OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• orthopaedics in the ED
• fractured distal radius in children
• Bier's block - iv regional anaesthesia for LAMPs
• scaphoid fracture
• elbow fractures in children
• the child with a limp
• supracondylar fracture humerus in children

• see also patient information sheets
• RCH - fractures (pdf)
• RCH - plaster care (pdf)
• Vic DHS - Fractures and plaster care (pdf)
• Vic DHS - ankle sprains (pdf)
• Vic DHS - Soft tissue injuries (Sprains and strains) pdf
• RCH - orthopaedic wound care (pdf)
• RCH - pulled elbow (pdf)

• provide adequate and timely pain relief
  • options include:
    • splint and elevate limb
    • pain, analgesia and analgesics
    • intranasal fentanyl
    • inhaled methoxyflurane (Penthrox)
      • if dislocated patella, consider reduction ASAP (esp. if arrives by ambulance with Penthrane analgiser)
    • inhaled nitrous oxide - especially for situations where limb needs to be moved eg. application of splint.
    • iv opiates and opioids
    • regional blocks - especially for femoral fractures
• fasting status
  • unless it is clear that manipulation, surgery or anaesthetics will not be needed, keep nil oral.
• children under age 10 years tend to fracture bone rather than strain ligaments or dislocate joints.
  • ⇒ have low threshold for performing x-rays on children injured after falls who are still in pain or limping.
• always examine whole limb especially clavicle
  • two separate fractures on same limb is not uncommon and usually the proximal one is the one that is missed.
  • bilateral fractures from falls are not uncommon.
  • always exclude compound injury and check neurovascular status.
    • if compound:
      • cleanse wound and cover
      • tetanus prophylaxis as indicated
      • iv antibiotics - usually cephazolin
      • most will need surgical Mx in theatre by orthopaedic or plastics team (if fingers)
• don’t be misled by:
  • swelling of wrist in young children, this may be gravitational due to not using arm. Fracture may be of the humerus.
  • lack of tenderness or obvious injury in toddlers with limps:
    • toddler’s fracture of tibia often presents this way from minimal trauma
• if history suggests pulled elbow, confirm by:
  • painfree flexion/extension of elbow but pain on supination/pronation
  • absence of clinical elbow effusion
  • if fall unlikely, and findings suggest pulled elbow, attempt reduction and if successful or pulled elbow highly likely, then Xray not usually required. Delayed presentations more than a few hours may not be able to be reduced - these can generally be allowed home with expectant spontaneous reduction within a few days once inflammation subsides.
• specifically check for other sites commonly injured with that mechanism:
  • eg. fall onto outstretched hands:
    • wrist, elbow, supracondylar and surgical neck humerus
    • other limb as bilateral fractures not uncommon.
  • inversion injury ankle:
    • base 5th metatarsal often avulsed
  • fall from height onto feet:
    • feet, calcaneum, lower limbs, spine
  • child abuse
    • have a high index of suspicion for possibility of child abuse / non-accidental injury, particularly in those under 2 years
• a third of paediatric fractures involve the growth plate
  • familiarise yourself with the Salter-Harris classification (I - V)
  • if growth plate is displaced or angulated, manipulation must be done within the first week otherwise delayed reduction substantially increases the risk of growth problems.
  • parents should be warned of risk of delayed growth plate problems (usually pain in 6-12 months), although the incidence is quite small and tends to increase with the number of the S-H classification (ie. SH V is more likely to result in growth arrest).
• some important ossification dates:
  • radial head and medial epicondyle of humerus do not ossify until age 5-6 years.
    • This has two useful applications:
      • if a radial head is visible, but not the medial epicondyle on XR, then this raises the possibility of an avulsed medial epicondyle, esp. if elbow is dislocated.
      • radial head may be damaged without evidence on XR, so follow up XR’s should be done if elbow effusion present to assess injury adequately.
  • the scaphoid bone does not ossify until age 6 -7 years.
    • scaphoid fractures under age 7 years are exceedingly rare and thus scaphoid x-rays, are not usually indicated in this age group.
• remodeling
  • Certain angular deformities will remodel over time to produce a limb without any detectable deformity. However, one cannot always rely on remodeling to occur, and one should attempt to achieve as near as possible anatomical reduction.
  • The remodeling capacity in these circumstances is determined by four factors:
    • age of child (younger the better).
    • distance of the fracture from end of the bone:
      • closer to the end, the better chance for remodeling.
    • amount of angulation.
    • plane of angulation.
  • Remodeling will not usually correct the following deformities:
    • angular deformity of diaphyseal fractures.
    • angular deformity not in plane of movement of contiguous joint.
      • eg. lateral angulation of distal radius;
    • rotational deformity.
    • displaced intra-articular fractures.