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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 INFORMATiON REPOSITORY

 

 
 
Bottom Line Recommendations English (1) French (1) All (2)

UNDER REVIEW Bottom Line Recommendations: Fractures

Download

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. Original (version 1.0) published online: November 2015. Updated (version 2.0) published online: February 2018.

UNDER REVIEW: Recommandations de Base: Fractures chez l'enfant

Download

Boutis, K & TREKK Network

Recommandations de base pour le diagnostic et le traitement des fractures chez les enfants. Original (version 1.0) publié en ligne en décembre 2016. Mise à jour (version 2.0) publiée en ligne février 2018.

 

UNDER REVIEW Bottom Line Recommendations: Fractures

Download

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. Original (version 1.0) published online: November 2015. Updated (version 2.0) published online: February 2018.

UNDER REVIEW: Recommandations de Base: Fractures chez l'enfant

Download

Boutis, K & TREKK Network

Recommandations de base pour le diagnostic et le traitement des fractures chez les enfants. Original (version 1.0) publié en ligne en décembre 2016. Mise à jour (version 2.0) publiée en ligne février 2018.

 

Clinical guidelines English (5) French All (5)

Clinical Practice Guideline: Paediatric fracture guidelines

Visit

Victorian Paediatric Orthopaedic Network

Summary of paediatric fracture types, emergency department management, and information for fracture clinics.

Clinical Practice Guideline: Peripheral neurovascular checklist

Visit

SicKids Division of Orthopaedic Surgery

Peripheral Neurovascular Checklist.

Clinical Practice Guideline: Management of fractures in adolescents

Visit

Parikh, SN, Wells, L, Mehlman, CT & Scherl, SA

Summary of classifications, imaging, and treatments of fractures.

Clinical Practice Guideline: AboutKidsHealth: Tools for measuring pain

Visit

Stinson, J

Objectives: To assess the level of pain felt by children through the use of pain scales and other measurement tools such as behavioural and composite measures.

Clinical Practice Guideline: Splinting ABCs: upper and lower extremity splinting in the emergency department

Visit

Sarwark, JF, Maizels, M, Adler, MD & Nicholson, D

This guideline describes preparation and application of plaster and fiberglass short arm splints and short leg splints. Materials and set up for each type of splint are discussed in detail and the advantages and disadvantages of using fiberglass splints are outlined.

Clinical Practice Guideline: Paediatric fracture guidelines

Visit

Victorian Paediatric Orthopaedic Network

Summary of paediatric fracture types, emergency department management, and information for fracture clinics.

Clinical Practice Guideline: Peripheral neurovascular checklist

Visit

SicKids Division of Orthopaedic Surgery

Peripheral Neurovascular Checklist.

Clinical Practice Guideline: Management of fractures in adolescents

Visit

Parikh, SN, Wells, L, Mehlman, CT & Scherl, SA

Summary of classifications, imaging, and treatments of fractures.

Clinical Practice Guideline: AboutKidsHealth: Tools for measuring pain

Visit

Stinson, J

Objectives: To assess the level of pain felt by children through the use of pain scales and other measurement tools such as behavioural and composite measures.

Clinical Practice Guideline: Splinting ABCs: upper and lower extremity splinting in the emergency department

Visit

Sarwark, JF, Maizels, M, Adler, MD & Nicholson, D

This guideline describes preparation and application of plaster and fiberglass short arm splints and short leg splints. Materials and set up for each type of splint are discussed in detail and the advantages and disadvantages of using fiberglass splints are outlined.

Summaries of systematic reviews English (2) French All (2)

Book: Rockwood and Wilkins' Fractures in Children

Visit

Flynn, JM, Skaggs, DL, Waters, PM

Written by leading orthopaedic surgeons from around the world, the revised and expanded 8th edition of this classic bestselling text presents complete, up-to-date coverage of all types of children's fractures.

Cochrane Summary: Antibiotics for preventing infection in open limb fractures

Visit

Gosselin, RA, Roberts, I & Gillespie, WJ

Objective: To review the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

Book: Rockwood and Wilkins' Fractures in Children

Visit

Flynn, JM, Skaggs, DL, Waters, PM

Written by leading orthopaedic surgeons from around the world, the revised and expanded 8th edition of this classic bestselling text presents complete, up-to-date coverage of all types of children's fractures.

