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Lower Limb Injuries in Children
Femoral fractures
- Often high-energy injuries. Should nearly without exception be treated in specialized care.
- Any visible malposition should be corrected by gentle traction and the lower limb supported with a splint for transportation.
Dislocation of the patella
- See also article Dislocation of the patella Dislocation of the Patella.
- This is the most common cause of haemarthrosis of the knee in growing children.
- The patella is laterally displaced and either remains displaced or reduces spontaneously.
- In about one in three patients, there is a chondral or osteochondral fragment detached from the patella or the lateral femoral condyle.
- If the patella remains laterally dislocated, there is normally no significant injury to the joint surface.
- A laterally dislocated patella can usually be easily reduced by extending the knee. If necessary, the patella can be gently pressed inward with the knee extended.
- Tense haemarthrosis of the knee can be aspirated once to treat the pain using a large-bore needle inserted from the upper lateral aspect of the patella.
- X-rays (AP, lateral and Laurin views) should be taken to exclude fractures (Image ).
- Weight bearing can be allowed immediately unless there are loose fragments in the knee joint. Elbow crutches are usually needed at first.
- Refer the patient to a physiotherapist a few days after first dislocation for guidance regarding knee movement and muscle exercises. The patient should be instructed to do the exercises several times every day to restore and increase the strength of the femoral muscle.
- Physical hobbies can be resumed about a month from the injury, provided that the full range of knee motion has been restored and is painless.
- Recurring dislocation of the patella does not necessarily cause swelling of the knee.
- First aid and physical exercise guided by a physiotherapist should always be provided as for the first dislocation but no x-raying is necessarily needed if there are no findings suggesting a fracture (no significant swelling of the knee, patient able to bear weight on the leg and to move the knee).
- Write a non-emergency referral to a paediatric orthopaedic outpatient clinic for assessment for further treatment.
Fracture in a toddler
- Usually occurs when a 1-3-year-old child falls twisting and fracturing his/her tibia. Crying ensues, and the child refuses to stand on the fractured leg.
- The child is pain-free if the leg is not moved, and there are no external signs of injury.
- Fractures in toddlers are usually well-aligned and not always clearly visible on x-ray.
- A plaster cast is not necessary for the fracture to heal but may help to manage pain.
- Fractures will heal in 2-3 weeks, which can be seen in that the child starts to walk. After confirming the diagnosis, repeat imaging is unnecessary.
Other fractures of the tibial shaft
- Indirect injury creates oblique and spiral fractures; the fibula usually remains intact.
- Most such fractures can be treated with a leg cast. After ossification, there should be no remaining angle or rotation (> 10°). Surgery is indicated if the fracture cannot be held in a good position.
- Any visible malposition of the lower leg should be straightened by gentle traction before splinting and other examinations.
- The fracture should be supported by a leg cast for 3-4 weeks, which can subsequently be replaced by a boot cast, as necessary.
- The total duration of cast treatment is usually 4-7 weeks.
- Towards the end of cast treatment, weight bearing should be gradually introduced, and to speed up recovery after cast removal, the patient should be placing full weight on the leg for 1-2 weeks before the cast is removed.
Lower tibial fractures
- Lower tibial fractures are among the most common lower limb injuries in growing children.
- They often involve the physis. A physeal fracture should be reduced under general anaesthesia because such fractures involve a significant risk of bone bridge formation increased by attempts to realign the fracture, delayed treatment and unsatisfactory alignment of the fracture.
- Any malposition should be corrected by gentle traction before splinting and further examinations.
- Fractures involving a joint are often treated surgically if there is even the slightest displacement of the joint surface.
- Immobilization can be established by either a boot cast or a leg cast kept on for 4-6 weeks.
- A leg cast is needed if the fracture is rotationally unstable.
- To speed up recovery after cast removal, the patient should be placing full weight on the leg for 1-2 weeks before the cast is removed.
- A well-aligned lower fibular fracture is treated with a boot cast, even if the fracture reaches the epiphyseal line.
Ankle sprain
- See also Ankle Sprain.
- In children, some ligament injuries are avulsion injuries, where a small fragment of cartilage or bone is detached from the ligament attachment site. Avulsion with a bone fragment can usually be seen on x-ray.
- An avulsion fracture is treated like a ligament injury without avulsion.
- The Ottawa rules can also be applied to children, and adolescents, in particular.
- Injuries to the anterior talofibular ligament (ATFL) between the fibula and the ankle bone are common, producing lateral ankle swelling anterior to the lateral malleolus.
- It is not necessary to test the stability of the ankle.
- If the patient can calmly bear weight on the leg and no fracture can be seen on x-ray, it is probably a ligament injury.
- The ankle should be supported with a soft cast or inflatable splint for 2-4 weeks. It can subsequently be supported with a lace-up orthosis for a further 2-3 months.
- At first, some patients feel unable to walk on the injured leg. If so, the child should be provided with elbow crutches which should not be used for more than a couple of weeks.
- Physical hobbies can be started gradually as soon as movement does not cause symptoms and depending on the type of sports and the injury and the patient's condition.
Foot and toe fractures
- Fractures of toe and foot bones are common in children.
- The diagnosis should be made from dedicated x-ray images taken based on clinical examination. Imaging of the whole foot is often unnecessary.
- Most foot fractures can be treated by wearing a shoe with a hard sole or a slipper cast allowing weight bearing as permitted by pain.
- Fractures of the 2nd-5th toes should primarily be treated by taping the toe to the neighbouring toe for 2-3 weeks, if the toe position remains appropriate when bearing weight on the foot.
- If the fracture involves the 1st toe or MTP joints, a paediatric orthopaedist should be consulted for the line of treatment.
References
- Yeung DE, Jia X, Miller CA et al. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev 2016;4():CD010836. [PubMed]
- Madhuri V, Dutt V, Gahukamble AD et al. Interventions for treating femoral shaft fractures in children and adolescents. Cochrane Database Syst Rev 2014;(7):CD009076. [PubMed]
- Black KJ, Bevan CA, Murphy NG et al. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev 2013;(12):CD009587. [PubMed]