling (risk of compartment syndrome) or
associated fibula fracture
Distal: below-knee backslab. Mid-shaft
or proximal: above-knee backslab for
6-8 weeks
Toddler’s fracture
Initial X-ray often negative (exclude infection)
Above-knee backslab for 2-3 weeks or
non-weight-bearing without slab
Distal tibia/fibula
Refer if angulated, displaced or if involves both
tibia and fibula or tibial articular surface
Below-knee backslab for six weeks
(three weeks for isolated fibula)
Mid-foot
May require CT scan for diagnosis
Below-knee backslab
Metatarsals
Exclude Lisfranc fracture (base of second
metatarsal)
Stiff-soled shoes or below-knee
backslab for 4-6 weeks
Phalanges (foot)
Reduce under digital block if displaced
Buddy-strap for three weeks
Undisplaced greenstick fractures
and toddler’s fractures are treated
in an above-knee backslab. Greater
forces may cause displaced or
angulated fractures, which are at
risk of compartment syndrome, so
refer for inpatient analgesia, elevation and reduction if required.
Fibular fracture typically results
from a twisting injury in young
children or from motor vehicle
Management of undisplaced fracture
injury in older children. The peroneal nerve is vulnerable to
damage from fibular head fractures, which may be associated
with ankle injury.
Ankle and foot
Mid-foot fractures are rare, usually due to direct trauma and may
require a CT scan for diagnosis.
Lisfranc fracture of the base of the
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second metatarsal after jumping
from the tiptoe position is associated with impaired stability of the
midfoot and potential vascular
impairment.
For ankle injuries, examination
should also include palpation of
the base of the fifth metatarsal, the
calcaneus and the proximal fibula.
From age eight until adolescence
epiphyseal injury of the distal tibia
and fibula is more likely than ligamentous injuries.
Tenderness at the physis without
a visible fracture line is likely to be
a Salter-Harris type I injury and
best treated in a supportive plaster
slab. Sprains in teenagers are best
treated with brief splinting or functional bracing.
Forefoot injuries result from
falls, crushing injuries and stubbing. These may be greenstick in
young children or greenstick, transverse or oblique in older children.
Phalangeal injuries can be buddystrapped after rotational deformity
has been excluded or corrected.
Fractures of the great toe phalanx or metatarsal require accurate
reduction and occasionally pinning.
Nailbed injury of the toe is less
aggressively managed than for fingertip injury. Young children are
usually better managed in wide-fitting hard-soled shoes than a belowknee backslab, which is best
reserved for older children with displaced or multiple metatarsal fractures or stress fractures.
Children who have their foot
caught in the spokes of a bicycle
wheel are prone to develop neurovascular and skin complications,
so consider inpatient observation
and elevation.
AD_039___OCT26_07 Page 5 18/10/07 3:59 PM
Joint dislocations
Immobilisation tips
Remove potentially constricting jewellery.
Plaster slab — have all equipment ready. Measure the limb and trim to size a slab of plaster
8-10 layers thick. Below-knee or below-elbow slabs require a couple of finger-breadths’ space
to the nearby joint. Apply stockingette then wrap the limb evenly with cotton wadding, ensuring
extra padding over bony prominences. Immerse the slab in lukewarm water and concertina
gently to remove excess water before applying evenly to the limb. Fold back the stockingette to
ensure smooth edges and wrap the slab in crepe bandage. Use your palms to apply three-point
moulding if required.
■ Inadequate immobilisation is commonly due to failure to extend far enough up the limb or loosening of the crepe wrap. Parents can reapply the crepe bandage as required to ensure a
snug fit.
■ Upper-limb fractures — below-elbow volar slabs are useful for torus fractures of the distal radius
(moulded synthetic splints are a convenient but expensive option). Most other upper-limb
fractures, especially in young children, are probably more stable in a long arm backslab. Plaster backslabs are appropriate management for the duration of immobilisation.
