Fractures and dislocations

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24.2 Fractures and dislocations

Robyn Brady, John Walsh

Essentials

1 Fractures are common in childhood, due to high-level motor activity, developing co-ordination, and the mechanical properties of the growing skeleton. However, compared to adult mechanisms, the majority are relatively low-force injuries.

2 The patterns of bony disruption are completely different from adult fracture patterns and include buckle and greenstick fractures and growth-plate injuries. Bony disruption/deformity is more common than ligamentous disruption: ‘sprains’ and ruptures are uncommon.

3 Displaced fractures are a common and highly traumatic event for children and rapid attention to physical and psychological distress can minimise the effects of this trauma.

4 Certain missed fractures have a high propensity for serious long-term functional morbidity and must be actively sought. These include elbow injuries, such as lateral condylar and Monteggia-type fractures.

Fracture patterns in childhood

In the previous chapter the impact of development (behavioural and physiological) on musculoskeletal pathology was broadly outlined (see Table 24.1.1). With respect to injury, this means different points of cleavage or deformation from a given injury mechanism, and an extra anatomical structure (the physis) to consider when analysing the effects of trauma and the future outcome of a given disruption.

Fig. 24.2.1 shows the frequency of common fractures presenting to a children’s emergency department (ED). Within different age subgroups, the distribution varies thus:

• infants/toddlers – higher proportions femur and skull fractures;

• primary school – higher proportion of elbow-region fractures, especially supracondylar;

• adolescents – complex ankle fractures; higher force sporting injuries; transition to adult pattern with increasing ligamentous injuries, e.g. elbow dislocations.

Fig. 24.2.1 Frequency of fracture types at Brisbane Mater Children’s Hospital ED.

The majority of ED paediatric fracture presentations occur at the distal radius and ulna. This is one of the top ten ED diagnoses for children in Australia. Many displaced forearm fractures can be reduced under sedation by emergency staff with appropriate training and follow-up, making this a most valuable area of expertise.

Paediatric limb fractures, depending on the angle of force to which they have been subjected, can occur to shaft, metaphysis, or physeal region. The different quality of developing bone means that even injuries to shaft and metaphysis tend to have different patterns of deformation, including ‘torus’ or buckle injuries, bowing, and greenstick fractures. The importance of this awareness for the emergency physician is best illustrated by the Monteggia equivalent injury in which ‘shortening’ from proximal radial dislocation is ‘matched’ by ulnar bowing. The resultant injury has no radiologically obvious ‘fracture’ in the traditional sense but has serious consequences if not recognised and reduced (Fig. 24.2.2).

Fig. 24.2.2 Monteggia fracture-dislocation. Demonstration of the abnormal radio-capitellar relationship (see Fig. 24.2.8 for contrast).

Drawing by Terry McGuire.

The Salter–Harris classification (Fig. 24.2.3) remains the most useful way of describing the pattern of cleavage with respect to the physis. In reality, types 1 and 5 represent mechanical force patterns (separation and compression) rather than a radiological pattern as, unless there is lateral translation or adjacent bony or soft-tissue deformation, the physis may appear radiologically normal in these injuries. An example of Salter–Harris type 1 injuries with lateral shift is the so-called ‘slipped distal radial epiphysis’ (Fig. 24.2.4). The disorder of slipped upper femoral epiphysis (SUFE) has been discussed in Chapter 24.1 as, although minor trauma may precipitate an acute slippage, the cleavage is due to an abnormal physeal predisposition and should not be looked upon as truly traumatic.

Fig. 24.2.3 Salter–Harris classification of epiphyseal fractures.

Drawing by Terry McGuire.

Fig. 24.2.4 Common distal radial epiphyseal fractures.

(A) Partial slipped distal radial epiphysis (Salter–Harris 1) with 10% translation; (B) slipped distal radial epiphysis (Salter–Harris 1) with 50% translation and probable intact dorsal periosteal sleeve; (C) Salter–Harris 2 fracture of distal radius with metaphyseal fragment angulated to 45 degrees and 50% translation of epiphyseal plate.

Drawing by Terry McGuire.

Salter–Harris type 2 injuries are the most common physeal injury pattern seen, the metaphyseal corner (the ‘Thurston-Holland’ fragment) ranging in size from a barely visible fragment to an extensive triangle. Injuries through the epiphysis itself, Salter–Harris types 3 and 4, are more worrying in their prognosis because they are intra-articular as well as involving the physis. The classic example of a Salter–Harris type 3 injury is the Tillaux fracture (Fig. 24.2.5), while lateral condylar fractures at the elbow are Salter–Harris 4 in type.

Fig. 24.2.5 Tillaux fracture (Salter–Harris 3).

Early fusion of the medial distal tibial physis and relative superior strength of the distal tibiofibular ligament cause shearing force to separate the central physeal region and travel along the lateral distal tibial physis. Sometimes a metaphyseal fragment is also cleaved (Salter–Harris 4).