Cochrane Summary: Antibiotics for preventing infection in open limb fractures

Visit

Gosselin, RA, Roberts, I & Gillespie, WJ

Objective: To review the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

Systematic reviews English (3) French All (3)

Systematic Review: Common pediatric fractures treated with minimal intervention

Visit

Boutis, K

This article will review the evidence that recommends that management of some of the most common upper and lower pediatric extremity fractures be treated with minimal interventions, such as removable splints and follow-up with a primary care provider.

Systematic Review: Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review

Visit

Migita RT, Klein EJ, Garrison MM

This review assessed the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations.

Cochrane Systematic Review: Antibiotics for preventing infection in open limb fractures

Visit

Gosselin, RA, Roberts, I, & Gillespie, WJ

Objective: To quantify the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

Systematic Review: Common pediatric fractures treated with minimal intervention

Visit

Boutis, K

This article will review the evidence that recommends that management of some of the most common upper and lower pediatric extremity fractures be treated with minimal interventions, such as removable splints and follow-up with a primary care provider.

Systematic Review: Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review

Visit

Migita RT, Klein EJ, Garrison MM

This review assessed the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations.

Cochrane Systematic Review: Antibiotics for preventing infection in open limb fractures

Visit

Gosselin, RA, Roberts, I, & Gillespie, WJ

Objective: To quantify the evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limbs.

Key studies English (24) French All (24)

Key Study: Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective

Visit

Yang, B W and Waters, P M

This study describes the epidemiology and outcomes associated with fracture conscious sedation and reduction in a level I paediatric ED.

Key Study: Factors Affecting Family Presence During Fracture Reduction in the Pediatric Emergency Department

Visit

Zhang, A, Yocum, R M, Repplinger, M D, Broman, A T and Kim, M K

The aim of this study was to determine factors related to family members' choice to be present or absent during fracture reductions in a pediatric emergency department (ED), and their satisfaction with that choice.

Key Study: Behavioral Changes in Children After Emergency Department Procedural Sedation

Visit

Pearce, J I, Brousseau, D C, Yan, K, Hainsworth, K R, Hoffmann, R G and Drend...

The purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative postdischarge behaviors. Predictors of negative behaviors were evaluated, including anxiety.

Key Study: Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures

Visit

Reynolds, S L, Bryant, K K, Studnek, J R, Hogg, M, Dunn, C, Templin, M A, Moo...

We compared the tolerability and efficacy of intranasal subdissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger noninferiority trial that could investigate the potential opioid-sparing effects of intranasal ketamine.

Key Study: Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?

Visit

DePeter, K C, Blumberg, S M, Dienstag Becker, S and Meltzer, J A

OBJECTIVE: To determine if exposure to ibuprofen is associated with an increased risk of bone healing complications in children with fractures.

Key Study: Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study

Visit

Hoeffe, J, Doyon Trottier, E, Bailey, B, Shellshear, D, Lagace, M, Sutter, C,...

Procedural sedation and analgesia (PSA) are frequently used for fracture reduction in pediatric emergency departments (ED). Combining intranasal (IN) fentanyl with inhalation of nitrous oxide (N2O) allow for short recovery time and obviates painful and time-consuming IV access insertions.

Key Study: Management of toddler's fractures in the pediatric emergency department

Visit

Schuh, AM, Whitlock, KB, & Klein, EJ

Objectives: To evaluate current practice in treatment of toddler's fractures, as well as subsequent healthcare utilization and complications.

Key Study: Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries

Visit

Disel, N R, Yilmaz, H L, Sertdemir, Y, Yesilagac, H and Avci, A

The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department.

Key Study: A RCT of a Combination of Analgesics for Pain Management in Children With a Suspected Fracture

Visit

Alam Khan, T, Jamil Khattak, Y, Awais, M, Alam Khan, A, Husen, Y, Nadeem, N a...

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children.