■ Lower-limb fractures — a child under 6-8 years is unlikely to be able to use crutches safely. For
younger children a pram is a useful mobility aid. Plaster backslabs are not designed for
weight-bearing. If weight-bearing is permissible, a full plaster or synthetic cast should be
applied after swelling subsides. Plaster casts require 48 hours to dry before weight-bearing.
Synthetic casts do not require this drying period and are lighter and more durable but considerably more expensive than plaster.
■ Elevate the limb with pillows or a sling for the first 48 hours.
■ Duration of immobilisation — a shorter period is required for younger children. Radial torus fractures only require 2-3 weeks of immobilisation; elbow and most physeal injuries require about
3-4 weeks; and other fractures about six weeks.
■
Upper limb
‘Nursemaid’ (pulled) elbow
THIS common and easily
treated condition is a subluxation of the radial head. Typically a child aged 1-4 years
refuses to use the arm after
receiving a sudden pull to the
extended arm or, occasionally, when a parent assists the
arm through a sleeve when
dressing. The child holds the
arm limp or supports it
pronated in slight flexion.
X-rays are only indicated if
the history is unclear or if
manipulation is unsuccessful.
Use one hand to press over
the radial head and immobilise the elbow and the other
hand to apply traction while
firmly supinating the forearm.
A pop may be felt as the
annular ligament is restored
to its correct position around
the head of the radius.
Review the child in the
playroom after 10 minutes
and, if the movement has
returned to normal, advise the
parents on how to avoid
recurrence and reassure them
that there will be no longterm effect.
Dislocated elbow
A dislocation of the radial
head is usually associated
with a bending or fracture of
the ulna (Monteggia fracturedislocation injury). Always
check the radiocapitellar line
on an elbow radiograph to
ensure dislocation is not
missed. Reduction is required
to avoid long-term disability.
The child with a dislocated
X-rays are
only indicated if
the history is
unclear or if
manipulation is
unsuccessful.
Dislocated shoulder
Dislocation of the shoulder
occurs only after epiphyseal
fusion, usually in late adolescence. The humeral head dislocates anteriorly, giving the
shoulder a squared-off
appearance. Check sensation
of the ‘regimental badge area’
over the deltoid muscle (axillary nerve). Pain is severe, and
immediate reduction (usually
under sedation) is required.
Dislocated finger
Children are more likely to
have a finger fracture than a
finger dislocation, so generally it is preferable to X-ray
before attempting reduction.
After fracture has been
excluded, reduce using a digital nerve block, then buddystrap till discomfort settles.
■
Dislocated wrist
Carpometacarpal dislocation
is a rare injury, and urgent
referral is required.
elbow presents with severe
pain, usually after a fall from
a height onto a partially
flexed arm. The deformity is
obvious and the usual equilateral triangle relationship
between the olecranon and
the medial and lateral epicondyles is distorted (typically
preserved in supracondylar
fractures).
Administer parenteral analgesia, splint in the presenting
position and refer immediately for reduction. The arm
is immobilised for 2-3 weeks
after reduction.
Lower limb
In teenage girls, patella dislocation may occur from pivoting on a fixed foot while the
knee is flexed. As dislocation
occurs laterally, reduce by
gently pushing the patella
medially while extending the
knee, with the aid of nitrous
oxide if available.
Consider slipped upperfemoral epiphysis in teenagers
(especially obese boys) with a
subacute or acute history of
hip or knee pain, often with a
history of minor trauma.
Urgent referral is required.
Follow-up tips
On discharge:
— provide verbal and written information on plaster care, signs of neurovascular compromise
and follow-up arrangements
— ensure adequate supply of appropriate analgesics.
■ Next day — plaster check (neurovascular status of the limb, patient comfort, plaster integrity and
fit).
■ One week — fracture clinic, usually with repeat X-ray (not required for clavicular fractures and
torus fracture of radius).
■ Progress visits and repeat radiography as indicated.
■ Removal of cast/sling/collar and cuff-bone union is indicated by no abnormal mobility and
minimal pain and tenderness at the fracture site.