Table 24.2.1 shows some examples of the corresponding injury occurring in adults and children for a given mechanism. This table illustrates the maxim that children tend to fracture rather than ‘sprain’, as the physis is the weakest point of the musculoskeletal continuum, i.e. a ligament will avulse its bony origin or insertion rather than tearing. In some cases, this is to the child’s advantage, as the cellular architects of bone development which contribute to its mechanical weakness contribute to rapid healing and extensive remodelling. A midshaft femoral fracture, for example, will heal in 2–3 weeks in an infant, whereas the same disruption will take 12 weeks to union in a teenager.

Mechanism Adult injury Paediatric injury Fall onto point of shoulder AC separation Lateral clavicular fracture Shoulder extension/compression Shoulder dislocation Proximal humeral fracture Fall on hand, elbow hyperextension Elbow dislocation Supracondylar/condylar fractures Wrist hyperextension/compression Scaphoid fracture Distal forearm fracture Fall onto hand Colles’ fracture Midshaft, metaphyseal, or epiphyseal fracture Thumb abduction 1 Bennet’s fracture Metaphyseal fracture base first metacarpal Thumb abduction 2 Gamekeeper’s thumb (UCL) UCL avulsion fracture (Salter–Harris type 3 proximal phalanx thumb) Rotation of knee on lower leg ACL, cartilage tear Tibial spine fracture Valgus/varus knee stress Ligament, cartilage tear Distal femoral physeal separation Forceful jump (quadriceps) Ligament tear Patellar tendon avulsion fracture (Tibial tubercle) fracture Forceful jump (calf) Achilles tendon tear Calcaneal avulsion fracture Rotation of tibia on calcaneus Ankle sprains, Pott’s fractures Tibial spiral fracture, Tillaux fracture, triplane fracture Inversion ankle Talofibular ligament tear Salter–Harris type 1 or 2 distal fibula

Initial assessment and management

The initial assessment of the paediatric isolated limb injury (fracture/dislocation) is shown in Table 24.2.2 and the neurovascular assessment in Table 24.2.3. Limb injury must always be considered in the broader context of trauma. Primary and secondary survey, however brief and targeted, should always be carried out bearing in mind the described injury mechanism and the child’s complaints of pain, so that any associated injuries, e.g. to head, abdomen, or spine, may be recognised and evaluated early. An efficient early assessment should be able to establish mechanism, possible other sites of injury, probable fracture type, presence or absence of compound features or neurovascular impairment, and organise pain relief, fasting, radiology, splintage, and antibiotics if required, within a brief period.

1. Rapport: establish rapport and explain procedures

2. Mechanism and associated dangers: rapidly ascertain mechanism and ensure primary survey stability and allergy potential

3. Pain management: where there is a greater than 90% likelihood of initial IV success, insert a small IV cannula into the opposite hand and titrate morphine 0.05 mg kg^–1 until pain relieved (appropriate monitoring should be in place). When no parent is present the risks of medication must be weighed against the potential benefit and attempts made to contact someone familiar with serious allergies or other medical problems. Other means of rapid pain relief include inhaled Penthrane or NO_2, and or intranasal fentanyl

4. Assess for site of anatomical disruption: look at and gently palpate the injured limb to estimate probable anatomical site of disruption, e.g. lateral elbow, mid-shaft forearm, etc. (comparison with other limb is often helpful)

5. Check for associated neurovascular dysfunction: (see Table 24.2.3), document and notify deficits immediately

6. Check for any evidence of an open wound: if this is present, cover with a sterile dressing and commence appropriate antibiotics IV, e.g. cefalothin 50 mg kg^–1 and notify orthopaedic team immediately

7. Immobilise limb: provide appropriate splintage (e.g. we use a POP slab for distal fractures, leaving radial artery palpable, and a fibreglass slab for elbow injuries, less radiological artefact-mouldable, re-usable, radiolucent slabs)

8. Keep stomach empty: identify time of last ingestion and inform patient and parent about fasting

9. Organise appropriate radiology

10. Discuss clinical and radiological findings with orthopaedic team

Table 24.2.3 Presence/absence of associated neurovascular injury
• Radial a: Pulse, cf. other side Hand perfusion/capillary refill, cf. other side • Brachial a: Beware spasm or intimal shear in supracondylar injuries • Radial n: Sensation dorsum hand, action = dorsiflex wrist, extend fingers (displaced humeral shaft injury) • Median n: Sensation thenar eminence, action = opposition, flexion IP thumb (supracondylar # or elbow dislocation) • Ulnar n: Sensation hypothenar eminence, action = abduction, adduction fingers (elbow dislocation, supracondylar #) • Posterior interosseous n: Branch of radial n, action = finger extension, e.g. (Monteggia #/dislocation)

Fracture descriptions to the orthopaedic team should start with the child’s age, mechanism, and clinical findings, and proceed to the part of bone, type of fracture, and extent of angulation and/or displacement and associated findings. Clinical findings must always be kept paramount. Skin breach must be actively sought and described, then photographed and covered with a sterile dressing. Prominently placed photographic displays of common paediatric fractures within the emergency department may aid accurate description.

