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Upper Extremity Fractures

Children break bones more easily than adults - so pediatric fractures are very common. There are several unique features of the pediatric musculoskeletal system that need to be considered in management decisions of all of these injuries - growth plates, plasticity, callus formation, remodeling potential, and partial breaks are some of the key ones. Recognition and appropriate management of pediatric fractures by ED providers is critical. While some common minor wrist and ankle fractures can be treated with a less conservative approach encouraging an early return to activities, other fractures if not treated properly can result in long term functional problems for the child and/or be a sign of child maltreatment.

BROWSE EVIDENCE REPOSITORY

 

En bref

Bottom Line Recommendations: Fractures

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Boutis, K, Camp, M & TREKK Network

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of fractures in children. Published online: November 2015.

Recommendations de base: Fractures chez l'enfant

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Boutis, K, Camp, M & TREKK Network

Bottom line recommendations for the treatment and management of pediatric fractures - French. Published online: December, 2015.

directive clinique

Clinical Practice Guideline: Paediatric fracture guidelines - Clavicle

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Victorian Paediatric Orthopaedic Network

Summary of fracture type, ED management, and follow-up.

Clinical Practice Guideline: Paediatric fracture guidelines - Wrist (distal radius and ulna)

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Victorian Paediatric Orthopaedic Network

Clinical practice guidelines: Wrist fractures

Clinical Practice Guideline: Paediatric fracture guidelines - Forearm

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Victorian Paediatric Orthopaedic Network

Clinical practice guidelines: Forearm fractures

Clinical Practice Guideline: Paediatric fracture guidelines - Elbow

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Victorian Paediatric Orthopaedic Network

Clinical practice guidelines: Elbow fractures

Clinical Practice Guideline: Paediatric fracture guidelines - Humeral shaft (diaphysis)

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Victorian Paediatric Orthopaedic Network

Reduction is seldom required for humeral shaft fractures. Fractures will usually "hang out" (i.e. under influence of gravity) to good alignment and apposition using a collar and cuff. Mid-shaft humeral fractures should be followed up in fracture clinic at 1 week. Spiral fractures of the humerus in toddler age and younger are strongly linked with non-accidental injury. Careful history and examination are required to determine the child at risk.

Clinical Practice Guideline: Paediatric fracture guidelines - Proximal humerus

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Victorian Paediatric Orthopaedic Network

Most proximal humeral fractures do not require reduction as remodelling is extremely effective in the proximal humerus. The usual treatment for this fracture is immobilisation of the shoulder in a sling, body swathe or shoulder immobiliser. Patients should be seen in the fracture clinic or by an interested GP within 7 days for follow-up with x-rays to assess further displacement.

Clinical Practice Guideline: Supracondylar Fractures

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Camp, M

Supracondylar fractures: ED management, outpatient/fracture clinic management, operative management

Clinical Practice Guideline: The treatment of pediatric supracondylar humerus fractures

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Howard, A, Mulpuri, K, Abel, MF, Braun, S, Bueche, M, Epps, H, Hosalkar, H, M...

Based on the best current evidence and a systematic review of published studies, 14 recommendations have been created to guide clinical practice and management of supracondylar fractures of the humerus in children.

Clinical Practice Guideline: Proximal Humerus Fractures in Children

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Weber, E & Hardeski, DP

This is an AAOS clinical guideline on the pathophysiology and etiology, diagnosis, and management of proximal humerus fractures in children.

Clinical Practice Guideline: Supracondylar Fractures of the Humerus in Children

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Sullivan, JA

This is an AAOS clinical guideline on the pathophysiology and etiology, diagnosis, and management of supraondylar fractures of the humerus in children.

Clinical Practice Guideline: Pediatric Forearm Fractures

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Pring, M, Chambers, HG,

This is an AAOS clinical guideline on the pathophysiology and etiology, diagnosis, and management of pediatric forearm fractures.

Clinical Practice Guideline: Fractures of the Radial Head and Neck and Monteggia Fractures

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Carmichael, KD

This is an AAOS clinical guideline for fractures of the radial head and neck and monteggia fractures.