Key Study: Evidence into practice: pediatric orthopaedic surgeon use of removable splints for common pediatric fractures

Visit

Boutis, K, Howard, A, Constantine, E, Cuomo, A, Somji, Z, & Narayanan, UG

Removable splints when compared with circumferential casts in randomized trials have been shown to be a safe and cost-effective method of managing many common minor distal radius and fibular fractures. This study estimated the extent to which this evidence is being implemented in clinical practice, and determined the perceived barriers to the adoption of this evidence.

Key Study: Epidemiology of pediatric fractures presenting to emergency departments in the United States

Visit

Naranje, SM, Erali, RA, Warner, WC Jr, Sawyer, JR, & Kelly, DM

Objective: To identify the most frequent pediatric fractures per 1000 population at risk in the United States using the 2010 National Electronic Injury Surveillance System database and 2010 Census information.

Key Study: Utility of complete trauma series radiographs in alert pediatric patients presenting to Emergency Department of a Tertiary Care Hospital

Visit

Alam Khan T1,Jamil Khattak Y,Awais M,Alam Khan A,Husen Y,Nadeem N,Rehman A.

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children.

Key Study: Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies

Visit

Barcelos, A, Garcia, P C, Portela, J L, Piva, J P, Garcia, J P and Santana, J C

To compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children.

Key Study: Evidence into practice: emergency physician management of common pediatric fractures

Visit

Boutis, K, Howard, A, Constantine, E, Cuomo, A, & Narayanan, U

Objectives: To determine the proportion of emergency physicians who prescribe removable devices for distal radius buckle fractures and/or nondisplaced distal fibular Salter-Harris I fractures. The investigators also examined follow-up referral patterns for these injuries.

Key Study: Paediatrician office follow-up of common minor fractures

Visit

Koelink, E, & Boutis, K

Objectives: To determine paediatricians opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office.

Key Study: Bone fractures in children: is there an association with obesity?

Visit

Sabhaney, V, Boutis, K, Yang, G, Barra, L, Tripathi, R, Tran, TT, & Doan, Q

Objective: To determine the relationship between body mass index (BMI) and odds of extremity bone fractures in children.

Key Study: Who are we missing? Too few skeletal surveys for children with humeral and femoral fractures

Visit

Shelmerdine, SC, Das, R, Ingram, MD, & Negus, S

Objective: To determine the potential shortfall in skeletal survey referral for children presenting with an acute non-supracondylar humeral or femoral fracture.

Key Study: Emergency ultrasound in the detection of pediatric long-bone fractures

Visit

Barata, I, Spencer, R, Suppiah, A, Raio, C, Ward, MF, & Sama, A

Objective: The goal of this study was to assess the agreement between emergency physicians' and radiologists' final assessments of suspected long-bone fractures using emergency ultrasound and radiography, respectively, in the pediatric population.

Key Study: Extremity fracture pain after emergency department reduction and casting: predictors of pain after discharge

Visit

Thompson, RW, Krauss, B, Kim, YJ, Monuteaux, MC, Zerriny, S, & Lee, LK

Objectives: To determine the prevalence of pediatric extremity fracture pain after emergency department (ED) discharge, compare pain severity between fractures requiring simple casting versus sedated reduction and casting, and explore predictors of postdischarge pain.

Key Study: Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients

Visit

Sinha, TP, Bhoi, S, Kumar, S, Ramchandani, R, Goswami, A, Kurrey, L, & Ga...

Objective: To assess the diagnostic accuracy of bedside ultrasound for fractures in pediatric trauma patients.

Key Study: Emergency room visits by pediatric fracture patients treated with cast immobilization

Visit

Sawyer, JR, Ivie, CB, Huff, AL, Wheeler, C, Kelly, DM, Beaty, JH, & Canal...

Objectives: To determine when and why pediatric patients with cast complaints return to the emergency room (ER). If this could be determined, educational and treatment strategies may help decrease the number of these visits and the cost of care.

Key Study: Sonographic detection of radiographically occult fractures in pediatric ankle and wrist injuries

Visit

Simanovsky, N, Lamdan, R, Hiller, N, Simanovsky, N,

Objective: To determine the effectiveness of high-resolution ultrasound (US) in differentiating radiographically occult fractures from sprains.

