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

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