Clinical Practice Guideline: Distal Forearm Fractures

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Carmichael, KD

This an an AAOS clinical guideline for pediatric forearm fractures (distal, diaphyseal radius and ulnar fractures)

Clinical Practice Guideline: Fractures of the Lateral Condyle of the Humerus in Children

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Letts, M & Davidson, D

This is an AAOS clinical guideline for fractures of the lateral condyle of the humerus in children.

Résumé de l'examen systématique

Cochrane Summary: Conservative interventions for shaft fractures of the forearm bones in children

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Madhuri, V, Dutt, V, Gahukamble, AD & Tharyan, P

The forearm consists of two bones, the radius and the ulna. Fractures (broken bones) in the middle portion (shaft) of one or both of these bones are common injuries in children. Most of these fractures are treated conservatively (i.e. without surgery). Conservative treatment usually involves gently putting the broken bone back into place (reduction). Part of the arm is then put in a cast to protect and support the broken bones while they heal. There are different ways of immobilising the injured arm. For example, some casts include the elbow whereas others do not. When casts include the elbow, the elbow may be in a bent or extended position. While these fractures usually heal, the results are not always satisfactory and sometimes there are complications. This review aimed to find out which conservative treatment methods give the best results for children with these fractures by looking at the evidence from randomised controlled trials comparing different conservative interventions. While we found two completed trials, both were published only in conference abstracts that failed to provide any usable data. We also found two ongoing trials. In all, the review found no evidence from randomised trials to inform on the best ways to treat these fractures.

Cochrane Summary: Surgical treatment for forearm fractures in children (fractures involving the shafts of the radius and ulna)

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Abraham, A, Kumar, S, Chaudhry, S & Ibrahim, T

Fractures of the shafts of the forearm bones in children are common injuries and occur after a fall on an outstretched hand. There are two bones in the forearm: the radius and the ulna. After a fall either one or both bones may fracture. The shape of forearm bones are important for the twisting motion of the hand, such as in receiving change from a shop keeper with an open palm (supination) or turning a key in a door (turning the palm facing down - pronation). Treatment of the forearm fracture aims to restore the shape of the bones such that supination and pronation ability is restored. The first stage of treatment involves manipulating (setting) the bones to the correct shape. This is usually done under anaesthesia. The second stage involves stabilising the fractured bones either with a plaster cast (conservative treatment) or metal implants (surgical treatment). This review aimed to examine the evidence from randomised controlled trials comparing conservative versus surgical methods and trials comparing different surgical methods for treatment of these fractures. We hoped to find which are the best methods in terms of function and complications. In spite of a thorough search we found no evidence from properly conducted studies to help inform decisions on treatment of these fractures.

examen systématique

Systematic Review: The treatment of displaced supracondylar humerus fractures: evidence-based guideline

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Mulpuri, K & Wilkins, K

The guidelines provided answers for the following questions regarding the treatment for type III supracondylar fractures (1) which is the preferred treatment for displaced supracondylar fractures of the humerus: reduction and casting versus closed reduction and percutaneous pinning; (2) which is the preferred method for fixing displaced supracondylar fractures of the humerus: medial (crossed) versus lateral pinning; and lastly, (3) does open reduction cause increased stiffness or have a high rate of complication? The purpose of this paper is to summarize and highlight the major findings from this systematic review.

Cochrane Systematic Review: Surgical interventions for diaphyseal fractures of the radius and ulna in children

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Abraham, A, Kumar, S, Chaudhry, S & Ibrahim, T

Objectives: To assess the effects (benefits and harms) of a) surgical versus non-surgical interventions, and b) different surgical interventions for the fixation of diaphyseal fractures of the forearm bones in children.

Systematic Review: Above- or below-elbow casts for distal third forearm fractures in children? A meta-analysis of the literature

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Hendrickx, RP, Campo, MM, van Lieshout, AP, Struijs, PA & van den Bekerom, MP

The purpose of this meta-analysis is to investigate whether above- or below-elbow cast should be considered the first-choice for conservative treatment.

Systematic Review: Splinting versus casting of "torus" fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): a literature review

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Firmin, F & Crouch, R

Aim: To compare outcomes regarding splinting versus casting of paediatric torus fractures in the ED with the aim of establishing the preferred treatment.

étude clé

Key Study: Feasibility of a reduction protocol in the emergency department for diaphyseal forearm fractures in children

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Pesenti, S, Litzelmann, E, Kahil, M, Mallet, C, Jehanno, P, Mercier, JC, Ilha...