Key Study: A randomized prospective study of music therapy for reducing anxiety during cast room procedures

Visit

Liu, RW, Mehta, P, Fortuna, S, Armstrong, DG, Cooperman, DR, Thompson, GH, &a...

Objective: To decrease anxiety through the use of music therapy.

Key Study: A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma

Visit

Clark, E, Plint, AC, Correll, R, et al

To determine which of 3 analgesics, acetaminophen, ibuprofen, or codeine, given as a single dose, provides the most efficacious analgesia for children presenting to the emergency department with pain from acute musculoskeletal injuries.

Key Study: Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective

Visit

Yang, B W and Waters, P M

This study describes the epidemiology and outcomes associated with fracture conscious sedation and reduction in a level I paediatric ED.

Key Study: Factors Affecting Family Presence During Fracture Reduction in the Pediatric Emergency Department

Visit

Zhang, A, Yocum, R M, Repplinger, M D, Broman, A T and Kim, M K

The aim of this study was to determine factors related to family members' choice to be present or absent during fracture reductions in a pediatric emergency department (ED), and their satisfaction with that choice.

Key Study: Behavioral Changes in Children After Emergency Department Procedural Sedation

Visit

Pearce, J I, Brousseau, D C, Yan, K, Hainsworth, K R, Hoffmann, R G and Drend...

The purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative postdischarge behaviors. Predictors of negative behaviors were evaluated, including anxiety.

Key Study: Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures

Visit

Reynolds, S L, Bryant, K K, Studnek, J R, Hogg, M, Dunn, C, Templin, M A, Moo...

We compared the tolerability and efficacy of intranasal subdissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger noninferiority trial that could investigate the potential opioid-sparing effects of intranasal ketamine.

Key Study: Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications?

Visit

DePeter, K C, Blumberg, S M, Dienstag Becker, S and Meltzer, J A

OBJECTIVE: To determine if exposure to ibuprofen is associated with an increased risk of bone healing complications in children with fractures.

Key Study: Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study

Visit

Hoeffe, J, Doyon Trottier, E, Bailey, B, Shellshear, D, Lagace, M, Sutter, C,...

Procedural sedation and analgesia (PSA) are frequently used for fracture reduction in pediatric emergency departments (ED). Combining intranasal (IN) fentanyl with inhalation of nitrous oxide (N2O) allow for short recovery time and obviates painful and time-consuming IV access insertions.

Key Study: Management of toddler's fractures in the pediatric emergency department

Visit

Schuh, AM, Whitlock, KB, & Klein, EJ

Objectives: To evaluate current practice in treatment of toddler's fractures, as well as subsequent healthcare utilization and complications.

Key Study: Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries

Visit

Disel, N R, Yilmaz, H L, Sertdemir, Y, Yesilagac, H and Avci, A

The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department.

Key Study: A RCT of a Combination of Analgesics for Pain Management in Children With a Suspected Fracture

Visit

Alam Khan, T, Jamil Khattak, Y, Awais, M, Alam Khan, A, Husen, Y, Nadeem, N a...

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children.

Key Study: Evidence into practice: pediatric orthopaedic surgeon use of removable splints for common pediatric fractures

Visit

Boutis, K, Howard, A, Constantine, E, Cuomo, A, Somji, Z, & Narayanan, UG

Removable splints when compared with circumferential casts in randomized trials have been shown to be a safe and cost-effective method of managing many common minor distal radius and fibular fractures. This study estimated the extent to which this evidence is being implemented in clinical practice, and determined the perceived barriers to the adoption of this evidence.

Key Study: Epidemiology of pediatric fractures presenting to emergency departments in the United States

Visit

Naranje, SM, Erali, RA, Warner, WC Jr, Sawyer, JR, & Kelly, DM

Objective: To identify the most frequent pediatric fractures per 1000 population at risk in the United States using the 2010 National Electronic Injury Surveillance System database and 2010 Census information.

