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Common Pediatric Fractures in Primary Care

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Emily Wolff

on 8 April 2014

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Transcript of Common Pediatric Fractures in Primary Care

When to refer to orthopods:
Open fractures
Acute compartment syndrome or neurovascular compromise
Pathologic fractures (osteogenesis imperfecta)
Unstable fractures
Seriously displaced/angulated fractures
Loss of rotational alignment during healing
Treatment
Pediatric Distal Radius Fractures in Primary Care
Splinting and Casting
Pediatric Fractures
Assessment of Wrist and Forearm Fractures
Evaluate NEUROLOGICAL function distal to fracture:
Median
Ulnar
Radial
Scaphoid Fracture?
Anatomic Snuffbox tenderness
Radiology
Case Presentation
5 year old normally healthy girl
Presents to ED following an accident on the ice
Ice skating, fell forward onto outstretched arms
Felt pain in left wrist
Child immediately cried
No bleeding, swelling, bruising, deformity noted by parents
No significant medical or surgical history, no past traumas documented
Pregnancy and birth unremarkable, NSVD, full term infant
No allergies
No medications
Lives with parents
Emily Wolff, MS3
Presented 8 April, 2014

*HPI*
*EXam*
General:
Alert, appropriate for age.
In distress, crying in mom's arms.
Skin: Warm, dry, pink and intact.
Head: Normocephalic and atraumatic.
Cardiovascular:
Normal peripheral perfusion.
Radial pulse intact bilaterally.
Neurological:
Sensation intact distal to injury over median, radial and ulnar dermatomes.
Musculoskeletal:
No edema, erythema or deformity noted in left upper extremity.
Patient withdraws left arm from light touch.
No snuffbox tenderness of left hand
No formal range of motion testing performed.
Child was flexing and extending both wrists voluntarily during exam.

*Imaging*
Distal forearm fractures most common pediatric fracture
Account for approximately 23% of pediatric fractures
Other common fractures include distal tibia, femur, clavicle and elbow fractures
Children's Bones
Not just little adults
Bone is generally weaker than ligaments in kids
More plastic - more greenstick and torus fractures than adults
More rapid healing than adults- nonunion is rare
More remodeling- a great deal of angulation can be corrected without reduction!
Even 35 degrees of angulation will correct over 1-2 years in a 5 year old
Physeal fractures most common in adolescents
Findings:
Location
Articular involvement
Angulation
Displacement
Comminution

Evaluate CIRCULATION at fingertips
Radiology:
PA and lateral views
Include wrist and elbow
Usually no comparison films needed
History
Acute onset of pain, tenderness
Trauma, usually fall onto outstretched hand
Swelling and deformity
Loss of function
Exam
Features concerning for abuse
Potential Complications of Pediatric Fractures
Malunion
Loss of function
Deformity
Growth arrest (physeal fractures)
Compartment Syndrome
Osteomyelitis

Flaherty et al. Evaluating Children With Fractures for Child Physical Abuse. Pediatrics, 2014;133;e477
Kemp et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ, 2008;337:a1518
Multiple Fractures
Unexplained trauma
Pattern of injury does not fit findings
Most common in infants and toddlers <3yrs
Location
Rib fractures have highest probability of abuse (esp. posteriomedial)
Humeral (non-supracondylar), skull, scapula, sternum, "CML's"
If suspected, a skeletal survey is appropriate
2 views of each extremity
AP and lateral skull
AP and lateral spine
chest, abdomen, pelvis, hands, and feet.
MN has mandatory reporting of child abuse
Abuse is the cause of 12-20% of childhood fractures.
Approximately 20% of fractures due to abuse are misdiagnosed in children <3 years old.
80% of fractures due to abuse occur in children less than 18 months old.
Physeal Fracture
Galleazzi's Fracture
Displaced fracture of distal radius, ulna inact
Injury to distal radioulnar joint
Closed reduction
Immobilization x6 wks in long arm cast
Usually in adolescents
Salter type II typically
Closed reduction and immobilization x6 wks
Sugar tong splint or long arm cast
Angulated fractures
>15 degrees (30 in infants) requires closed reduction
Immobilization x6-10 wks
Long arm cast if both bones broken, can convert to short arm at 4 wks
Greenstick Fracture
Incomplete fracture, one cortex intact
Torus/buckle= "buckling" on one side
Radius +/- ulna
Do not usually require reduction
Removeable splint or short arm cast x4 wks
Colles Fracture
Most common pattern, due to fall onto extended wrist
Typically 4 cm proximal to articular surface, but can be used to describe any fracture with dorsal displacement
Does not need reduction
Short arm cast for 4-6 weeks
Long arm if ulna broken
Displacement is okay!
Distal Radial Fracture
Generally speaking...
Splint for first 3-4 days after fracture (swelling!)
Then consider casting
Include thumb if scaphoid fracture (thumb spica splint or cast)
Repeat xrays at 1 and 2 weeks, then again at 4-6 weeks

Indication:
Nondisplaced or minimally displaced distal radius fractures (Colles)
Physeal fractures
Greenstick fractures
Application
Plaster or fiberglass splint from 2 finger lengths below elbow to distal palmar crease
Wrist neutral, slightly extended
Allows full range or motion at MCP joints
Does not limit pronation/supination
Inclusion of thumb in functional position= Thumb spica cast!
Splint vs Cast
Circumferential
More effective immobilization
Not removable- pro and a con
Increased risk of complications
Definitive treatment of most fractures
Plaster or fiberglass
Non circumferential
Allows for swelling
Removable- Lack of compliance
Decreased risks of complications
Fast, easy application
Definitive treatment for select, stable fractures
Temporary stabilization
Skin breakdown
Ischemia
Pressure sores
Dermatitis
Heat injury
Stiffness
Atrophy
Neurologic Injury

Indication:
Torus/buckle fractures of distal radius
Short term immobilization of stable distal radial fractures
Application:
Plaster splint from volar mid arm to distal palmar crease
Wrist in slight extension
Does not limit pronation/supination
SHORT ARM CAST
VOLAR SPLINT
General concepts:
Everyone has their own style
No great evidence based recommendations
Place injured extremity in functional position
Apply stockinette, then 2-3 layers of cotton padding, then plaster or fiberglass
Typically use 2-4 inch materials on upper extremities
When splinting, consider making a cast then cutting down sides and wrapping with Ace- can later convert to a cast by applying another layer of cast material
Apply extra padding around edges of cast, especially around the thumb, and over bony areas
Sources:
Boyd et al. Splints and Casts: Indications and Methods. American Family Physician, 2009; 80(5):491.
Snider, RK. Essentials of Musculoskeletal Care, 1999. Fourth Edition.
Wheeless Textbook of Orthopaedics Online, http://www.wheelessonline.com/
Source: Snider, RK. Essentials of Musculoskeletal Care, 1999. Fourth Edition


Valgus= Distal part of fracture heads AWAY from midline

Varus= Distal part of fracture heads TOWARD midline


Findings: Buckle fracture of left distal radius. Mild soft tissue swelling .
R
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