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Evidence repositories are collections of best available resources and evidence (clinical guidelines, peer reviewed literature, systematic reviews, etc.), collated by our knowledge synthesis team and content advisors. This evidence repository is not intended to be an exhaustive list of resources for a topic, but rather a curated list of current, evidence-based resources, based on expert consensus of relevance and usability for a general emergency department setting. We search databases (Cochrane Library, PubMed, TRIP Database) and web search engines (Google, Google Scholar) to locate evidence. Additionally, hospital websites are browsed for guidance documents, such as clinical practice guidelines (CPG) for healthcare professionals. 

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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. Updated (version 3.0) published online: May 2021.

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.  Mise à jour (version 3.0) publiée en ligne mai 2021.

This is an AAOS clinical guideline on the pathophysiology and etiology, classification, diagnosis, and management of apophyseal avulsion fractures of the Pelvis and lower extremity.

The POSNA Study Guide provides an overview of practice points related to fractures and other pediatric orthopaedic injuries of the upper extremity.

This is a summary of the recommendations in the AAOS clinical practice guideline, The Treatment of Pediatric Diaphyseal Femur Fractures.

This is an AAOS clinical guideline on the pathophysiology and etiology, classification, diagnosis, and management of tibial shaft fractures.

This is an AAOS clinical guideline on the pathophysiology and etiology, classification, diagnosis, and management of ankle fractures in adolescents.

Summary and classification of hip and proximal femur fractures.

Summary of femoral shaft fractures, ED management, and follow-up.

Summary of tibial shaft fracture, ED management, and follow-up.

Summary of distal tibia and-or fibula physeal fractures, ED management, and follow-up.

This is an AAOS clinical guideline on the treatment of pediatric diaphyseal femur fractures (PDFF).

Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions for pediatric supracondylar humerus fractures with vascular injury.

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.

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

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.

The American Academy of Orthopaedic Surgeons approved appropriate use criteria for the treatment of pediatric supracondylar humerus fractures in an effort to assist the clinician in caring for these injuries.

The American Academy of Orthopaedic Surgeons has developed Appropriate Use Criteria on the Management of Pediatric Supracondylar Humerus Fractures (PSHF). Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions

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.

This clinical practice guideline is based on a systematic review of published studies on the treatment of supracondylar fractures of the humerus in children. In addition to providing practice recommendations, this guideline highlights gaps in the literature and areas that require future research.

This an an AAOS clinical guideline for pediatric distal radial fractures.

This is an AAOS clinical guideline on the pathophysiology, classification, diagnosis, and management of pediatric femoral shaft fractures.

Objective: To assess the effects (benefits and harms) of interventions for treating femoral shaft fractures in children and adolescents.

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.

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.

Objectives: To determine in the treatment of LRTIs: the effectiveness of oxygen therapy and oxygen delivery methods; the safety of these methods; and indications for oxygen therapy.

Objectives: The objective of this review is to assess the efficacy of aerosolized ribavirin for infants and children with lower respiratory tract infections due to RSV.

OBJECTIVES: This review aims to summarise the benefits and harms of antibiotics for treating lower UTI in children.

OBJECTIVES: The objective was to assess the efficacy and safety and to establish a benefit-risk ratio of acetylcysteine and carbocysteine as symptomatic treatments for acute upper and lower RTIs in paediatric patients without chronic broncho-pulmonary disease.

OBJECTIVES: To determine whether antibiotics are effective in the treatment of childhood LRTI secondary to M. pneumoniae infections acquired in the community.

OBJECTIVES: To assess the effects of chest radiography on clinical outcome in acute lower respiratory infections.

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

OBJECTIVES: To evaluate the effects of different methods for conservative (non-operative) treatment for acute (treated soon after injury) middle third clavicle fractures in adolescents and adults.

OBJECTIVES: We aimed to evaluate removable splintage versus plaster casts (requiring removal by a specialist) for undisplaced compression (buckle) fractures; cast length and position; and the role of surgical fixation for displaced wrist fractures in children.

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.