Key Study: Utility of complete trauma series radiographs in alert pediatric patients presenting to Emergency Department of a Tertiary Care Hospital

Visit

Alam Khan T1,Jamil Khattak Y,Awais M,Alam Khan A,Husen Y,Nadeem N,Rehman A.

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children.

Key Study: Comparison of two analgesia protocols for the treatment of pediatric orthopedic emergencies

Visit

Barcelos, A, Garcia, P C, Portela, J L, Piva, J P, Garcia, J P and Santana, J C

To compare the efficacy of two analgesia protocols (ketamine versus morphine) associated with midazolam for the reduction of dislocations or closed fractures in children.

Key Study: Evidence into practice: emergency physician management of common pediatric fractures

Visit

Boutis, K, Howard, A, Constantine, E, Cuomo, A, & Narayanan, U

Objectives: To determine the proportion of emergency physicians who prescribe removable devices for distal radius buckle fractures and/or nondisplaced distal fibular Salter-Harris I fractures. The investigators also examined follow-up referral patterns for these injuries.

Key Study: Paediatrician office follow-up of common minor fractures

Visit

Koelink, E, & Boutis, K

Objectives: To determine paediatricians opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office.

Key Study: Bone fractures in children: is there an association with obesity?

Visit

Sabhaney, V, Boutis, K, Yang, G, Barra, L, Tripathi, R, Tran, TT, & Doan, Q

Objective: To determine the relationship between body mass index (BMI) and odds of extremity bone fractures in children.

Key Study: Who are we missing? Too few skeletal surveys for children with humeral and femoral fractures

Visit

Shelmerdine, SC, Das, R, Ingram, MD, & Negus, S

Objective: To determine the potential shortfall in skeletal survey referral for children presenting with an acute non-supracondylar humeral or femoral fracture.

Key Study: Emergency ultrasound in the detection of pediatric long-bone fractures

Visit

Barata, I, Spencer, R, Suppiah, A, Raio, C, Ward, MF, & Sama, A

Objective: The goal of this study was to assess the agreement between emergency physicians' and radiologists' final assessments of suspected long-bone fractures using emergency ultrasound and radiography, respectively, in the pediatric population.

Key Study: Extremity fracture pain after emergency department reduction and casting: predictors of pain after discharge

Visit

Thompson, RW, Krauss, B, Kim, YJ, Monuteaux, MC, Zerriny, S, & Lee, LK

Objectives: To determine the prevalence of pediatric extremity fracture pain after emergency department (ED) discharge, compare pain severity between fractures requiring simple casting versus sedated reduction and casting, and explore predictors of postdischarge pain.

Key Study: Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients

Visit

Sinha, TP, Bhoi, S, Kumar, S, Ramchandani, R, Goswami, A, Kurrey, L, & Ga...

Objective: To assess the diagnostic accuracy of bedside ultrasound for fractures in pediatric trauma patients.

Key Study: Emergency room visits by pediatric fracture patients treated with cast immobilization

Visit

Sawyer, JR, Ivie, CB, Huff, AL, Wheeler, C, Kelly, DM, Beaty, JH, & Canal...

Objectives: To determine when and why pediatric patients with cast complaints return to the emergency room (ER). If this could be determined, educational and treatment strategies may help decrease the number of these visits and the cost of care.

Key Study: Sonographic detection of radiographically occult fractures in pediatric ankle and wrist injuries

Visit

Simanovsky, N, Lamdan, R, Hiller, N, Simanovsky, N,

Objective: To determine the effectiveness of high-resolution ultrasound (US) in differentiating radiographically occult fractures from sprains.

Key Study: A randomized prospective study of music therapy for reducing anxiety during cast room procedures

Visit

Liu, RW, Mehta, P, Fortuna, S, Armstrong, DG, Cooperman, DR, Thompson, GH, &a...

Objective: To decrease anxiety through the use of music therapy.

Key Study: A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma

Visit

Clark, E, Plint, AC, Correll, R, et al

To determine which of 3 analgesics, acetaminophen, ibuprofen, or codeine, given as a single dose, provides the most efficacious analgesia for children presenting to the emergency department with pain from acute musculoskeletal injuries.