■ Rehabilitation:
— physiotherapy may be helpful in adolescents after ankle sprains and dislocated patella
(rarely required for other injuries as post-immobilisation stiffness resolves rapidly with usual
childhood activity)
— advise on risk of re-injury — return to contact sports should usually be deferred for 6-8
weeks after removal of cast/sling/collar and cuff. (A shorter period such as three weeks
may be acceptable for younger children with simple fractures.)
■
Non-accidental injury
CHILD abuse is the cause
of a substantial proportion
of fractures in children
under three years of age. A
vague or changing history
or a history inconsistent
with the development of
the child or the pattern of
injury should arouse concern.
Injuries in infants not yet
walking independently,
and long-bone fractures in
the child under two years,
should arouse particular
concern, and closer examination and investigation
may reveal evidence of
multiple injuries.
Fracture types in the
young child that are
indicative of child abuse
are:
■ Metaphyseal corner fractures.
■ Spiral fractures of the
humerus or femur.
■ Rib fractures.
■ Multiple fractures, especially of different ages.
Management of the fracture itself is rarely problematic, but immediate
referral to a child protection unit ensures multidisciplinary assessment and
management of the child
and family.
Wealth of experience
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Injuries in
infants not
yet walking
independently,
and long-bone
fractures in the
child under two
years, should
arouse
particular
concern.
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Pfizer Australia Pty Ltd, ABN 50 008 422 348, 38-42 Wharf Road, West Ryde NSW 2114. www.pfizer.com.au Medical Information: 1800 675 229. Celebrex is a registered trademark of Pharmacia. Pharmacia is a wholly-owned subsidiary of Pfizer Inc. 09/07 PFI0923AD/CJB.
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39
AD_041___OCT26_07 Page 6 18/10/07 4:00 PM
How to treat – paediatric limb fractures and dislocations
Further reading
Figure 5: Lateral X-ray view of the elbow.
■
McRae R, Esser M. Practical Fracture Treatment. 4th
edn. Churchill Livingstone,
London, 2002.
Acknowledgement
Thanks to the Department of
Medical Illustrations at
Princess Margaret Hospital
for Children, Perth, for their
assistance with the clinical
photographs.
Online resources
Clinical practice guidelines
■
Royal Children’s Hospital,
Melbourne. Clinical Practice
Guidelines. Fractures.
www.rch.org.au/clinical
guide
Parent information handouts
■
Royal Children’s Hospital,
Melbourne. Kids health
info for parents. Plaster
Care.
www.rch.org.au/kidsinfo
■ The Children’s Hospital at
Westmead, NSW. Factsheets — Bones and Muscles. Fractures — bone
healing and Plaster cast or
backslab care instructions
for patients and their
carers:
www.chw.edu.au/parents/
factsheets
Author’s case study
AN eight-year-old girl presents after falling from
monkey-bars onto her outstretched arm. She did not
lose consciousness and her
only complaint is of a painful
elbow. She is only mildly distressed and you administer
an oral paracetamol-codeine
mixture.
You examine her to
exclude other injuries and
palpate the whole limb up to
the clavicle. The skin is intact
but there is moderate
swelling with pain and tenderness localised to the
elbow. The usual equilateral
relationship between the olecranon and the medial and
lateral condyles is maintained, so dislocation of the
elbow is unlikely.
The pulses of both upper
limbs are of similar strength
and there is no difference in
finger colour, warmth or
capillary return. Motor and
sensory function of the limb
is normal.
You suspect a supracondylar fracture of the distal
Stress the
importance of
urgent review if
there is
increasing pain
or signs of
impaired
circulation.
humerus and request lateral
and anteroposterior X-ray
views of the elbow (figure 5).
The anteroposterior film
appears normal, with no
apparent fracture. You confirm the radial head is appropriately located (the radiocapitellar line intersects the
capitellum on the lateral film).
However, the anterior
humeral line passes through
the anterior aspect rather
than the middle-third of the
capitellum, indicating minor
displacement of the distal
fragment posteriorly. A faint
radiolucent fracture line and
a posterior cortical buckle
are seen in the distal
humerus.