Doctors share in the community responsibility for child safety. Within the ED setting this means getting a clear description of the setting and mechanism of injury, particularly with injuries to pre-verbal children. These data are important:

• to more clearly anticipate associated injuries (e.g. foreign bodies or distant possibility of abusive injury);

• to gather cumulative injury prevention data to support legislative change (e.g. road access); and

• to flag possible abusive injury, which is thought to have occurred in 1–2% of paediatric injury presentations, particularly in very young children.¹

In general, fractures in pre-verbal children without a clear, developmentally appropriate mechanism/history or with other concerning features, will need further assessment. Features suggestive of non-accidental injury are shown in Table 24.2.4, and child abuse is discussed in more detail in Chapter 18.2. As a minimum, all fractures occurring in children under 12 months should be discussed with a paediatrician or child-protection specialist.

Table 24.2.4 Features suggestive of possible non-accidental injury
Fractures • Proximal humeral or humeral shaft fractures under 3 years • Fractures with a shearing or distracting mechanism • Corner or ‘bucket-handle’ metaphyseal injuries • Femoral fractures in infants • Rib fractures • Complex skull fractures • Multiple fractures, especially different ages
Presentation features • Delayed presentation • Different care-giver • Unwitnessed injury • Recurrent fractures • Unexplained soft-tissue markings • Unexplained tension/anxiety
Assessment • Draw diagram of injury history as described by witness • Examine child all over and plot weight • Ascertain any previous history of burns or fractures • Is the developmental level compatible with the explanation? • Is the history adequate to explain the injury?
Rule of thumb • Infants within view, toddlers within earshot, unless asleep, i.e. injuries to pre-school children are usually seen or heard
Refer • All fractures in children under 12 months, and all fractures in children under 4 years in which there is an inadequate or questionable mechanism, should be discussed with a child-protection specialist. In the interim, supportive and non-judgemental care for child and care-giver must be maintained

The following sections describe the mechanism, recognition, and ED treatment of individual fractures.

Upper limb and shoulder girdle injuries

Midshaft clavicular fractures

These may occur at any age from a fall onto the shoulder or outstretched hand, are usually greenstick in nature and heal well in a sling or figure-of-eight bandaging. A fall onto the point of the shoulder, such as would cause an acromioclavicular disruption in an adult, may cause a lateral clavicular physeal fracture-separation. If these are posteriorly displaced, operative treatment may be required. Treatment is by sling or shoulder immobilisation followed by graduated exercises.

The neonatal shoulder may come to medical attention due to asymmetrical arm movement or swelling. Causes include birth injury with clavicular fracture or brachial plexus injury, proximal humeral physeal separation, and joint or bone infection. Senior orthopaedic involvement is essential for the diagnosis, and non-accidental injury must be considered. The prognosis for neonatal clavicular injuries is excellent.

Shoulder dislocation

This is uncommon under 10. The adolescent anterior dislocation can be reduced by traction in the prone position or by gentle arm traction to a seated child against counter-traction with a sheeted thorax.

Proximal humerus

These fractures vary from minor buckling at the proximal metaphysis, to proximal humeral epiphyseal Salter–Harris type 2 fracture-separations (Fig. 24.2.6). Because of the universal motion at the glenohumeral joint and the remodelling potential of children, a remarkable range of initial traumatic deformity is acceptable in children prior to physeal closure (age 14–16), including complete displacement and up to 60 degrees of angulation.² A collar and cuff is the usual treatment.

Fig. 24.2.6 Proximal humeral fractures.

(A) Normal undulating physeal line (not a fracture); (B) greenstick metaphyseal fracture; (C) severely angulated and displaced Salter–Harris 2 fracture at the proximal humeral epiphysis. Due to the universal motion of the shoulder joint, this fracture will still unite and remodel completely with conservative treatment.

Drawing by Terry McGuire.

Midshaft humeral fractures

These are less common and sometimes the result of blunt or non-accidental trauma. Check and document radial nerve function, and immobilise with a U-slab.

Injuries to the elbow region

The elbow region accounts for 10% of all paediatric fractures. Supracondylar fractures make up 75% of these, and lateral condylar fractures 17%.³ Missed or inadequately treated paediatric elbow injuries figure prominently in orthopaedic litigation series.⁴ Post-traumatic elbow effusion in childhood without a radiologically apparent fracture line most commonly represents a minimally displaced supracondylar fracture. These must be immobilised by collar and cuff to avoid any potential extension from further falls, and followed up in a fracture clinic for a repeat X-ray at 7–14 days. It is sometimes useful to start with the examination findings in the normal elbow, as outlined in Table 24.2.5 (Figs 24.2.7 and 24.2.8). The first point in itself will define an anatomically intact elbow, while the other points help the physician to narrow down the type of abnormality where the first point is abnormal.

The normal paediatric elbow must have

• Full extension, supination and pronation

• No swelling or significant focal bony tenderness

• No abnormal anterior or posterior fat-pad sign on radiographs

• Normally placed and age-appropriate ossification centres (see Fig. 24.2.7)

• An intact radio-capitellar relationship (see Fig. 24.2.8)

Fig. 24.2.7 CRITOE.

The approximate order of appearance of the six elbow ossification centres according to the CRITOE mnemonic.

Drawing by Terry McGuire.

Fig. 24.2.8 The normal capitello-radial head relationship.

Drawing by Terry McGuire.

