Fractures and dislocations (peds): Difference between revisions

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== Fractures and Dislocations (Peds)  ==
==Clavicle &amp; Shoulder==


{| cellspacing="0" cellpadding="2" border="1" align="left"
{| class="wikitable"  
|-
|-
| Clavicle<br>
| [[Clavicle fracture (peds)|Clavicle fracture]]
|  
|  
Tx: Sling/swathe x3 weeks, no sports x3 weeks  
treatment: Sling/swathe x3 weeks, no sports x3 weeks  


Consult ortho immediately for neurovascular compromise<br>  
Consult ortho immediately for neurovascular compromise<br>


|-
|-
| Shoulder dislocation<br>
| [[Shoulder dislocation]]
|  
|  
Usually anterior/inferior, always get axillary view film  
Usually anterior/inferior, always get axillary view film  


Tx: Closed reduction, sling/swathe for several weeks w/ ortho outpatient f/u due to high risk of recurrence<br>  
treatment: Closed reduction, sling/swathe for several weeks with ortho outpatient follow up due to high risk of recurrence<br>


If posterior dislocation or neurovascular compromise, consult ortho immediately<br>  
If posterior dislocation or neurovascular compromise, consult ortho immediately<br>


|}
|}


<br>
==Humerus==
 
{| class="wikitable"
<br>  
|-
| [[Proximal humerus fracture]]
|
Generally can tolerate >50° angulation


<br>  
'''Classification''' - using the Neer classification system to divide humerus into 4 parts:<br>


<br>
*greater tuberosity
*lesser tuberosity
*anatomic neck
*surgical neck


<br>
treatment: Sling and swathe for several weeks, ortho outpatient follow up in 3-5 days if


<br>  
'''<br>'''


<br>
== Humerus<br>  ==
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
|-
| Proximal fracture<br>
| Shaft fracture
|  
|  
Generally can tolerate &gt;50° angulation
Consider abuse of <3 years old


Tx: Sling and swathe for several weeks, ortho outpatient f/u in 3-5 days<br>  
Radial nerve palsy is common, resolved with treatment<br>


|-
treatment: Older kids/adolescents - Hanging long arm cast, ortho outpatient follow up in 3-5 days
| Shaft fracture<br>
|
Consider abuse of &lt;3 years old
 
Radial nerve palsy is common, resolved with treatment<br>
 
Tx: Older kids/adolescents - Hanging long arm cast, ortho outpatient f/u in 3-5 days<br>
 
Immediate ortho consult: Child &gt;20° or adolescent &gt;10° angulation and/or radial nerve injury<br>


Immediate ortho consult: Child >20° or adolescent >10° angulation and/or radial nerve injury
|}
|}


<br>
==Elbow==
 
<br>
 
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<br>


<br>
{| class="wikitable"  
 
== Elbow<br>  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
|-
| Supracondylar fracture<br>
| [[Supracondylar fracture]]
|  
|  
On XR - posterior and anterior fat pads, anterior humeral line (bisects mid 1/3 of capitellum)  
On XR - posterior and anterior fat pads, anterior humeral line (bisects mid 1/3 of capitellum)  


Radial/median/ulnar palsies generally resolve with reduction<br>  
Radial/median/ulnar palsies generally resolve with reduction<br>


Tx: Minimally displaced: long arm posterior splint with elbow at 90° and forearm protonated/neutral<br>  
treatment: Minimally displaced: long arm posterior splint with elbow at 90° and forearm protonated/neutral<br>


Ortho f/u in 3-5 days with immobilization for 3 weeks<br>  
Ortho follow up in 3-5 days with immobilization for 3 weeks<br>


Immediate ortho consult for more than minimal displacement or neurovascular compromise<br>  
Immediate ortho consult for more than minimal displacement or neurovascular compromise<br>


|-
|-
| Lateral condylar<br>
| Lateral condylar
| Displace &gt;2 mm, requires ortho reduction<br>
| Displace >2 mm, requires ortho reduction<br>
|-
|-
| Medial epicondylar<br>
| Medial epicondylar
|  
|  
Displaced: requires open reduction by ortho  
Displaced: requires open reduction by ortho  


Nondisplaced: posterior splint with forearm pronated<br>  
Nondisplaced: posterior splint with forearm pronated<br>


|-
|-
| Radial head and neck<br>
| Radial head and neck
|  
|  
Tx: splint elbow 90° forearm pronated/neutrol, always f/u with ortho  
treatment: splint elbow 90° forearm pronated/neutrol, always follow up with ortho  


