• Mechanism of injury:
  • Velocity of car, bike, etc.
  • Height of fall
• Neurologic compromise
• Events surrounding injury
• Other injuries

• Thorough secondary survey looking for deformities, bruising, other injuries
• Assess neurovascular status:
  • Motor/sensation
  • Distal pulses
  • Capillary refill
• Range of motion of all joints involved
• Exclude concurrent injuries
• Ensure that history is consistent with injury

• Required only if concomitant injuries, surgery anticipated, or multiple/major bone involvement
• CBC, ESR if infection suspected

• Anteroposterior (AP), lateral, and oblique radiographs as necessary, including the joint above and below the fracture
• Comparison views may be useful if growth plates are involved
• Follow-up radiographs at 7-10 d may be required to exclude avascular necrosis or Salter I fractures
• Bone scan/CT/MRI may be useful to exclude fractures if plain radiographs are unhelpful or to evaluate for infection

Arthrocentesis if infection is suspected

Salter-Harris Fractures

• Type I and type II fractures require immobilization and orthopedic follow-up
• Type II distal femur fractures require urgent orthopedic consultation
• Type III and type IV require urgent orthopedic consultation for anatomic reduction
• Type V fractures require immobilization and consultation
• Anatomic reduction does not eliminate possibility of growth disturbance

Clavicle Fracture

• Figure-of-8 splint or sling for comfort
• Distal third clavicle fractures should be referred with initial sling and swathe or shoulder immobilizer

Elbow Fracture

• 10% of all pediatric fractures
• >50% are supracondylar
  • 10-15% have neural injury
• May present with only posterior effusion on lateral radiograph
• Orthopedic consultation because of potential neurovascular complications
• Brachial artery injury occur in 6-20% of supracondylar fractures
• Median nerve injury occur in 10-20% of supracondylar fractures
• Volar compartment syndrome of forearm can occur after supracondylar fracture:
  • Develops within 12-24 hr post injury
  • Can result in Volkmann ischemic contracture
    • Fixed flexion of elbow, pronation of forearm, flexion at wrist, metacarpal-phalangeal joint extension
• Epiphyseal injury with long-term growth abnormalities

Distal Radius and Ulna Fractures

• Most common site of pediatric fracture: Distal radius
• Reduce angulated fractures >15 degrees
• Pronator fat pad along volar radius may indicate occult fracture
• Colles fracture:
  • Reduce by traction in the line of deformity to disimpact the fragments, followed by pressure on the dorsal aspect of the distal fragment and volar aspect of the proximal fragment
  • Correct radial deviation
  • Immobilize wrist and elbow (sugar-tong splint)
  • Orthopedic consultation
• Torus fracture (incomplete fracture; buckling or angulation on the compression side of the bone only):
  • Most often in distal forearm
• Greenstick fracture (incomplete fracture of diaphysis of long bone with fracture on tension side of cortex):
  • Immobilize
  • Reduction if angulation >30 degrees in infants, >15 degrees in children

Tibia or Fibula Fracture

• Isolated fibular fractures: Short-leg walking cast
• Nondisplaced tibial fracture: Long-leg posterior splint, nonweight bearing
• Displaced tibial fracture and complex fractures require consultation
• Toddler's fractures:
  • Nondisplaced, oblique, distal tibia fracture
  • May need tangential view radiograph or bone scan to diagnose
  • Splint if suspect and repeat radiograph in 7-10 d
• May apply Ottawa Ankle Rules to children

Slipped Capital Femoral Epiphysis

• Disruption thorough capital femoral epiphysis
• Need AP and frog-leg x-rays
• Overweight adolescent boys
• May have referred pain to knee, thigh, or groin
• Nonweight bearing with prompt orthopedic follow-up
• Often bilateral

Femur Fracture

Most common long-bone fracture

Stress Fractures

• Increasingly common
• Insidious onset
• Vague, achy pain
• Usually associated with rigorous activity
• Treatment:
  • Selective bracing
  • Activity modification

Open Fractures

• Irrigate and dress with moist saline gauze
• Immobilize
• Cefazolin if only small laceration and minimal contamination
• Gentamicin if moderate contamination, high-energy injury, or significant soft tissue injury
• Consider penicillin if concern for clostridia infection (farm injury, fecal or soil contamination)
• Small wounds with minimal soft tissue injury may be treated with oral antibiotics and immobilization in consultation with orthopedist
• Better prognosis than adults

Child With Limp

• Careful exam and review of systems for signs of rheumatologic disease, infection, or malignancy:
  • Pediatric patients with leukemia may present with limp as their initial complaint
• CBC, ESR, CRP, arthrocentesis may be indicated
• Transient synovitis vs. septic hip
  • More likely septic if:
    • Fever
    • Elevated ESR/CRP
    • WBC elevation
    • Refusal to bear weight

• NAT (or per social services)
• Open fracture
• Potential neurovascular compromise/compartment syndrome:
  • Condylar or supracondylar humerus fracture
  • Femoral shaft

• Uncomplicated fracture: No concurrent injury or neurovascular/compartment compromise
• Follow-up arranged and parents understand injury and management

All Salter-Harris fractures should have orthopedic follow-up