Bone fractures

Question 1

Define

Answer 1

Unique fracture patterns in children because of:

• Compressibility of bones
• Increased fibrous strength of periosteum
• Presence of physes (growth plates)

Consider NAI with every child fracture

Question 2

Most common fractures

Answer 2

Neonatal fracture:

1. Clavicle – from shoulder dystocia -> great prognosis, no specific treatment needed
2. Humerus or femur – from breech delivery -> heals rapidly with immobilisation

The most common fractures associated with child abuse are:
1. Radial
2. Humeral
3. Femoral

Common fractures in paediatrics not associated with NAI are:
1. Distal radial 
2. Elbow
3. Clavicular
4. Tibial

Question 3

Salter Harris Classification

Answer 3

Salter Harris Fracture - classification in relation to the growth plate

T2 = most common (followed by T3)

T1 + 2 = good prognosis - no surgery needed , can sometimes need a cast/ splint/ sling

T3 - 5 = poor prognosis as proliferative and reserve zones are affected

T5 - may need surgery

Question 4

Management

Answer 4

Pain management:

• <16yo: oral ibuprofen/paracetamol (IV if severe)
• > 16yo -> paracetamol ± codeine ± IV morphine

Sedation for manipulation:

• 1st line: intranasal/oral midazolam or NO
• 2nd line / severe: intranasal ketamine

Manipulation and reduction (consider IV local anaesthetic)
* Radial fractures -> elbow plaster cast or k-wire fixation
* Femoral shaft fractures:
* Neonates (0-28 days) – padded splints or Pavlik’s harness
* <18 months – Gallows traction
* 1-6 years – straight leg skin traction
* >4 years – intramedullary nail (+ more support if >11y)

 

Question 5

Ottawa ankle rule

Answer 5

Ottawa ankle rule – “X-ray only indicated if…”

Pain in malleolar zone and…

1. Bone tenderness at the posterior edge or tip of the lateral malleolus (A); OR
2. Bone tenderness at the posterior edge or tip of the medial malleolus (B); OR
3. An inability to bear weight both immediately and in the emergency department for four steps

Pain in the mid-foot zone and…
1. Bone tenderness at the base of the fifth metatarsal (C); OR
2. Bone tenderness at the navicular (D); OR
3. An inability to bear weight both immediately and in the emergency department for four steps

Question 6

Ottawa knee rule

Answer 6

Ottawa knee rule – “X-ray only indicated if…” (for age 2yo+)

Age 55+; OR

Isolated patellar tenderness; OR

Cannot flex to 90 degrees; OR

An inability to bear weight both immediately and in the emergency department for four steps