Fractures - Overview

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

This guideline provides PCH ED staff with an overview of how to assess and manage limb fractures in children. There are specific guidelines for each fracture – please refer to these for specific management.

Background

  • Musculoskeletal injuries account for 10-15% of Emergency Department presentations.
  • Fractures in children are more likely than sprains and ligamentous injury due to relatively lower bony strength.
  • Anatomical and physiological differences between adults and children account for the unique fracture types seen in paediatrics such as torus (buckle), greenstick, bowing, physeal and avulsion fractures.

General

Types of fracture

Fractures in children should be described in terms of:

1. Whether the fracture is:

  • Simple: Fracture results in only two pieces or fragments
  • Compound/Open: Any fracture where damage to overlying skin and soft tissue results in exposure of the bone

2. The type of fracture (relates to the mechanism of injury):

  • Complete fractures:
    • Transverse
    • Oblique
    • Spiral
    • Comminuted – several fracture lines resulting in at least three fragments

An image showing a series of complete fractures

  • Incomplete fractures unique to children:

An image of plastic deformity or bowing of the paired long bone         An image showing the bulging buckle fracture in a child            An image of a Greenstick fracture

a. Plastic deformity      b. Buckle fracture      c. Greenstick fracture
Plastic deformity (bowing)  Results from stress beyond the bone's capacity for recoil. The periosteum and bone cortices remain intact. Seen most frequently in the fibular and ulna and typically with fracture of the paired long bone.
Buckle (torus) fracture  Usually occurs at the metaphysis, and are the result of relatively mild compression/impaction forces along the long axis of the bone. The periosteum remains intact, and is a relatively stable fracture.
Greenstick fractures  Usually incomplete fractures unique to children. They tend to be angulated, but not displaced. The periostuem 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.

3. Relationship of the bone ends relative to each other

An image of a displacement fractureAn image showing an angulated fracture

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

4. Part of the bone involved

  • Diaphysis
  • Metaphysis
  • Growth plate (physis) - unique to children. Consult the Salter-Harris classification below.
  • Epiphysis.

Salter-Harris classifiction

Any fracture that involves a growth plate must be referred to the Orthopaedic surgical team

  • Salter-Harris I and II fractures - refer within one week.
  • Salter-Harris III, IV, and V fractures immediate referral.
An image of Salter-Harris classification of fractures
Salter-Harris I  Growth plate separation within the physis. No damage to the mataphysis or epiphysis 
Salter-Harris II  Fracture line across the growth plate with a component of the metaphysis attached to the displaced epiphysis fragment 
Salter-Harris III  Fracture line enters the epiphysis from the physis. Commonly involves the articular surface with separation of the epiphysis fragment. 
Salter-Harris IV  Fracture line extends across the growth plate from the articular surface into the metaphisis. 
Salter-Harris V  Compression of part or all (rarely) of the growth plate. Very rare. Initial X-Rays appear normal. 

Assessment

  • Suspect a fracture if there is pain, swelling or deformity
  • Examine joints above and below the point of injury, especially with midshaft fractures
  • Assess for neurovascular compromise

History

  • Document a clear mechanism of injury. The mechanism will provide an idea of the type of fracture expected.
  • Neonates and young infants may present with irritability and/or distress.

Examination

  • Look for bruising, swelling, tenderness and deformity. Self-immobilisation of the limb may be evident.
  • Assess for neurovascular compromise – check distal pulses and perfusion, sensory and motor function.
  • Look for puncture wounds and lacerations (open fracture).
  • Assess the joints above and below the injury. Assess passive and active movements.
  • Look for other injuries – especially in multi trauma patients.

Investigations

  • X-Ray the area where a fracture is suspected.

Differential diagnoses

  • Soft tissue injury
  • Osteomyelitis
  • Septic arthritis
  • Non accidental injury (especially if injury does not fit with mechanism or other multiple injuries/bruises).

Management

  • Analgesia
  • Immobilise suspected fracture before X-Rays (e.g. splint, board)
  • Neurovascular deficit is to be treated urgently – refer to Orthopaedic Team

Initial management

  • Analgesia
  • Examine for neurovascular injury – if deficit evident manage immediately (urgent Orthopaedic team referral)
  • Ice and elevation of the affected limb
  • Immobilise the limb
  • Intravenous antibiotics and tetanus booster for compound/open fractures
  • Some fractures (e.g. toddler and scaphoid) may be subtle on X-Ray. If a fracture is suspected and the X-Ray looks normal, treat the patient as if a fracture is present and repeat the X-Ray in 1-2 weeks
  • Complete an Injury Proforma form for children under 2 years.

Endorsed by:  Director, Emergency Department   Date:  Jun 2017


 Review date:   Jun 2020


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