Management Guidelines

LIMB FRACTURES IN CHILDREN Emergency Department

Princess Margaret Hospital for Children
Perth, Western Australia
Last reviewed: July 2004
Page 1 of 10
Dr Gary Geelhoed

Description of the type of fracture

Fractures in children should be described in terms of:

A: Whether the fracture is:

a) Simple - fracture results in only two bone pieces or fragments.
b) Comminuted – several fracture lines resulting in at least three fragments.
c) Compound (open) – any fracture where damage to overlying skin and soft
tissue results in exposure of the bone.

B: The type of fracture (this relates to the mechanism of injury):

a) Transverse Complete fractures
b) Oblique
c) Spiral
d) Plastic deformity (bowing)
Incomplete fractures,
e) Buckle (torus) fracture unique to children
f) Greenstick

C: Relationship of bone ends relative to each other:

a) Displacement: The percentage of the bone’s diameter (at the level of the
fracture) by which one fragment is displaced from or
overrides the other.
b) Angulation of the distal fragment relative to the proximal fragment.
c) Rotation (in the axial plane) of the distal fragment relative to the proximal.
d) Shortening: Complete fractures are unstable, and muscle traction forces
may result in the distal fragment being pulled proximally
relative to the proximal fragment, resulting in a relative
shortening of the bone.

D: What part of the bone is involved: Diaphysis (shaft)

Metaphysis, Growth plate injuries are
Growth plate (physis) unique to children and are
classified according to the
Epiphysis Salter-Harris classification
(see page 2)

Transverse Oblique Spiral Comminuted

Limb Fractures in Children DPMS No 3521 Page 1

 Plastic bowing: results from Buckle (or “torus”) fractures
stress beyond the bone’s usually occur at the
capacity for recoil. The metaphysis, and are the result
periosteum and bone of relatively mild compression/
cortices remain intact. impaction forces along the
Seen most often in fibula long axis of the bone. The
and ulna, and always with periosteum remains intact, and
fracture of the paired long it is a relatively stable fracture.
bone.

Greenstick fractures are incomplete fractures unique to

children. They tend to be angulated, but not displaced. The
periosteum and cortex are disrupted on one side, but the
thick periosteum typical of children is preserved on the
opposite side. Some degree of impaction occurs on this
side, so that buckling of the concave side may be seen. If
angulation is not corrected, the intact periosteum on the
concave side may undergo overgrowth or “scarring” which
will result in progressive worsening of the deformity.

Displacement Angulation

Salter-Harris classification of
physeal injuries
(ie. involving the growth plate)

I II III IV V
Limb Fractures in Children DPMS No 3521 Page 2
EMERGENCY DEPARTMENT MANAGEMENT OF COMMON PAEDIATRIC FRACTURES

UPPER LIMB FRACTURES

CLAVICLE

‰ Middle third - even grossly displaced fractures remodel well

- support in a broad arm sling (under the clothes) for 3 weeks
- GP follow up (no repeat X-ray necessary)
- no contact sport for at least 3 months In the child with
- warn parents that a bony lump will develop at multiple injuries,
the fracture site and be visible for up to a year. clavicle fractures and
upper rib fractures
may be associated
with injury of the great
‰ Medial + Lateral thirds - seek Orthopaedic advice vessels or brachial
plexus.

HUMERUS

The degree of
‰ Proximal humerus (metaphysis, growth plate and epiphysis) angulation is
not an issue.
¾ Displacement < 50% - treat in collar and cuff (remodels by gravity) This will
- follow up in Fracture Clinic in 1 week correct itself
¾ Displacement > 50% / off-ended - refer to Orthopaedics under
influence of
gravity

‰ Shaft fractures

¾ Angulated greenstick fracture - may need manipulation

- seek Orthopaedic advice

¾ Complete fractures, even if displaced or angulated, don’t need

manipulation. They remodel well by gravity.
Complete fractures
- Treat in collar and cuff with elbow at 90° can be fairly
- Apply a plaster U-slab to provide protection against painful and may
knocks, and to stabilise the fracture (but not to take require admission
weight off the hanging arm) for pain control
- Plaster U-slab should come as high as possible up to
the shoulder.
- Follow up in Fracture Clinic in 1 week.

Limb Fractures in Children DPMS No 3521 Page 3

 FRACTURES AROUND THE ELBOW

1. Radiological lines of normal anatomy on lateral elbow X-ray: (adapted from Rockwood, CA : Fractures in
Children ; 3rd Edition. Lippincott. 1991)

A = normal 45º anterior angulation of lateral condyle relative to humerus shaft.

B = Anterior humeral line should pass through the middle of the capitellum.
C = Coronoid line: a line extended proximally along the anterior border of the
coronoid process should just touch the anterior portion of the lateral condyle.
D = The radio-capitellar line: a line drawn through the long axis of the radius
should bisect the capitellum, irrespective of the degree of flexion or extension
of the elbow (the X-ray must be a true lateral view for this to apply).