Immediate ortho consult for angulation &gt;15°<br>  
Immediate ortho consult for angulation >15°<br>


|-
|-
| Elbow dislocation<br>
| [[Elbow dislocation]]
| High risk of neurovascular injury, always consult ortho for reduction<br>
| High risk of neurovascular injury, always consult ortho for reduction<br>
|-
|-
| Radial head subluxation<br>
| Radial head subluxation
|  
|  
AKA 'nursemaid's elbow'  
AKA 'nursemaid's elbow'  


Child holds are pronated, slightly flexed<br>
Child holds are pronated, slightly flexed


Tx: reduce with supination and flexion, post reduction patient uses arm in 5-10 minutes<br>  
treatment: reduce with supination and flexion, post reduction patient uses arm in 5-10 minutes<br>


|}
|}


<br>
==Forearm/Wrist==


<br>
{| class="wikitable"  
 
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== Forearm/Wrist<br>  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
|-
| Radius/ulna shaft<br>
| Radius/ulna shaft
|  
|  
75% are distal third, isolated ulna very rare  
75% are distal third, isolated ulna very rare  


Tx: &lt;10° sugar-tong splint, immediately consult ortho for &gt;10° angulation<br>  
treatment: <10° sugar-tong splint, immediately consult ortho for >10° angulation<br>


|-
|-
| Monteggia fracture<br>
| [[Monteggia fracture]]
|  
|  
Ulna fracture and radial head dislocation  
Ulna fracture and radial head dislocation  


Always consult ortho immediately!<br>
Always consult ortho immediately!


|-
|-
| Galeazzi fracture<br>
| [[Galeazzi fracture]]
|  
|  
Radial shart disruption of distal radioulnar joint  
Radial shart disruption of distal radioulnar joint  


Always consult ortho immediately!<br>
Always consult ortho immediately!


|-
|-
| Distal radius/ulna<br>
| Distal radius/ulna
|  
|  
Distal radius AKA Colles' fracture  
Distal radius AKA Colles' fracture  


Tx: Splint and ortho f/u in 3-5 days<br>
treatment: Splint and ortho follow up in 3-5 days


*Torus: Volar/short arm<br>
*Torus: Volar/short arm
*Greenstick/complete: Long are posterior or sugar-tong<br>
*Greenstick/complete: Long arm posterior or sugar-tong


Immediate ortho consult for angluation &gt;10-15°<br>
Immediate ortho consult for angluation >10-15°


|-
|-
| Carpal bones<br>
| Carpal bones
|  
|  
Fractures are rare  
Fractures are rare  


If scaphoid injury even suspected, thumb spica/cast for at least 2 weeks<br>
If scaphoid injury even suspected, thumb spica/cast for at least 2 weeks


|}
|}


<br>
==Hand/Fingers==
 
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<br>
 
== Hand/Fingers<br>  ==


{| cellspacing="0" cellpadding="2" border="1" align="left"
{| class="wikitable"  
|-
|-
| Metacarpal fracture<br>
| [[Metacarpal fracture]]
|  
|  
Tx: Distal 5th (boxer's) if nondisplaced apply gutter splint with MCP joint at 70°  
treatment: Distal 5th (boxer's) if nondisplaced apply gutter splint with MCP joint at 70°  


Immediate ortho consult if &gt;30-40° angulation; closed reduction often needed<br>
Immediate ortho consult if >30-40° angulation; closed reduction often needed


|-
|-
| Phalangeal dislocation<br>
| [[Phalangeal finger dislocation]]
|  
|  
PIP/DIP - Reduce and buddy tape x3 weeks, if PIP consider digital block pre-reduction  
PIP/DIP - Reduce and buddy tape x3 weeks, if PIP consider digital block pre-reduction  
Line 248: Line 159:
MCP - If initial reduction fails. consult hand surgeon (plastics)  
MCP - If initial reduction fails. consult hand surgeon (plastics)  


Refer gamekeeper's thump (avulsion of ulnar collateral ligament; requires thumb spica x3-6 weeks  
Refer gamekeeper's thump (avulsion of ulnar collateral ligament; requires thumb spica x3-6 weeks


|-
|-
| Phalangeal fracture  
| [[Phalangeal finger fracture]]
|  
|  
Distal tuft crush injury -&nbsp;Tx: laceration closure  
Distal tuft crush injury -&nbsp;treatment: laceration closure  


Most other fractures - Tx: buddy tape  
Most other fractures - treatment: buddy tape


|}
|}


<br>
==Hip/Femur==
 
<br>
 
<br>
 
<br>


<br>
{| class="wikitable"  
 