The purpose of this study was to analyze the results of diaphyseal forearm fractures in the emergency department (ED) in children.

Key Study: Using softcast to treat torus fractures in a paediatric emergency department

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Callender, O & Koe, S

Guidelines were developed in order to standardise the care for children who attended the ED with a torus fracture.

Key Study: Forearm fractures in children: split opinions about splitting the cast

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Schulte, D, Habernig, S, Zuzak, T, Staubl,i G, Altermatt, S, Horst, M & Garci...

Fractures of the forearm are the most common fractures in children. Various methods of cast immobilization have been recommended. Currently, there is still controversy regarding the optimal method of treatment, especially regarding the need for cast splitting.

Key Study: Accuracy of Ultrasonography for Determining Successful Realignment of Pediatric Forearm Fractures

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Dubrovsky, AS, Kempinska, A, Bank, I & Mok, E

The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluoroscopy in determining successful realignment of pediatric forearm fractures. The secondary objective is to determine the rate of agreement of ultrasonography and fluoroscopy in real-time by the treating physician.

Key Study: Synthetic versus plaster of Paris casts in the treatment of fractures of the forearm in children: a randomised trial of clinical outcomes and patient satisfaction

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Inglis, M, McClelland, B, Sutherland, LM & Cundy, PJ

The aim of this study was to investigate which cast material is superior for the management of these fractures.

Key Study: Soft cast versus rigid cast for treatment of distal radius buckle fractures in children

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Witney-Lagen, C, Smith, C & Walsh, G

This study aimed to ascertain whether buckle fractures of the distal radius can be safely and effectively treated in soft cast with only a single orthopaedic outpatient clinic appointment.

Key Study: Pediatric clavicular fractures: assessment of fracture patterns and predictors of complicated outcome

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Strauss, BJ, Carey, TP, Seabrook, JA & Lim, R

Study Objectives: The study aim was to identify the radiological and clinical variables that increase the complication rate of clavicular fractures. Identification of these variables would help emergency physicians identify patients who require more thorough follow-up or surgical intervention.

Key Study: Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study

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Colaris, JW, Biter, LU, Allema, JH, Bloem, RM, van de Ven, CP, de Vries, MR, ...

Minimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC.

Key Study: Bedside ultrasound in the diagnosis of pediatric clavicle fractures

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Chien, M, Bulloch, B, Garcia-Filion, P, Youssfi, M, Shrader, MW & Segal, LS

Objective: The objective of the study was to determine the diagnostic accuracy of pediatric emergency physicians in diagnosing clavicle fractures by bedside ultrasound (US).

Key Study: Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department

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Chaar-Alvarez, FM, Warkentine, F, Cross, K, Herr, S & Paul, RI

Objectives: Ultrasound (US) may be a useful tool for rapidly diagnosing fractures. Our objective was to determine the accuracy of US as compared with radiographs in the detection of nonangulated distal forearm fractures.

Key Study: Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial

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Boutis, K, Willan, A, Babyn, P, Goeree, R & Howard, A

Minimally angulated fractures of the distal radius are common in children and have excellent outcomes. We conducted a randomized controlled trial to determine whether the use of a prefabricated splint is as effective as a cast in the recovery of physical function.

Key Study: Are frequent radiographs necessary in the management of closed forearm fractures in children?

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Bochang, C, Katz, K, Weigl, D, Jie, Y, Zhigang, W & Bar-On, E

A prospective pooled case series was used to assess the value of frequent radiographic examinations during treatment of closed forearm fractures in children from major university pediatric medical centers in Israel and China.

Key Study: A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children

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Plint, AC, Perry, JJ, Correll, R, Gaboury, I & Lawton, L

The objective was to determine if children with distal radius and/or ulna buckle fractures treated with a removable splint have better physical functioning than those treated with a short arm cast for 3 weeks.

Key Study: Simple treatment for torus fractures of the distal radius

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Davidson, JS, Brown, DJ, Barnes, SN & Bruce, CE

Torus (buckle) fractures of the distal radius are common in childhood. Based on the results of a postal questionnaire and a prospective, randomised trial, we describe a simple treatment for this injury, which saves both time and money.