Pediatric Fractures

MANAGE THE CHILD’S PAIN

• To rate pain and for medication/dosing recommendations, refer to TREKK’s Pain TreatmentBottom Line Recommendations.
• Provide analgesia early and allow adequate time to take effect (depending on route of administration) before imaging or examination. Ibuprofen +/- acetaminophen PO should be offered to any child complaining of pain. Intranasal fentanyl is commonly used for pediatric patients with moderate/severe pain.
• Use a splint to immobilize joints above and below the injury. Elevate injured limb. Apply ice.

ASSESS THE INJURY

• Document child/caregiver’s description(s) of injury mechanism and timing. If high-energy mechanism, assess child for other injuries. Refer to TREKK’s Multisystem Trauma Bottom Line Recommendations.
• For extremity injuries, examine above and below the injury on the same limb, compare with uninjured opposite limb, examine neurovascular status and assess for an open fracture.

ASSESS FOR POTENTIAL INJURY DUE TO MALTREATMENT

• Ensure that the developmental abilities of the child and the reported mechanism align with the fracture location and morphology. If not, discuss with the Child Protection Specialist at Pediatric Referral Centre. A detailed list of factors to consider when assessing for child abuse can be found at TREKK’s Physical Child Abuse Bottom Line Recommendations.

• All injuries that demonstrate focal swelling, pain, deformity or change in use of limb should have x-ray imaging unless otherwise indicated by the four musculoskeletal clinical decision rules validated in children:^1,2
  • • Low Risk Ankle Rule
    • Ottawa Ankle Rules
    • Ottawa Knee Rules
    • Amsterdam Wrist Rules³

• In children with forearm injuries without visible deformities, point-of-care ultrasound has been found to be non-inferior to radiographs with respect to functional outcome.
• Approximately 10% of pediatric fractures are not identified on the initial ED visit.¹
  • The most commonly missed serious fractures include: Growth plate fractures, Tillaux fractures, bowing forearm fractures, slipped capital femoral epiphysis and Monteggia fractures.
  • If the physical exam findings do not align with a negative radiograph, consult Diagnostic Imaging or Orthopedic Surgery for next steps and/or immobilize the injury and refer to Orthopedic Surgery for prompt reassessment of a possible occult fracture.
• Identify the bone(s) injured, location (proximal, middle, distal), type (spiral/oblique, transverse, comminuted, buckle, greenstick, growth plate, avulsion), and degree and direction of displacement and/or angulation. Describe growth plate fractures using the Salter-Harris classification.
• Additional imaging modalities such as computed tomography (CT) are rarely required in the acute setting and should be done in consultation with Orthopedic Surgery.

• Refer to site-specific protocols for specific fracture management, if available. Reliable pediatric fracture management guidelines: www.rch.org.au/clinicalguide/fractures/.
• For patients requiring closed reduction under procedural sedation, refer to TREKK’s Procedural Sedation Bottom Line Recommendations.

 

• Ibuprofen PO every 6-8 hours as needed is as effective as morphine in children.⁶ Acetaminophen can be added or used alternately for additional pain management as needed.
• Fractures requiring reduction and other more complex injuries may require a short course (i.e., 3 days duration or 10 doses in total) of adjuvant opioids post-discharge to adequately manage pain and function. Refer to TREKK’s Pain TreatmentBottom Line Recommendations for dosing.
• Provide information on home care of immobilization device, anticipatory guidance on recovery and participation in sports, and scheduled follow-up.
• Return to the ED if increased pain, swelling, fever, cold fingers/toes, cast too tight or other concerns.

ADDITIONAL RESOURCES

• Online resources for follow-up care are available at About Kids Health and include cast care, splinting, distal radius buckle fractures, upper arm and lower leg injuries, and minor ankle injuries.
• For additional practice in pediatric musculoskeletal radiograph interpretation, refer to www.imagesim.com, an online non-profit evidence-based image interpretation learning system.

Thank you to the following content experts who led the development of the Pediatric Fractures Bottom Line Recommendations:

Kathy Boutis, B.Sc., M.Sc., MD, FRCPC, Pediatric Emergency Physician, Division of Emergency Medicine, Sick Kids

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), who provided editorial support and expertise in the  development of this resource. Thank you as well to Mateja Carevic, TREKK Project Coordinator (University of Manitoba) who  coordinated the development process, Taylor Nimchonok, (University of Manitoba) who reviewed the Evidence Repository, and  Matthieu Vincent (CHU Sainte-Justine) for reviewing the translation.

(as cited in the Pediatric Fractures Bottom Line Recommendations):

1. Al-Sani F, Prasad S, Panwar J, Stimec J, Khosroawshahi A, Mizzi M, Camp M, Colaco K, Kramer A, Boutis K. Pediatric  Musculoskeletal Radiograph Interpretation – Pediatric Extremity Radiograph Interpretation Errors: A Prospective Cohort  Study. Acad Emerg Med. 2020 Feb;27(2):128-138.
2. Perry, Daniel CAhmad, Rahail et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised  controlled equivalence trial in the UK. The Lancet, Volume 400, Issue 10345, 39-47.
3. Slaar et al. A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and  external validation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol 2015; published online August 23, 2015.
4. Boutis K, Plint A, Stimec J, Miller E, Babyn P, Schuh S, Brison R, Lawton L, Narayanan UG. Radiograph-Negative Lateral  Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain? JAMA Pediatr. 2016 Jan;170(1):e154114. doi:  10.1001/jamapediatrics.2015.4114. Epub 2016 Jan 4. PMID: 26747077.
5. Clinical Practice Guidelines : Clavicle fractures – Emergency Department (rch.org.au)
6. Poonai N, Bhullar G, Lin K, Papini A, Mainprize D, Howard J, Teefy J, Bale M, Langford C, Lim R, Stitt L, Rieder MJ, Ali S.  Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ. 2014  Dec 9;186(18):1358-63. doi: 10.1503/cmaj.140907. Epub 2014 Oct 27. PMID: 25349008; PMCID: PMC4259768.

For a complete list of the evidence that informed the creation of the Pediatric Fractures Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use