Supracondylar fracture

Supracondylar injuries occur in the young school-age child as a result of a fall on the outstretched hand, transmitted through elbow hyperextension to the narrow region between olecranon and coronoid fossae. Degrees of rotation of the distal region relative to the main axis of the humerus are common, depending on the degree of pronation/supination at the time of fall.

Gartland Type 1 – undisplaced supracondylar fracture

This is the presumptive diagnosis with elbow effusions that are tender bilaterally and have no ulnar or radial dislocations or significant displacement/angulation. The fracture line through the bone between olecranon and coronoid fossae may be seen on the AP view or recognised as a disruption to the normal ‘teardrop’ between the opposing fossae on the lateral humeral view, but its absence should not prevent the immobilisation of these elbow effusions until early orthopaedic review.

Gartland Type 2 – posterior angulation with probable intact periosteal hinge (Fig. 24.2.9A)

In this situation it is important to check for associated rotation or varus/valgus injury. Use the ‘anterior humeral line’ as a guide to the degree of posterior angulation (Fig. 24.2.10), and consult orthopaedics about all injuries. Simple (2a) fractures with less than 20 degrees of angulation may be managed conservatively in a backslab and collar and cuff, with orthopaedic follow up. If there is varus/valgus angulation or rotation on the AP view (Gartland Type 2b), then orthopaedic consultation is required acutely as surgery may be indicated. Remember that remodelling may correct some loss of flexion or extension but will not correct rotation or varus/valgus deformity.

Fig. 24.2.9 Supracondylar fractures.

(A) Grade Gartland Type 2, approximately 45 degrees dorsal angulation but probable intact dorsal periosteal ‘hinge’; (B) grade Gartland Type 3, complete displacement, often co-existent rotation and/or neurovascular impairment.

Drawing by Terry McGuire.

Fig. 24.2.10 The anterior humeral line rule for subtle supracondylar fractures.

A line passed along the anterior humeral cortex on a lateral elbow radiograph should bisect the anterior and middle thirds of the capitellum. If it passes anterior to the capitellum, there is at least 20 degrees dorsal angulation of the distal humerus.

Drawing by Terry McGuire.

Gartland Type 3 – grossly displaced/rotated (Fig. 24.2.9 B)

Check for open injury or neurovascular compromise. Brachial artery spasm or kinking is common with this injury, and the gross associated swelling may predispose to compartment syndrome. Radial pulse and hand perfusion should be continuously reassessed. In cases with extreme swelling, extension may be safest. Immediate orthopaedic notification is required.

If orthopaedic help is not available within 1 hour of the onset of poor hand perfusion, attempt gentle traction and reduction under anaesthesia, e.g. ketamine, aiming for the position with best hand perfusion.

Median or radial nerve injury may also occur (usually as praxis), and require orthopaedic evaluation. Ulnar nerve injury is most commonly reported as an iatrogenic injury following internal fixation.

Supracondylar Gartland Types 2b and 3 fractures require admission for MUA and K-wiring and occasionally open reduction, and appropriate management of complications.

Intercondylar (T-condylar) fracture

This is a variant of the supracondylar fracture occurring in adolescents. It results from axial impaction and intra-articular separation of capitellum and trochlea, as well as proximal disruption of the medial and lateral distal humeral columns. Treatment is by internal fixation, with or without open reduction.

Lateral condyle

This fracture results from a varus force on the supinated forearm, avulsing the condyle (Figs 24.2.11 and 24.2.12). There is clinical swelling and tenderness, which is maximal over the lateral condyle. It is usually a Salter–Harris type 4 fracture, but the late appearance of the trochlear and lateral epicondylar ossification centres means that the true structural disruption is not demonstrated by radiology, and therefore not appreciated by emergency staff, particularly in the younger child. The varus angulating force characteristically causes disruption commencing above the lateral condyle, passing to a varying extent along the physis, and in complete disruptions exiting either lateral (in the majority of cases; Milch type 1), or medial (Milch type 2) to the capitellar-trochlear groove. If uncorrected, the injury may result in valgus deformity, and possible delayed ulnar nerve palsy and degenerative elbow disease.

Fig. 24.2.11 Subtle lateral condylar fracture in a toddler.

Note only two ossification centres (capitellum and radial head) and thin rim of metaphysis shorn away with capitellum. Greater angulation/displacement of metaphyseal fragment may be shown on lateral view. Gross clinical swelling is the key.

Drawing by Terry McGuire.

Fig. 24.2.12 Displaced and rotated lateral condylar fracture (Milch type I).

Long-term complications may ensue if not surgically fixed.

Drawing by Terry McGuire.

Bony displacement is often best seen on the lateral X-ray.

The clinical significance of this fracture means that:

Any lateral condyle fracture with a greater than 2 mm separation of fracture segments is likely to require internal fixation, particularly if displacement is proximal.

All young children with major elbow deformity/swelling as a result of injury should be assessed early by experienced orthopaedic personnel. Ultrasound, magnetic resonance imaging, and arthrography may all have a role to play in determining the line of injury and consequent best means of fixation. Within the ED, an internal oblique radiograph can be helpful.

The elbow may be supported in a radiolucent backslab while awaiting orthopaedic review, but X-rays in this radiologically complex region are best performed prior to plaster application.

