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TopiLaaksonen
YrjänäNietosvaara

Common Limb Injuries in Children: General Aspects

Essentials

  • If after even a mild injury a growing child refuses to use his/her upper limb or place full weight on his/her lower limb, there is usually a fracture.
  • Limb fractures in children do not necessarily show any signs of external injury.
  • X-ray is the first-line investigation to diagnose fractures.
  • Treatment decisions depend on the location, type and alignment of the fracture and the stage of the patient's growth.
  • Analgesics, casting and closed or open reduction can be used for treatment.
  • The possibility of abuse should be kept in mind.

Clinical examination

  • Whenever limb injury is suspected, both limbs should be completely exposed for comparison.
  • Small children should be held by a parent or caregiver when examined.
  • Is there malposition, oedema, bruising?
  • Examine the skin colour, warmth, circulation and sensation in the lower part of the limb.
  • Examine the healthy limb first. If you suspect a fracture, do not examine the range of joint movement on the injured side but first take a targeted x-ray.
  • Range of movement can be examined if no fractures can be seen on x-ray and joints are in correct position or a fracture is highly unlikely based on patient history.

Treatment

  • Not all children's fractures are visible on x-ray. Nevertheless, treatment should be started as for a well-aligned fracture if there is no other cause for the symptoms and there is a history of an evident injury.
  • The fracture should usually be reduced if it causes visible malposition of the limb.
  • Fractures involving a joint are often treated surgically.
  • Fracture alignment should be checked by x-ray, as necessary. Follow-up x-rays of incomplete fractures (bowing fracture, torus fracture) are unnecessary; this usually also applies to fractures treated surgically.
  • Healing of fractures in growing children can most reliably be assessed clinically. X-rays to assess ossification are rarely justified.
  • Fractures in children can be divided into four treatment classes.
    • Class 1. Fracture alignment is acceptable and cannot change or, alternatively, a change would be of no significance. Class 1 fractures need not be checked by a physician; the parent or caregiver can remove the plaster cast, collar cuff sling or bandage after the agreed time.
    • Class 2. Fracture alignment is acceptable but may become worse, and should this happen, the fracture needs to be realigned. Checkup visit and x-ray are necessary.
    • Class 3. Fracture alignment is unacceptable, and the fracture must be realigned. Checkup visit and x-ray are necessary.
    • Class 4. Fracture alignment is unacceptable and cannot be sustained reliably without fixation. The fracture is treated surgically.
  • Fractures belonging to treatment classes 1 and 2 can be treated in primary health care. For class 2 fractures, a paediatric orthopaedist should be consulted during the week.
  • In older children, it may be possible to realign class 3 fractures under local anaesthesia in primary health care. A paediatric orthopaedist should be consulted after realignment.
  • For younger children, realignment should be done under nitrous oxide or general anaesthesia.
  • Treatment class 4 patients should be treated under general anaesthesia in specialized care.