Fractures and dislocations (peds)

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

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

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

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

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 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 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

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

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

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