2. Fat pad signs (From Rockwood, CA : Fractures in Children; 3rd Edition. Lippincott. 1991)

A = Normal relationship of the two elbow fat pads (Normally, the anterior fad pad
may be just visible as a dark triangle anterior to the distal humerus. Any
visible posterior fad pad is always abnormal.)
B = Intra-articular effusion displacing both fat pads (visible as dark radiolucent
areas anterior and posterior to the distal humerus)
C = Intra-articular effusion displacing only the anterior fat pad (dark radiolucent
area noticeably anterior to expected position)

A visible effusion (ie positive fat pad sign) on X-ray indicates an injury around the elbow,
and may be the only radiological evidence of a fracture.

Limb Fractures in Children DPMS No 3521 Page 4

‰ Supracondylar fractures

¾ Uncomplicated supracondylar fractures

Treat in collar and cuff
• Undisplaced complete fracture (under shirt)
Follow up in Fracture Clinic
• Greenstick fracture with < 20° angulation in 1 week

¾ Complicated supracondylar fractures

Refer to Orthopaedics
• Displaced complete fractures
A severely swollen elbow is
• Greenstick fracture with > 20° angulation at major risk of
• Any neurovascular abnormality compartment syndrome
• Severely swollen (threatened compartment and is an
syndrome) Orthopaedic Emergency
Urgent referral !

‰ Epicondyle fractures - almost always medial, so

check ulnar nerve function. Seek Orthopaedic advice

If uncertain, X-ray the

‰ Intra-articular fractures - involve capitellum or condyles opposite elbow for
- operative treatment essential comparison

Extent of joint capsule

Medial epicondyle
Lateral epicondyle

Medial condyle Lateral condyle (includes capitellum)

PROXIMAL ULNA

‰ Olecranon process

¾ Articular surface disrupted - refer to Orthopaedics

¾ Articular surface not involved - treat in collar and cuff or backslab in 90° flexion
- follow up in Fracture Clinic in 1 week

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 PROXIMAL RADIUS

‰ Fractured neck of radius

¾ < 30° angulation of head - immobilise in above-elbow backslab

- follow-up in Fracture Clinic in 1 week

¾ > 30° angulation of head

Refer to Orthopaedics
¾ Any associated fracture (eg olecranon)

FOREARM FRACTURES Make sure the Midshaft fracture (either

elbow and the wrist greenstick or complete) of
are included in a single forearm bone
X-rays will always have
associated disruption of
the proximal or distal
radio-ulnar joint

‰ Midshaft radius + ulna - The two bones may have different types of fractures; various
combinations of complete, greenstick or bowing (plastic
deformity) fractures. Plastic deformity usually occurs in the
< 10 year old age group, and minimal remodelling occurs
in children > 4 years (thus important to identify). It may be
useful to compare with the other arm.
- Midshaft fracture of a single bone never occurs in isolation.
There is always associated disruption of either the proximal
or distal radio-ulnar joint, thus the need to X-ray both joints.

¾ No displacement Treat in above-elbow backslab

Angulation < 10° Follow up in Fracture Clinic in 1week

¾ Any displacement
Angulation > 10° Refer to Orthopaedics for manipulation
Any bowing deformity

‰ Monteggia fracture dislocation - Proximal or mid-third ulna fracture, with associated

dislocation of the radial head.
- Occurs from 2 years of age to puberty.

A true lateral view Isolated radial head

is essential to dislocation never occurs
make the except in “pulled elbow” in
diagnosis. If in toddlers. There is always an
doubt, do associated ulna fracture (this
comparative views may be subtle, in the form of
of the other arm. plastic deformity).

¾ Refer to Orthopaedics.

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 Fracture of the distal third of the
DISTAL FOREARM / WRIST radius (± ulna) is the commonest
childhood fracture

‰ Distal third Radius / Ulna (Metaphysis)

- Radius usually has greater degree of injury than does ulna.

- When both bones are involved, they often each have a different fracture type, a
combination of complete, greenstick, torus (buckle) fractures, or plastic bowing
deformity.
- Radius can be involved in isolation (never ulna in isolation).
- But, if only one forearm bone appears fractured, it is very likely that a subtle
injury of the other bone is present: either greenstick fracture, plastic deformity or
a Monteggia / Galeazzi fracture dislocation.
- Buckle fracture is the only stable variation; complete and greenstick fractures
are always unstable.

¾ Simple buckle fracture of radius only - below-elbow backslab

- follow up in Fracture Clinic in 1 week

¾ Greenstick fracture - child <10 years old Above-elbow backslab

- <20° radiological angulation Fracture Clinic in 1 week
- no clinical deformity Will be in POP for 3 weeks

¾ Greenstick fracture - child >10 years old

- > 20° radiological angulation
- any clinical deformity Refer to Orthopaedics

¾ Complete fracture with any angulation or displacement

¾ Complete fracture without any angulation or displacement - this is essentially a

greenstick fracture without angulation and is treated as such.

