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paediatric limb fractures

patient information sheets

general tips

  • provide adequate and timely pain relief
    • options include:
      • splint and elevate limb
      • 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.
      • 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
  • 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.
fractures_paed.txt · Last modified: 2013/05/26 09:33 by

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