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Asynchrony PEM: Upper Extremity Fractures in Kids

Let’s face it, kids are total klutzes! As they start learning how to get around and become increasingly mobile during play, they start falling and ending up with upper extremity fractures. In fact, nearly two-thirds of all boys and half of all girls will have sustained a fracture by age 15. While the majority of these injuries will likely heal quickly with minimal intervention, it is important to maintain a high level of suspicion for growth plate injuries. If undetected, these could result in growth arrest.

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  Pull the Other One: Which Fractures Should PEM Reduce?

For me, few things are as gratifying as a perfect fracture reduction. The thrilling ‘click’ of the bone fragment into its rightful place, the careful crafting of a presentable plaster of Paris, and the self-satisfied glow when reviewing a flawless check x-ray. Of course, not all go so smoothly.

 A New Sensation for Diagnosing Pediatric fractures

Pediatric fractures are a common type of injury seen in the emergency department. The most common type of fractures seen in children are distal forearm fractures. POCUS can be used to confirm a distal forearm fracture, but misses a few minor fractures. X-ray should continue to be the clinical standard, but shared decision making may reduce the use of x-ray in some cases.

 Pediatric Fractures

The anatomy and biomechanics of pediatric bone differ from that of adult bone, leading to unique pediatric fracture patterns, healing mechanisms, and management. In comparison to adult bone, pediatric bone is significantly less dense, more porous and penetrated throughout by capillary channels. Pediatric bone has a lower modulus of elasticity, lower bending strength, and lower mineral content.

 Pediatric Orthopedics Pearls and Pitfalls

Dr. Sanjay Mehta & Dr. Jonathan Pirie, two experienced Pediatric EM docs from The Hospital for Sick Children in Toronto discuss their approach to a variety of common, occult, challenging and easy to miss pediatric orthopedics diagnoses including: differentiating Septic Arthritis from Transient Synovitis of the hip, Toddler’s Fracture, Tillaux Fracture, Suprachondylar Fracture, ACL tear, tibial spine & Segond fractures.

Articles of Interest

Emergency Medicine Pearls, Pitfalls for Treatment of Pediatric Distal Radius Fractures

If you see kids in your emergency department, then you’re managing pediatric fractures. Distal radius fractures are the most common.

Top 10 Things to Know about Pediatric Fractures

Perform a methodical exam every time, the same way. It may not be easiest, but it is the best tool.

A Visual Guide to Upper Extremity Joint Aspirations

A thorough understanding of these techniques is essential to the general emergency physician. Outside of an academic center, you will be the one aspirating joints in the ED (with the exception of the hip). Rare is the day you'll have your orthopedist in the department for help with this diagnostic part of the work-up. So it is imperative we can safely and efficiently get this done.

Acute Fractures and Dislocations of the Ankle and Foot in Children

Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. In children, increasing participation in competitive sports activities has led to an increased incidence of acute injuries that affect the foot and ankle. These injuries represent approximately 13% of all pediatric osseous injuries.

Can’t Miss Pediatric Elbow Injuries

Have you ever been working a shift at 3 am and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This can be a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify common and catastrophic injuries. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We reviewed the approach to the pediatric elbow previously. Now, the “Can’t Miss” pediatric elbow injuries.

Closed reduction and casting of distal forearm fractures in children

Childhood forearm fractures are very common and typically occur after a fall on an outstretched hand. Closed reduction and casting provides definitive treatment for displaced Salter-Harris I or II, greenstick, and complete distal forearm fractures in children and is often accomplished under sedation in the emergency department.

Common Orthopedic Injuries in the Pediatric ED Part II

Although lower extremity fractures are much less common than upper extremity fractures in children, the correct diagnosis and management of this type of injury is critical. In the second part of this series the authors review common lower extremity fractures, fractures common in abused children and the diagnosis and treatment of radial head subluxation. Children are much more likely to sustain fractures rather than ligamentous injuries and identification of injuries and timely management will maximize an optimal outcome.

Distal Radius Fractures - Pediatric

Treatment is generally closed reduction and casting for the majority of fractures. Surgical intervention is indicated for significantly displaced or angulated fractures in patients approaching skeletal maturity.

EM Cases – Elbow Injuries – Ten Pitfalls in Diagnosis and Management

Although it doesn’t get the spotlight much in emergency medicine, the ED diagnosis and management of elbow injuries is of significant clinical importance. There are several easy-to-miss injuries that can lead to functional impairment. Even minor errors in management can result in long term consequences for patients.

EM in 5: Elbow Xrays

The anterior fat pad is normal. What is NOT normal is if you see it bulging out in what we call the “sail sign.” This is an abnormal effusion of the joint that indicates a fracture is present (even if you can’t see it!)

Fracture Fridays: Buckle Up!