<br>
 
<br>
 
<br>
 
<br>
 
<br>
 
== Hip/Femur  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
|-
| Hip dislocation  
| [[Hip dislocation]]
| Closed reduction within 6 hours
| Closed reduction within 6 hours
|-
|-
| SCFE  
| [[SCFE]]
| 8-15yo M:F 2:1, associated with obesity, increased risk in blacks, pt complains of hip/knee pain
| 8-15yo M:F 2:1, associated with obesity, increased risk in blacks, patient complains of hip/knee pain
|-
|-
| Femoral shaft fractures
| [[Femoral shaft fracture]]
|  
|  
Birth-2yo: Traction or immediate casting  
Birth-2yo: Traction or immediate casting  
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2-10yo: Ortho consult, traction with spica casting  
2-10yo: Ortho consult, traction with spica casting  


Adolescent: Stabilize with traction splint, consult ortho  
Adolescent: Stabilize with traction splint, consult ortho


|-
|-
| Femoral neck fractures
| [[Femoral neck fracture]]
| Traction/splint with ortho consult for closed or open reduction
| Traction/splint with ortho consult for closed or open reduction
|}
|}


<br>
==Knee==
 
<br>
 
<br>
 
<br>
 
<br>
 
<br>
 
<br>


<br>
{| class="wikitable"  
 
== Knee  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
|-
| Knee dislocation  
| [[Knee dislocation]]
| Immediate reduction recommended, arteriogram post reduction
| Immediate reduction recommended, arteriogram post reduction
|-
|-
| Patella fracture  
| [[Patella fracture]]
|  
|  
Non-dislocated: cylindrical cast x4-6 weeks  
Non-dislocated: cylindrical cast x4-6 weeks  


Displaced &gt;3-4mm: ORIF  
Displaced >3-4mm: ORIF


|-
|-
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|}
|}


<br>
==Tib/Fib==


<br>
{| class="wikitable"  
 
<br>
 
<br>
 
<br>
 
<br>
 
== Tib/Fib  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
|-
| Proximal tibia  
| [[Proximal tibia fracture]]
| Early ortho consult especially if intra-articular
| Early ortho consult especially if intra-articular
|-
|-
| Tib/fib shaft  
| Tib/fib shaft  
| Long leg posterior splint, ortho f/u in 3-5 days
| Long leg posterior splint, ortho follow up in 3-5 days
|-
|-
| Toddler's  
| [[Toddler's fracture]]
|  
|  
Technically an oblique non displaced fracture of the distal tibia  
Technically an oblique non displaced fracture of the distal tibia  


Tx: Posterior splint  
treatment: Posterior splint


|}
|}


<br>
==Ankle & Foot==


<br>
{| class="wikitable"  
 
<br>
 
<br>
 
<br>
 
<br>
 
== Ankle &amp; Foot  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
|-
| Distal tibia/fibula fractures  
| Distal tibia/fibula fractures  
|  
|  
Non-displaced: bulky posterior splint and crutches with ortho f/u in 3-5 days  
Non-displaced: bulky posterior splint and crutches with ortho follow up in 3-5 days  


Tilaux: Salter III of distal tibia, requires ORIF  
Tilaux: Salter III of distal tibia, requires ORIF


|-
|-
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Midfoot fractures are rare  
Midfoot fractures are rare  


Tx: bulky posterior splint, crutches, ortho f/u in 3-5 days  
treatment: bulky posterior splint, crutches, ortho follow up in 3-5 days


|-
|-
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Phalanged: buddy tape, hard soled shoes  
Phalanged: buddy tape, hard soled shoes  


Intra-articular: great toe and/or significant displacement requires pinning  
Intra-articular: great toe and/or significant displacement requires pinning


|}
|}


<br>
==See Also==
 
*[[Fractures]]
<br>
 
<br>
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
== Source  ==


Cincinnati Children's Hospital "The Pocket" 2010-2011  
==References==
<references/>
*Cincinnati Children's Hospital "The Pocket" 2010-2011  


[[Category:Peds]] [[Category:Ortho]]
[[Category:Pediatrics]]  
[[Category:Orthopedics]]

Revision as of 21:41, 23 January 2017

Clavicle & Shoulder

Clavicle fracture

treatment: Sling/swathe x3 weeks, no sports x3 weeks

Consult ortho immediately for neurovascular compromise

Shoulder dislocation

Usually anterior/inferior, always get axillary view film

treatment: Closed reduction, sling/swathe for several weeks with ortho outpatient follow up due to high risk of recurrence

If posterior dislocation or neurovascular compromise, consult ortho immediately

Humerus

Proximal humerus fracture

Generally can tolerate >50° angulation

Classification - using the Neer classification system to divide humerus into 4 parts:

  • greater tuberosity
  • lesser tuberosity
  • anatomic neck
  • surgical neck

treatment: Sling and swathe for several weeks, ortho outpatient follow up in 3-5 days if


Shaft fracture

Consider abuse of <3 years old

Radial nerve palsy is common, resolved with treatment

treatment: Older kids/adolescents - Hanging long arm cast, ortho outpatient follow up in 3-5 days

Immediate ortho consult: Child >20° or adolescent >10° angulation and/or radial nerve injury

Elbow

Supracondylar fracture

On XR - posterior and anterior fat pads, anterior humeral line (bisects mid 1/3 of capitellum)

Radial/median/ulnar palsies generally resolve with reduction

treatment: Minimally displaced: long arm posterior splint with elbow at 90° and forearm protonated/neutral

Ortho follow up in 3-5 days with immobilization for 3 weeks

Immediate ortho consult for more than minimal displacement or neurovascular compromise

Lateral condylar Displace >2 mm, requires ortho reduction
Medial epicondylar

Displaced: requires open reduction by ortho

Nondisplaced: posterior splint with forearm pronated

Radial head and neck

treatment: splint elbow 90° forearm pronated/neutrol, always follow up with ortho

Immediate ortho consult for angulation >15°

Elbow dislocation High risk of neurovascular injury, always consult ortho for reduction
Radial head subluxation

AKA 'nursemaid's elbow'

Child holds are pronated, slightly flexed

treatment: reduce with supination and flexion, post reduction patient uses arm in 5-10 minutes

Forearm/Wrist

Radius/ulna shaft

75% are distal third, isolated ulna very rare

treatment: <10° sugar-tong splint, immediately consult ortho for >10° angulation

Monteggia fracture

Ulna fracture and radial head dislocation

Always consult ortho immediately!

Galeazzi fracture

Radial shart disruption of distal radioulnar joint

Always consult ortho immediately!

Distal radius/ulna

Distal radius AKA Colles' fracture

treatment: Splint and ortho follow up in 3-5 days

  • Torus: Volar/short arm
  • Greenstick/complete: Long arm posterior or sugar-tong

Immediate ortho consult for angluation >10-15°

Carpal bones

Fractures are rare

If scaphoid injury even suspected, thumb spica/cast for at least 2 weeks

Hand/Fingers

Metacarpal fracture

treatment: Distal 5th (boxer's) if nondisplaced apply gutter splint with MCP joint at 70°

Immediate ortho consult if >30-40° angulation; closed reduction often needed

Phalangeal finger dislocation

PIP/DIP - Reduce and buddy tape x3 weeks, if PIP consider digital block pre-reduction

MCP - If initial reduction fails. consult hand surgeon (plastics)

Refer gamekeeper's thump (avulsion of ulnar collateral ligament; requires thumb spica x3-6 weeks

Phalangeal finger fracture

Distal tuft crush injury - treatment: laceration closure

Most other fractures - treatment: buddy tape

Hip/Femur

Hip dislocation Closed reduction within 6 hours
SCFE 8-15yo M:F 2:1, associated with obesity, increased risk in blacks, patient complains of hip/knee pain
Femoral shaft fracture

Birth-2yo: Traction or immediate casting

2-10yo: Ortho consult, traction with spica casting

Adolescent: Stabilize with traction splint, consult ortho

Femoral neck fracture Traction/splint with ortho consult for closed or open reduction

Knee

Knee dislocation Immediate reduction recommended, arteriogram post reduction
Patella fracture

Non-dislocated: cylindrical cast x4-6 weeks

Displaced >3-4mm: ORIF

Patella dislocation Closed reduction with knee immobilizer x4 weeks

Tib/Fib

Proximal tibia fracture Early ortho consult especially if intra-articular
Tib/fib shaft Long leg posterior splint, ortho follow up in 3-5 days
Toddler's fracture

Technically an oblique non displaced fracture of the distal tibia

treatment: Posterior splint

Ankle & Foot

Distal tibia/fibula fractures

Non-displaced: bulky posterior splint and crutches with ortho follow up in 3-5 days

Tilaux: Salter III of distal tibia, requires ORIF

Mid/Hindfoot fractures

Talus: pain with dorsiflexion

Calcaneous: fall from a height

Midfoot fractures are rare

treatment: bulky posterior splint, crutches, ortho follow up in 3-5 days

Metatarsal/phalangeal

Base of 5th metatarsal: 'Jones fracture', high nonunion rate

Non-displaced - bulky splint and crutches

Phalanged: buddy tape, hard soled shoes

Intra-articular: great toe and/or significant displacement requires pinning

See Also

References

  • Cincinnati Children's Hospital "The Pocket" 2010-2011