In infants, lateral humeral condylar separation may occur as a Salter–Harris 1 type fracture and be difficult to diagnose radiologically, although the elbow will be grossly abnormal with maximal swelling laterally. History must explain the varus force, and abusive injury should be considered. Ultrasound may be useful diagnostically.

Medial epicondylar avulsion

This may occur in association with other disruptions, e.g. elbow dislocation, or as a discrete event (Fig. 24.2.13). The medial epicondyle is the origin of the common flexor tendon, and ossifies at approximately age six. It will generally reunite readily with the humerus if it lies within 5 mm, unless there is interposing tissue. Occasionally, particularly when the avulsion has occurred in association with a posterior elbow dislocation, the epicondyle and its attachments may become lodged within the elbow joint and may block an attempt at closed reduction. Ulnar nerve injury is a common association. This circumstance is one of the main practical uses of knowledge of elbow ossification centres (see Fig. 24.2.7). These must be systematically reviewed on every elbow X-ray so that missing or misplaced opacities may be identified.

Fig. 24.2.13 Medial epicondylar avulsion.

(A) The opacity below the humerus is the avulsed medial epicondyle, which should be sitting more proximal and medial. There should not be a trochlear opacity without a medial epicondylar ossification centre. Developmentally, there should not be an ossification centre in the trochlea position without one in the medial epicondylar position. (see Fig. 24.2.7). (B) Lateral view shows opacity ‘between’ capitellum and olecranon, possibly intra-articular.

Drawing by Terry McGuire.

Pulled elbow (radial head subluxation, RHS)

Children from age 6 months presenting with acute disuse of one arm, which they hold in a semi-flexed and pronated posture, and a history of traction, can be presumed to have pulled elbow or RHS if there is point tenderness at the radial head and no palpable elbow effusion, i.e. no infilling of the soft tissue space medial and lateral to the olecranon in comparison with the unaffected arm.

Subluxation occurs because the oval shape of the radial head allows the head to sublux slightly through the annular ligament when the forearm is pulled in pronation. Part of the ligament is ‘caught’ in the radiocapitellar space, and in fact partial tears can occur.⁵^,⁶ In older children the ligament is thicker and more densely attached, and subluxation in a child over 5 is unusual.

X-ray and/or ultrasound, seeking alternative diagnoses, should be obtained in any child with other points of focal tenderness, an elbow effusion, a mechanism of greater trauma, an atypical history, e.g. fever, or a failure of the procedure detailed below.

Reduction of RHS

A recent prospective randomised trial has suggested that hyperpronation is more likely than supination to reduce the pulled elbow on the first occasion, and elicits less discomfort.⁷

After a brief parental explanation and oral or intranasal pain relief, these children should be held firmly by a parent while the forearm is hyperpronated. It is helpful for the doctor to cradle the elbow in the outer hand with the thumb over the radial head while their inner arm rotates. Success is usually denoted by a momentary pain, a palpable click, and a return to functional use. If the procedure is not successful, the procedure can be repeated, and if this fails, the traditional method of full, firm supination and flexion can be attempted. This combination of techniques should elicit success in >90% of cases of radial head subluxation.⁷ If the above process is unsuccessful, the history and examination should be revisited and imaging sought. Interestingly, while radiographs should be normal (and should not show posterior fat pad elevation, which should suggest alternative diagnoses), the radiocapitellar distance is significantly increased in radial head subluxation on ultrasound due to the presence of the interposed ligament; a tear may sometimes be shown. If an alternative diagnosis is not suggested by imaging and careful re-assessment, RHS remains the most likely diagnosis: the child can be allowed home with the arm supported in a sling in a neutral position, and with review at 24-48 hours, at which time many will have spontaneously reduced. Persistent dysfunction beyond 48 hours requires orthopaedic evaluation. Although some children sustain recurrent RHS, it rarely requires operative intervention.⁸

Elbow dislocation

Appearing first in adolescence, this injury, the result of a fall on to the hand with partially flexed elbow, is uncommon in young children (who sustain supracondylar fractures instead). The majority dislocate posteriorly, tearing joint capsule, and stretching soft tissues. The displacement may cause fracture to the coronoid process of the ulna or radial neck, or the medial epicondyle may be avulsed. Neuropraxis of median or ulnar nerves may occur.

The dislocation should be suspected clinically. After assessing for associated injuries, it should be reduced in the ED, generally under ketamine anaesthesia (Fig. 24.2.14). Gentle downwards pressure can be applied to the supinated proximal forearm, with extension of the elbow to about 135 degrees, against countertraction to distal humerus. Full extension should be avoided as it may cause further damage to the ulnar nerve. If there is difficulty in resiting the olecranon, there may be soft tissue inter-position and orthopaedic help should be sought, as a computerised tomography (CT) scan may be indicated. The reduced elbow should be held in flexion with a posterior splint, a check X-ray performed, and orthopaedic follow up arranged.

Fig. 24.2.14 Reduction of elbow dislocation.

Assistant anchors humerus to avoid distal/anterior movement. Bring forearm in full supination to approximately 20 degrees from full extension, and provide simultaneous downwards traction and downwards pressure over the proximal forearm to lever the coronoid process back under the distal humerus.