The sail sign of the anterior fat pad and a posterior
fat pad (always abnormal)
indicate a significant joint
effusion. You apply a collar
and cuff, with the elbow
flexed to 90°. The collar and
cuff is to be worn constantly
under the clothing. As the
swelling subsides over the
next couple of days, increas-
ing the degree of flexion by
raising the sling enhances the
effect of gravity in maintaining alignment.
You provide an information handout to the parents
and stress the importance of
urgent review if there is
increasing pain or signs of
impaired circulation. You
arrange follow-up X-rays
and review in the fracture
clinic in one week. The
orthopaedic registrar reassures the parents there is no
valgus or varus deformity
and the posterior angulation
will remodel. Use of the sling
is continued for a further
three weeks.
Summary
Fractures in children are common and more likely than
sprains or dislocations; have a low threshold for imaging.
■ An understanding of normal growth assists appropriate
assessment and management of childhood injury.
■ Effective splinting and analgesia relieve pain and assist
examination and positioning for imaging.
■ Mismanagement of growth-plate injuries may lead to
deformity and functional impairment.
■ Many undisplaced limb fractures can be managed initially by the GP.
■
Evidence-based practice
There is surprisingly little evidence as to the most effective way to immobilise most fractures in children.
■ Minimally displaced buckle fractures of the distal radius
may be treated as effectively in fibreglass backslabs or
moulded splints as in traditional casts (NHMRC evidence
level III).
■
Superior upper and lower GI safety
1-5
6,7
compared to non-selective NSAIDs
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(celecoxib)
†GI safety = incidence of clinically meaningful GI events, i.e. ulcer complications (bleeding, perforation, gastric outflow obstruction). Celebrex does not eliminate the risk of GI haemorrhage. Vigilance should always be exercised in follow-up. ‡Non-selective
NSAIDs = naproxen, diclofenac and ibuprofen at commonly used doses. Before prescribing, please review Product Information and PBS Information found in the primary advertisement in this publication. 1. Mamdani M, et al. BMJ 2002;325:624-627. 2. Singh G, et al.
Am J Med 2006;119:255-266. 3. Goldstein JL, et al. Am J Gastroenterol 2000;95:1681-1690. 4. Deeks JJ, et al. BMJ 2002;325:619-623. 5. Rahme E, et al. Rheumatology (Oxford) 2007;46:265-272. 6. Goldstein JL, et al. Clin Gastroenterol Hepatol 2005;3:133-141. 7. Goldstein JL, et al.
Aliment Pharmacol Ther 2007;25:1211-1222. Pfizer Australia Pty Ltd, ABN 50 008 422 348, 38-42 Wharf Road, West Ryde NSW 2114. www.pfizer.com.au Medical Information: 1800 675 229. Celebrex is a registered trademark of Pharmacia. Pharmacia is a wholly-owned subsidiary of Pfizer Inc. 09/07 PFI0919AD/CJB.
®
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26 October 2007 | Australian Doctor |
41
AD_ 0 4 2 _ _ _ OCT 2 6 _ 0 7 . P DF
Pa ge
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1 0 / 1 8 / 0 7 ,
4 : 1 1
PM
How to treat – paediatric limb fractures and dislocations
GP’s contribution
Case study
DR CAROLYN BLOCK
Double Bay, NSW
THERE are some children whom you
just know will at some stage break a
bone. Tim was always on the move.
From the moment he could walk he was
like a whirlwind, climbing the furniture,
jumping off the couch and always running at full speed. His first couple of fractures were caused because of these activities, and his mother felt as if she were
collecting plaster casts!
When Tim was aged 4.5 years, his
mother rushed him into hospital with a
swollen and painful upper arm. He had a
spiral fracture of his humerus. Tim had
caught his arm in the stair railing when
going down the stairs, his foot slipped
and his arm twisted with a horrible cracking sound, which had resulted in his spiral
fracture.
Because of his previous fractures and
the nature of this fracture, the hospital
staff considered the possibility of child
abuse and questioned Tim’s mother several times about the cause of the fracture. Her story never wavered and after
treatment for the fracture she was
allowed to take him home.
Although Tim’s mother could understand the need to rule out abuse, the
experience was not a pleasant one. She
hopes Tim will “run out of steam” soon,
to avoid any more breaks!