‰ Distal Radius / Ulna (epiphysis)

¾ Juvenile Colles’ fracture (fracture separation of distal radial epiphysis)

- usually Salter-Harris 2 fracture
- look for associated ulna injury: - fracture of distal ulna
- avulsion of ulnar styloid
- rarely, fracture separation of ulna epiphysis
Refer to Orthopaedic surgeon.

Any fracture which involves a growth plate must be referred to an

Orthopaedic surgeon.

• Salter-Harris I and II fractures – refer within 1 week

• Salter-Harris III, IV and V fractures – immediate referral

Limb Fractures in Children DPMS No 3521 Page 7

 WRIST

“Wrist” injuries in children are far more likely to involve the distal radius / ulna rather
than carpal bones.

‰ Scaphoid fractures: - Rare < 12 years of age

- In children, it is usually the distal pole of scaphoid which is
involved.

¾ Suspected scaphoid fracture: - Immobilise in a scaphoid cast.

- Repeat X-ray after 10-14 days if fracture was
not visible on initial X-ray.
- If repeat X-ray at this stage still doesn’t show
a fracture, but the patient remains
symptomatic, arrange a bone scan.

‰ Other carpal fractures are extremely rare in children.

LOWER LIMB FRACTURES

FEMUR Shock is never the result of femoral If distal pulses are

shaft fracture alone in children. compromised, seek
Look for another site of haemorrhage ! urgent Orthopaedic help

¾ Initial management:
The entire shaft and both joints need to
be included in the initial X-rays:

IV Morphine - to assess angulation and alignment

- to exclude dislocations
Start with 0.1 mg/kg and titrate to
effect. May require higher doses.
Do not move the leg to take X-rays !
If a temporary traction splint (eg. Hare
Splint) is available, apply this after
femoral nerve block and prior to X-ray.
Femoral nerve block

(for details, see Femoral Nerve

Block guidelines)

Temporary traction splint

(eg Hare Splint)
If traction is to be applied on the
prior to X-ray Orthopaedic Ward, administer
the following in ED prior to
transfer to the ward:
• Diazepam 0.2 mg/kg po
• Painstop Day-Time 0.8 mL/kg
‰ X-rays • Ibuprofen 10 mg/kg po
‰ Refer to Orthopaedic surgeon
Limb Fractures in Children DPMS No 3521 Page 8
 FRACTURES AROUND THE KNEE Don’t force flexion / extension of
the knee for the purpose of trying
to take X-rays. This may result in
In children, ligaments are stronger than growth plates, so damage to the popliteal artery.
epiphyseal fractures are more common than torn ligaments.

¾ Refer all fractures around the knee to an Orthopaedic surgeon.

LOWER LEG Tibial midshaft and/or distal third

fracture is the commonest leg
injury at all ages

‰ Proximal tibial metaphysis - Refer to Orthopaedics

‰ Tibia / Fibula diaphysis:

• High velocity injuries → All require admission: - high risk of compartment syndrome
- admission for pain control
- associated skin problems common

• Low velocity injuries

¾ Angulation > 10° Refer to Orthopaedics

¾ Displacement > 30%

¾ Displaced < 30% Above-knee backslab

¾ Angulation < 10° Crutches: non weight-bearing
¾ Toddler’s fracture Follow up in Fracture Clinic in 1 week.

Toddler’s fracture is a fairly common fracture under 3 years of age. It appears as

an incomplete, usually vertical or oblique, hairline crack in the distal tibia. It
commonly occurs in the child who is learning to walk, and falls over. It typically is
seen in only one view. There may be an associated bowing fracture of the fibula. It
is treated as described above.

‰ Distal metaphysis of Tibia / Fibula - Refer to Orthopaedics

Limb Fractures in Children DPMS No 3521 Page 9

 ANKLE JOINT

Epiphyseal injuries are common, especially of the distal tibia.

Ligamentous injuries are rare (in children, ligaments are stronger than bones).
Talotibial joint rarely disrupted in children.

‰ Fracture of distal epiphysis of tibia / fibular - These may be difficult to see on X-ray
- Refer suspected or confirmed fractures
to Orthopaedics.
- Salter-Harris 4 fractures need CT scan.

FOOT Calcaneal views must be

specifically requested
since calcaneal fractures
may not be visible on
‰ Tarsals - Tarsal fractures uncommon, but difficult to diagnose. standard views.
- If clinical signs suggest fracture, then get
Orthopaedic opinion.
Requests for foot X-rays
must specify forefoot or
hindfoot, since different
exposures are used for
each.
‰ Metatarsals

¾ Uncomplicated shaft fractures - Below-knee backslab

- Crutches (non weight-bearing)
- Follow up in Fracture Clinic in 1 week

¾ Severe swelling - admit for elevation of foot and neurovascular observations.

‰ Phalanges - The degree of soft tissue injury is more important than the fracture.

¾ Compound fractures Refer to Orthopaedics

¾ Dislocations
¾ Fracture of proximal phalanx of big toe

¾ Minor fractures Buddy-strapping, crutches, elevation of foot.

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