Drawing by Terry McGuire.

Proximal radial and ulnar fractures

Olecranon fractures

These may occur in older children as: (1) avulsion (flexion) fractures (generally requiring internal fixation); (2) extension fractures with intra-articular opening (may be stable in flexion); or (3) comminuted fractures from a direct blow to the elbow. Clinical correlation must be sought in diagnosing olecranon fractures, as the ossification centre, which appears around 10 years of age and may be bipartite or fragmentary in appearance, is easily mistaken for a fracture.

Radial neck fractures

These are relatively common injuries in the paediatric population. The radial head itself is largely cartilaginous and rarely injured. Injuries range from subtle torus type ‘beaking’ of the neck, which is best seen on the lateral side on the lateral projection, to displaced Salter–Harris type 1 or 2 fractures. Suspicion of an isolated injury may be made by the presence of localised tenderness at the radial head. Neurovascular injury, particularly to posterior inter-osseous nerve (finger extension), should always be sought. Undisplaced fractures and those with up to 50–60% displacement do well with conservative treatment and may be immobilised in a collar and cuff with orthopaedic follow up.

Monteggia fracture dislocation

The peak incidence of this injury complex is in the 4–10 age group. Although, classically, radio-capitellar disruption accompanies an angulated or shortened ulnar fracture, the displacement may occur in association with any displacement to the radioulnar loop. Because of the significant complications of a missed radio-capitellar disruption, this lesion must be actively clinically and radiologically sought in any child with a forearm fracture and elbow swelling. Most units adopt a rule of always X-raying the elbow of any child with forearm or wrist injury, unless the elbow has been specifically clinically cleared (see Table 24.2.5).

The classical (Type 1) Monteggia lesion involves an angulated apex-volar ulnar shaft fracture and anterior displacement of the radial head (see Fig. 24.2.2). Variants include lateral radial head displacement, often in association with proximal ulnar/olecranon fractures (Type 3), ‘Monteggia equivalent’ fractures including proximal radial fracture/dislocation, and others. A bowing deformity may be the only evidence of fracture. Orthopaedic manipulation of the radial head into its articulation is the aim of the treatment.

Midshaft radial and ulnar fractures

These injuries fall into two broad groups: (1) common low-energy greenstick fractures as a common consequence of falls in childhood; and (2) higher-energy complete fractures, which may be difficult to reduce, requiring internal fixation in 5–10% of cases. In the former group, with the exception of bowing fractures (which generally require general anaesthetic/ orthopaedic reduction, as prolonged corrective force is necessary), ED reduction may be possible thus:

• apex volar – pronate forearm and apply wrist traction and volar pressure;

• apex dorsum – supinate forearm and apply wrist traction and dorsal pressure.

Although these fractures may be simple to relocate under anaesthesia, e.g. ketamine, their inherent instability makes expert three-point moulding essential. Therefore, manipulation should not be attempted unless such expertise and assistance is available, and follow up within 1 week is imperative in case of subsequent loss of position.

Distal radial and ulnar fractures

These common injuries may be metaphyseal or epiphyseal in nature. Dorsal angulation occurs in 80% of cases, but radial or volar angulation/displacement of the distal fragments may also occur. Regarding management, the following guidelines apply:

• Simple torus (buckle) fractures with no periosteal or cortical breach, which represent plastic deformation only, may be placed in a forearm splint or brace for comfort and referred for follow up in 1–2 weeks.⁹

• Undisplaced greenstick fractures, in which a cortex or periosteum has been breached, have inherent instability and the potential for further deformation. These should be managed in a well-moulded (three-point fixation) plaster in neutral position,¹⁰ and reviewed within 1 week.

• Angulated or displaced greenstick fractures of the distal forearm generally require reduction if the angulation is greater than 20 degrees, although remodelling potential varies with the age of the child and the distance of the fracture from the physis. Closed reduction may be performed in the ED if staffing and expertise permit.

Again, attention must be paid to ensure that a well-moulded plaster will maintain reduction, and follow-up orthopaedic review should be early enough to detect this and remanipulate if necessary i.e. within 1 week. Early orthopaedic referral should occur for angulated isolated radial fractures and for fractures of radius and ulna with complete displacement and shortening, as a significant proportion of these manipulations will be problematic or require internal fixation.¹¹

Distal radial epiphyseal fractures

These can generally be treated by manipulation and closed reduction in the same way as metaphyseal fractures. There is a very low incidence of subsequent premature physeal closure or other physeal disruption. This risk is greatest following multiple or delayed reduction attempts, or compressive injuries, or distal physeal separation of the ulna.² Following manipulation, referral to fracture clinic must be within a week as repeat manipulation of the physis is contraindicated after 7 days.