General questions for the author
Many parents are now using alternative
formula on the recommendation of their
naturopath. Is the calcium content of
these formulas adequate, and will this
have an effect on bone development?
Childhood is the time of building peak
bone mass — sevenfold from birth to
puberty and a further threefold during
adolescence, then stable till about 50
years of age, when it diminishes.
Achieving optimal bone mass by
skeletal maturity requires an adequate
total dietary calcium intake. Alternative
products marketed as ‘infant formula’
are regulated by Food Standards Australia and New Zealand and must contain vitamin D and calcium sufficient
How to Treat Quiz
Paediatric limb fractures and
dislocations — 26 October 2007
1. Which TWO statements about how
fractures in children differ from those in
adults are correct?
❏ a) A pre-adolescent child is more likely to
sustain a tear of an ankle ligament than a
fracture of their fibula
❏ b) Stress fractures are uncommon in primary-school-aged children
❏ c) Children’s bones bend more easily than
those of adults due to the high collagen
content of young bone
❏ d) Non-union is a common problem in
children’s fractures
2. Which THREE general statements about
managing fractures in children are correct?
❏ a) In managing femur fractures in young
children, overriding of the fracture
fragments may be desirable
❏ b) A fracture with a rotational deformity
requires accurate reduction
❏ c) All growth plate fractures are likely to
cause problems with growth arrest
❏ d) No reduction is usually required for fractures of the proximal humeral shaft
3. Alex, seven years, was playing on the
climbing equipment at school when he fell,
landing on his right forearm. He is brought
to your surgery for assessment. His arm is
slightly swollen and he is reluctant to move
it but there is no evidence of significant
deformity. Which TWO statements about
examination of Alex are correct?
❏ a) You should palpate the whole of his right
upper limb, from clavicle to fingers
❏ b) He should not be given analgesia until
examination is complete
❏ c) If Alex has lost sensation over the thumb
side of his index finger, he has damaged his
radial nerve
❏ d) If Alex has lost sensation over the outer
aspect of his little finger, he has damaged
his ulnar nerve
4. Alex is referred for an X-ray, which shows
a fracture of the distal radius/ulna with
minimal dorsal angulation, not affecting the
growth plate. Which TWO statements are
correct about management of Alex?
❏ a) He should be managed with an
above-elbow plaster slab for 4-6 weeks
❏ b) He should be managed in a short-arm
volar slab for 2-3 weeks
❏ c) He should be referred to a specialist if
the angulation of the fracture is more than
15°
❏ d) He should be placed in a collar and cuff
for four weeks
5. Peter, nine years, fell onto his left shoulder playing rugby. He has tenderness over
the mid-clavicle and his shoulder is
drooping, consistent with a fractured
clavicle. There is no evidence of
neurovascular compromise, or
acromioclavicular ligament injury and
no tenting of the skin over the fracture.
Which TWO statements about this
injury and management of Peter are
correct?
❏ a) Clavicle fractures are the most common
fracture in children
❏ b) Peter’s fracture will need reduction
under anaesthetic if the fracture is 100%
displaced
❏ c) Peter should be managed with a triangular sling under his clothes for 3-4 weeks
❏ d) He should have a repeat X-ray in
3-4 weeks’ time
for the needs of the child to 12 months
of age.
Parents using products other than these
should seek appropriate dietary guidance
to ensure the child’s nutritional requirements are met.
Because we are so diligent in protecting
our children from the sun, are we causing
vitamin D deficiency and has there been a
resulting noticeable increase in fracture
rates?
Although parents are often concerned
that their child with a fracture may have
‘brittle bones’, low bone density is rarely a
significant factor in childhood fractures.
Most fractures are understandable, given
the rough-and-tumble forces of normal
play-acting on ‘plastic’ bones.
Increased incidence of infantile rickets
in Australia (usually as a result of maternal vitamin D deficiency in dark-skinned
mothers with sun avoidance or veiling) is
a result of altered immigration patterns.
