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

• Fractures (main)
• Dislocations (main)

References

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