Carpal injuries: the scaphoid

Because of the flexibility of the paediatric wrist and the plastic properties of preossified bone, carpal injuries are very rare in children under 8 years. Scaphoid injuries are generally overdiagnosed in children in the ED setting. Of those fractures that do occur, 65% are distal pole and non-union is rare because of the different mechanical and vascular properties of immature bone. As children reach adolescence, their risk of adult-type scaphoid fractures increases. Scaphoid views (AP and oblique with attention to possible obliteration of the navicular fat pad) are suggested in older children if:¹²^–¹⁴

• adolescent (10 years and over);

• high-velocity injury, especially kickback;

• single-point tenderness and swelling over scaphoid both dorsally (in anatomical snuffbox) and on volar surface under base of first metacarpal (more specific finding);

• Kirk–Watson test (pain/clunk in scaphoid/scapholunar ligament on passive radial deviation of wrist);

• pain to compression along first metacarpal ray.

Suspected fractures should be managed with scaphoid plaster and orthopaedic follow up as usual: conservative treatment usually allows resolution of true injuries but may take up to 6 months.

Metacarpal fractures

Crush injuries to metacarpal bones may occur, and adolescence sees an increase in fractures of the head of the fifth metacarpal, as in adults, although the intact distal metacarpal physis will allow some remodelling to correct flexion loss. Penetrating trauma, tendon damage, open injuries and neurovascular impairment must be identified and referred. Multiple fractures may create an unstable hand plate, and finger flexion should be observed for possible associated rotational malalignment, which is not acceptable. Isolated metacarpal fractures will not create malrotation. Isolated metacarpal neck fractures should be treated with neighbour strapping and mobilisation.

Phalangeal fractures

Common paediatric phalangeal fractures include Salter–Harris 2 fractures at the base of the first phalanx, which may cause radial/ulnar angulation and should be corrected by traction after a ring block.

These may be radiologically subtle and require careful clinical evaluation. All open, intra-articular or oblique (unstable) fractures should be referred for orthopaedic evaluation.

Thumb fractures

Forced thumb abduction, e.g. from fall onto the splayed hand, can cause avulsion of part of the proximal thumb physis (a Salter–Harris type 3 injury instead of the adult ulnar collateral ligament tear), or a metaphyseal fracture of the base of the first metacarpal. The intra-articular Salter–Harris type 3 avulsion injury should be internally fixed, so referral is essential. However, in the metaphyseal injury, because of the universal motion of the first carpometacarpal joint, significant angulation and displacement will remodel if the child is under 10 years, and the child may have the fracture immobilised in a scaphoid type plaster extending to the tip of the thumb, elevated, and be referred for early orthopaedic consultation.

Fingertip injuries

These injuries to young children are extremely common from inadvertent closure in doors or gates, especially in cooler climates. Injuries include partial or complete amputation, nail-plate injuries, and distal phalangeal fractures.

The classical crush injury includes a distal phalangeal tuft fracture and a partial amputation anteriorly through the nail bed, with intact volar soft tissue attachments and vascular integrity. Tip salvage is usual. However, without meticulous repair to the nail-bed laceration nail deformities are common, so referral to orthopaedics or plastic services is recommended.

Tip amputations distal to the terminal phalanx may often heal by secondary intent, because of the excellent vascular supply in childhood. More proximal injuries require assessment of nail-bed integrity, the possibility of soft-tissue (e.g. nail-bed) interposition within an angulated/displaced fracture, or other indications for reconstructive procedures. Simple procedures may be performed in the ED under ketamine anaesthesia or sedation and ring block.

Lower limb and pelvis injuries

Pelvic fractures

These injuries are less common in paediatric than adult trauma. Avulsion injuries in athletic adolescents may occur. The implications for blood loss and urogenital injury of unstable pelvic fractures in children are similar to those in adulthood. The bladder is an intra-abdominal organ in infants.

Hip dislocation

This is uncommon in childhood, occurring either with low force as a result of increased ligamentous laxity, or in the high-force mechanisms more typical of adult hip dislocation. The sequel of avascular necrosis is less common, occurring in only about 5% of cases.² Reduction, by gentle closed longitudinal traction against a fixed pelvis, should be performed within 6 hours. Particular care must be taken in the adolescent in whom an occult physeal injury may be displaced. Post manipulation X-rays ± CT are indicated.

Femoral fractures

Although comprising less than 5% of paediatric fracture presentations to the ED, the infant or child presenting with a femoral fracture presents particular challenges to the emergency physician because of:

• the frequent association with major trauma and other unstable injuries;

• the high level of pain and emotional distress for the child and the family, particularly in the setting of road trauma;

• the need for procedural skills, such as femoral nerve block, and the application of traction splinting, such as the Thomas splint;

• The possibility of non-accidental injury (possible incidence suggested at between 30 and 80% in children under 12 months ^15,¹⁶).

The simultaneous management of all these challenging priorities is a good test of the mature, multidimensional emergency physician.

As has been mentioned earlier, all limb fractures should be initially approached with rapid primary and secondary survey while the integrity of airways, breathing, circulation, conscious state and spinal column are assessed, mechanism ascertained, and areas of tenderness identified. An intravenous (IV) cannula should be inserted immediately, under nitrous oxide or intra-nasal fentanyl if necessary. Early attention to issues of pain and anxiety has been shown to reduce the stress and pain of later procedures. Femoral nerve block, preferably ultrasound guided, should be inserted early, with Thomas splint immobilisation following in a timely fashion.

