Pediatric Fractures

Distal Radius

Torus/Buckle Fracture

• Usually FOOSH
• Removable wrist (volar) splint x 2-4 weeks
  • Start ROM if at 2w no tenderness (discontinue immobilization)
  • No need for repeat X-rays

Greenstick Fracture

• Non-displaced
  • Short-arm cast x 2-4 weeks
• Displaced >10 degrees angulation
  • Closed reduction (gentle steady pressure for physeal) under conscious sedation
  • Long-arm cast (elbow 90 degrees flexion, forearm in neutral rotation, and wrist in neutral flexion-extension
  • Repeat X-rays weekly
  • Remove cast at 4 weeks if healed clinically and radiographically

Physis Fracture

• Non-displaced (if X-rays normal initially, tenderness over growth plate, immobilize x 2 weeks, re-image and re-assess)
  • Short-arm cast x 3-6 weeks

Elbow

• Assess Vascular (Brachial) and Nerve (Ulnar/Anterior Interosseous Nerve)
  • Capillary refill, distal neurovascularity
  • Immobilize at flexion 20-30 degrees (least nerve tension) before X-rays to avoid further injury
• X-ray approach
  • Fat pad (sail) sign, posterior always indicates effusion (rule out fracture)
  • Anterior humeral line should intersect middle 1/3 of capitellum (if not think supracondylar fracture)
  • Radiocapitellar line shoulder intersect capitellum, if not think radial head dislocation (rule out Monteggia fracture-dislocation)
  • Remember CRITOE (Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon, External epicondyle)
    • Age 1, 3, 5, 7, 9, 11
      • Consider image bilaterally

Supracondylar

• For non-displaced, neurovascular intact
  • Long arm posterior splint then long arm casting with less than 90° of elbow flexion x 4 weeks with repeat X-ray

Lateral Condylar

• FOOSH + Varus force
• Non-displaced
  • Posterior splint, elbow 90°, weekly follow-up, if stable x2 weeks long-arm cast for 4-6 weeks

Proximal Humerus

• Acceptable deformity
  • Age 1-4yo = 70° without displacement
  • Age 5-12yo = 40° and displacement <51% width of shaft
  • Age >12yo = 15° and displacement <30% width of shaft
• If acceptable deformity, discuss conservative measures and consider Sarmiento brace with repeat X-rays in 2 weeks

Clavicular

• Most commonly middle third of clavicle after fall on shoulder (or may be from FOOSH)
• Broad arm sling (or figure of 8) 2 weeks until comfortable and fracture site non-tender
  • Repeat X-ray if lateral third fracture at 1 week (no repeat X-ray at middle-third)
  • ROM as tolerated (elbow/wrist/hand ROM throughout recovery)
  • Return to non-contact sports 6 weeks after injury
  • Avoid contact sports 1-2 months after healing
  • Advise that bony deformity possible
• Refer to ortho if displaced medial or lateral third fracture

Tibial

• Tibia fracture often occur with Fibula (look for plastic deformity)

Toddler's Fracture

• Children <2yo learning to walk (often no history of trauma)
  • Fall with twisting motion or from significant height
• Spiral fracture of distal/middle tibia (13-43% initial X-rays negative)
  • Pain with dorsiflexion of ankle
• Rule out abuse (bruising, other fracture)
• Non-displaced
  • Bent knee long-leg cast
    • X-rays weekly
    • May change to short-leg cast for 4-6 weeks if callus present
      • No evidence that casting speeds healing, but may decrease risk of displacement
    • Healing usually by 6-10 weeks
    • Varus deformity should remodel if <10 degrees
• Refer to ortho if open, pathologic, displaced >10 degrees anterior angulation, >5 degrees varus/valgus angulation, >1cm shortening, concurrent tibia/fobular fracture