Vitamin D supplementation should be
considered in high-risk mothers, and
high-risk infants should also receive supplementation, especially if breastfed.
Australian children exposed to morning or afternoon sun for 5-15 minutes 46 times a week obtain sufficient vitamin
D for normal bone development. It is
important that parental fear of fractures
does not diminish the importance of the
“Slip Slop Slap” message or the role of
physical activity in the development of
healthy children.
You discussed return to contact sport.
What are your recommendations for children returning to normal school sports
lessons after fracture?
Contact sports predispose to collisions
and falls, which substantially increase
the risk of refracture during the weeks to
months in which consolidation of the
fracture occurs (the duration depends on
the child’s age and the site and type of
the fracture). It may be reasonable to
resume lower-risk physical activity about
3-4 weeks after a cast or splint is
removed.
INSTRUCTIONS
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6. Jess, six years, was starting her bars routine at the local gymnastics competition when
she fell, landing awkwardly on her outstretched left arm. She is in significant pain
and refuses to move her left elbow, which
looks swollen. Which TWO statements about
features you may find on examination of Jess
and immediate management are correct?
❏ a) If Jess has a supracondylar fracture of the
distal humerus, the usual equilateral triangle
relationship between the olecranon and the
medial and lateral condyles will be disturbed
❏ b) One of the most important assessments is
to check the colour, warmth and capillary refill
of her hand
❏ c) A careful examination for any small puncture
marks in the skin around the elbow is important because this could signify a more serious
injury
❏ d) If it appears that Jess has a dislocated
elbow, you should attempt to reduce this
immediately, before further swelling makes it
more difficult
7. Jess has X-rays at the emergency department. If she has a supracondylar fracture of
her distal humerus which THREE statements
are correct about features you might see on
the X-ray?
❏ a) If the fracture is displaced posteriorly, the
anterior humeral line will intersect the capitellum more anteriorly than usual or not at all
❏ b) Any visible posterior fat pad indicates an
intra-articular fracture
❏ c) The ossification centre of the lateral epicondyle should be visible by this age
❏ d) No fracture line may be visible
8. You are doing a shift in the emergency
department at your local hospital. A
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for immediate feedback
16-month-old boy is brought to you with a
history that he fell over, twisting his leg after
his foot became stuck between stair railings.
He has refused to weight-bear since. Which
THREE features on X-ray would be most
likely to raise your suspicion of nonaccidental injury in this child?
❏ a) A hairline spiral fracture of the distal tibia
❏ b) A spiral fracture of the shaft of the femur
❏ c) A metaphyseal corner fracture of the
tibia
❏ d) A few old rib fractures found incidentally on
chest X-ray
9. Sam, an overweight 13-year-old, is brought
to you with a history of sudden onset of pain
in his knee, which started while playing at
school. He gives no history of significant
injury and has not noted any abnormality in
the appearance of his knee. He is afebrile and
feels otherwise well. He walks with a limp.
Which ONE condition do you consider most
important to exclude by examination and
investigation?
❏ a) Patello-femoral syndrome
❏ b) Patella dislocation
❏ c) Slipped upper femoral epiphysis
❏ d) Perthes’ disease
10. Which TWO statements about fracture/
dislocation management are correct?
❏ a) Children should avoid contact sport until
6-8 weeks after removal of plaster
❏ b) Children should avoid weight-bearing on
plaster leg casts for the first 12 hours
❏ c) Fractures of the proximal humerus can
generally be treated with a collar and cuff for
three weeks
❏ d) A pulled elbow should only be relocated
after the child has had an X-ray
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HOW TO TREAT Editor: Dr Marcela Cox
Co-ordinator: Julian McAllan
Quiz: Dr Marcela Cox
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.
NEXT WEEK Bowel cancer remains one of the most common internal malignancies in the Australian population, affecting about one in 20 Australians over their lifetime. Pre-symptomatic screening, early
treatment and effective management can save lives, so keep up to date with the latest on screening and management in next week’s How to Treat on bowel cancer. The author is Dr Paul J McMurrick,
clinical dean and senior lecturer, Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria.
42
| Australian Doctor | 26 October 2007
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