Not all femoral fractures are the result of major trauma. In the newly ambulant child, the torsion resulting from a change of forward momentum with the foot fixed at an angle may produce a spiral midshaft fracture. Mechanisms in abusive injury include forced external rotation or abduction, e.g. from nappy change position, or direct blows.

Types of femoral fracture in children, and their orthopaedic implications, are as follows:

• Proximal femoral fractures include transepiphyseal, transcervical, basicervical, and intertrochanteric fractures. These are serious injuries. Avascular necrosis and physeal growth arrest are significant potential complications of higher fractures, and early notification and reduction are urgent.

• Slipped upper femoral epiphysis (masquerading as trauma) is discussed in Chapter 24.1.

• In femoral shaft fractures, definitive orthopaedic management depends on the degree of precipitating force, associated injuries, the age of the child, home circumstances, and the institution. Low-force injuries in young children may be treated by closed reduction and early hip spica casting. Options in older children usually involve internal or external fixation.

Injuries about the knee

Distal femoral physeal separation

These injuries result from high-force trauma to the knee. Any of the Salter–Harris pattern injuries may occur. Undisplaced injuries may be managed by cast immobilisation. Orthopaedic consultation is imperative because of:

• the possibility of co-existent intra-articular ligament disruption;

• the need for perfect articular surface realignment;

• the significant possibility of subsequent asymmetrical physeal arrest.

Tibial spine injury

Because of the mechanical properties of developing bone, twisting injuries to the paediatric knee result in avulsion of the tibial attachment of the anterior cruciate ligament (Fig. 24.2.15). The child presents non-weight-bearing, with a large effusion and joint-line tenderness. Although AP X-ray may be deceptive, lateral projections show a characteristic beak-like appearance of the superior surface of the tibial plateau, with posterior hinging. All children with large effusions should be referred for orthopaedic evaluation. Orthopaedic management involves an assessment, generally under anaesthetic, of the reducibility of the avulsed spine and the likelihood of, e.g. meniscal interposition. Treatment options include immobilisation in extension or partial flexion, and internal fixation. Some degree of subsequent instability and loss of extension may follow.

Fig. 24.2.15 Lateral and AP views of the paediatric knee with an avulsed tibial spine.

Due to the intact anterior cruciate ligament, the tibial spine fracture (shaded) may be hinged posteriorly, opening anteriorly on knee flexion.

Drawing by Terry McGuire.

Lower leg fractures

Lower leg fractures are common in childhood. Factors to be considered in their assessment include:

• age;

• mechanism (low- or high-force, type of injury, e.g. valgus/rotation);

• degree of angulation or displacement;

• associated soft-tissue damage or other injuries;

• involvement of physes;

• integrity of fibula.

Compound injuries and those with physeal involvement or significant angulation or displacement should be referred for inpatient orthopaedic evaluation. Proximal tibial epiphyseal injury may be complicated by vascular compromise, as with adult knee dislocation. Varus or valgus deformity, particularly at the proximal tibia, may progress. Stable, undisplaced or minimally displaced oblique or spiral shaft fractures of the tibia may be placed in a well-moulded above-knee cast with the knee flexed to 90 degrees and the ankle in 15 degrees of plantar flexion.¹⁷ Admission is not required if swelling is minimal, mechanism is clear, and parents are sensible.

The so-called toddler fracture is an undisplaced tibial shaft fracture that occurs as a result of a rotational shearing force in the newly ambulant child. Presentation is with non-weight bearing or limp and the differential includes other pathologies, e.g. irritable or septic hip. Tenderness should be localised to the tibial shaft but initial radiology may be normal. If this diagnosis is suspected in a well child with normal joint examination, POP immobilisation and orthopaedic follow up with repeat X-ray at 10 days or nuclear bone scan may be helpful.

Controversies

Controversy exists surrounding boundary issues between emergency medicine and orthopaedics. Who performs which reduction should be determined by consideration of safe, effective resource use between emergency and orthopaedic services. Structured opportunities for interdepartmental teamwork help reduce angst and improve systems and service quality.

Length (SA vs LA POP) and type (circumferential vs 3/4 slab) of plaster for unstable forearm fractures post reduction is controversial; however, accuracy of moulding is probably more critical than either other variable.

Ankle fractures

As with adults, inversion, eversion and twisting mechanisms may cause a variety of injury patterns at the ankle depending on age, degree of force, and mechanism. Ankle injuries requiring same-day orthopaedic consultation include:

• open injuries;

• unstable injuries or ankles with extensive bilateral tenderness and swelling, suggesting possible mortice instability;

• displaced or angulated distal tibial fractures;

• Salter–Harris type 3 and 4 injuries;

• Triplane and Tillaux fractures.

Tillaux fracture

This is a Salter–Harris type 3 fracture at the distal tibial physis, occurring in adolescence after partial closure of the medial growth plate (see Fig. 24.2.5). External rotation of the foot and ankle causes avulsion of the anterolateral portion of the distal tibial physis by its attachment to the fibula (anterior tibiofibular ligament). The diagnosis should be suspected in a non-weight-bearing adolescent with significant anterolateral ankle swelling and tenderness. Oblique ankle views or CT assessment may be required to detail alignment.