A young man jumps from the cough. he anticipated that he would land smoothly, and stably like his cat Whiskers. He did not land smoothly. Instead he careened off of the coffee table and awkwardly landed on his outstretched arm. He told his mom, and Whiskers. Mom was concerned because he now has a swollen and painful wrist. Whiskers, as is apropos his species could care less. Fearing that his arm was broken, or worse fractured mom promptly took her son to the ED. Whiskers stayed behind.

Pediatric Ankle Injuries

No discussion on pediatric orthopedic injuries would be complete without a review of the Salter-Harris classification. There is a lot of practice pattern variation in the management of patients with negative radiographs but growth plate tenderness on exam (i.e. the potential Salter-Harris I fracture). The Boutis et al. group has done some great work in this area, and you highlight several key studies in your excellent review of the literature. I personally feel well-supported by this emerging evidence, and my practice pattern is to place patients in a removable ankle lacer (if able to bear weight) or a pneumatic walking boot (if unable to bear weight), with crutches as needed, and outpatient follow-up with their pediatrician versus Sports Medicine, rather than Orthopedics.

Pediatric Forearm Fractures

Most common fractures seen in pediatric patients; accounts for 17.8% of fractures (age 0-19 yrs) in the National Electronic Injury Surveillance System Database.

Pediatric Hand Injuries, Part I: Fractures and Dislocations

One of the major differences between the pediatric and the adult skeleton is the presence of growth plates or physes. When seeing a pediatric patient with any injury to the extremity, physeal injury must always be considered. The physis is the site of ossification and longitudinal bone growth.

Pediatric Orthopedic Injuries: Evidence-Based Management in the Urgent Care

Upper and lower extremity injuries are common in children. Pediatric bone anatomy and physiology produce age-specific injury patterns and conditions that are unique to children, which can make accurate diagnosis difficult for urgent care clinicians.

Pediatric Radial Head Fractures: Special Considerations and Diagnostic Tips

Though many of us encounter a large volume of pediatric patients during residency, that may drastically taper off as we transition to the community. As such, it is also essential to become familiar with special circumstances of orthopedic injuries as they pertain to the pediatric population.

Pediatric Supracondylar Fractures

Supracondylar humeral fractures may often present without evidence of fracture lines on diagnostic imaging. Always assess for indirect signs of fractures. Do not forget to conduct a thorough neurovascular exam as supracondylar fractures can be associated with neurapraxias, vascular injuries, and compartment syndrome. Type1 fractures can be splinted and discharged with close orthopedic follow-up; Type2/3 fractures generally require immediate orthopedic consultation.

Pediatric Wrist and Elbow Injuries: Mechanisms of Injury, Findings, and Treatment

This article will outline common, important wrist and elbow injuries in children and will review likely mechanisms of injury, radiographic findings, and treatment.

Peds Buckle Fractures

Older studies have shown that short term immobilization with a velcro splint and primary care follow up is sufficient. Recent randomized trial compared immobilization with Velcro splint with as needed wrist support using a gauze wrap. No significant differences noted in outcomes between the two cohorts.

Radial Head Fracture

One of the most commonly missed injuries in the ED and on radiographs.

Salter-Harris Fractures

Salter-Harris Fractures refer to fractures that involve the growth plate (physis). Therefore, these fractures are applicable specifically to the pediatric population, occurring most often during periods of rapid growth (growth spurts) when the growth plate is at its weakest, close to age ranges where children tend to participate in high-risk activities (11-12 in girls and 12-14 in boys).

Supracondylar Fractures

Supracondylar fracture of the humerus is one of the most talked-about and often encountered injuries (only after clavicle and both bone forearm fractures) in the pediatric age group with a male predominance accounting for 16% of all pediatric fractures and 60% of all pediatric elbow fractures, classically occurring as a result of fall on an outstretched hand [rx–rx]. In the pediatric age group, the more common age of presentation is 5-7 years (90% cases).

Supracondylar Fractures

Type 1: long arm posterior splint, ortho follow up. Type 2/3: OR with ortho for reduction (closed vs. open) and pinning.

Tibial Shaft Fractures in Children

3rd most common long bone injuries in children.

Resources

PedsCases

This episode describes the the anatomy and classification of common paediatric fractures and discusses how they are best managed. This podcast was written by Laura Vogels and Dr. Sukhdeep Dulai. Laura is a medical student at the University of Alberta. Dr. Dulai is a paediatric orthopaedic surgeon and assistant professor at the Stollery Children's Hospital in Edmonton, Alberta.

SAEM

A Salter Harris Type II fracture travels through the physis and then travels proximally through the metaphysis. This is the most common Salter Harris Fracture, accounting for 75% of all growth plate injuries.

The Growth Plate: Anatomy and Injuries

Incidence of physeal fractures ranges from 14.8%-30% in the literature.