OBJECTIVES: To evaluate the effectiveness of different methods of surgical treatment for acute fracture or non-union of the middle third of the clavicle.

OBJECTIVES: To assess the effects (benefits and harms) of surgical versus conservative interventions for treating middle third clavicle fractures.

OBJECTIVES: To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with BSF.

Objective: To assess the effects (benefits and harms) of interventions for treating femoral shaft fractures in children and adolescents.

Objective: To conduct a systematic review to determine the diagnostic accuracy of the Ottawa Ankle Rules (OAR) to exclude ankle and midfoot fractures in children and the extent to which x-ray use could be reduced without missing significant fractures.

The aim of this systematic review was to gather the best evidence of different treatment methods and their associated functional outcome, complication rates, rates of limb length discrepancies and radiological outcome for proximal humerus fractures in children and adolescents.

This systematic review provides a comparative investigation assessing outcomes after nonoperative treatment based on the presence or absence of elbow islocation.

The purpose of this review is to provide an overview of common pediatric forearm fractures, clarify the descriptions used to identify and therby appropriately treat them with a splint or cast, and explain osseous remodeling that is unique to the skeletally immature.

The objective of this study was to compare clinical outcomes following different treatment modalities for pediatric scaphoid fractures.

The aim was to analyze whether patients with a displaced midshaft clavicular fracture are best managed with plate fization or nonoperative treatment with respect to nonunion, secondary operations, and functional outcome, by evaluating all available randomized controlled trials on this subject.

This study describes treatment options for buckle fractures of the distal radius in children.

A systematic review was performed to analyze the complications of alternatic splinting compared to traditional management.

The aim of this study was to compare, in a systematic review, clinical efficacy of rigid cast with nonrigid methods for immobilization of the pediatric forearm torus fractures.

This is a systematic review of clinical studies evaluating ultrasound as a possible alternative to radiographs in diagnosing metaphyseal forearm fractures in children.

This systematic review was conducted of studies examining the radiographic and clinical outcomes of nonoperatively managed SH II distal radius fractures.

The objective was to evaluate the effects (benefits and harms) of different methods for conservative (non-operative) treatment for acute (treated soon after injury) middle third clavicle fractures in adolescents and adults.

Pediatric and adolescent forearm fractures continue to present treatment challenges. Despite high-level evidence to the contrary, traditional guidelines for nonsurgical treatment have been challenged in favor of surgical intervention, but it is unclear if this results in improved outcomes. Recent evidence suggests that certain open fractures in children may be successfully treated nonsurgically. Good results have been achieved with closed reduction and appropriate casting and clinical follow-up. Further research investigating functional outcomes into adulthood is needed

The purpose of this paper is to summarize and highlight the major findings from the systematic review that developed a clinical practice guideline from the American Academy of Orthopaedic Surgeons regarding treatment for type III supracondylar fractures.

The objective was 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.

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

This systematic review aims to provide the ideal treatment for minimally displaced fractures (measuring ≤2 mm)

This article offers a comprehensive review of the use of PoCUS for the diagnosis and reduction of LBFs.

Objective: To determine whether there are differences in fracture patterns and femur fracture treatment choices in obese versus nonobese pediatric trauma patients.

The purpose of this investigation was to compare patient/parent centered outcomes after the use of a customized sling compared with a standard sling by utilizing a prospective, randomized-controlled trial.

Objective: To determine if the below-knee fiberglass posterior splint was as effective as the Air-Stirrup ankle brace in returning children with a low risk ankle fracture to their normal level of activity.

Objective: To determine whether children who have low-risk ankle fractures that are treated with a removable ankle brace have at least as effective a recovery of physical function as those that are treated with a cast.

The aim of this study is to compare splint versus cast immobilization for maintaining alignment following closed reduction of distal 1/3 radius and both-bone forearm fractures.

Development of an evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the health care system.

The purpose of this study was to determine the effects of bivalved versus circumferential cast immobilization on maintenance of reduction and associated complications after closed reduction of radius and/or ulna fractures in children.

The purpose of this study was to determine the rate of cast-related complications when using split or intact casts.

The purpose of this study was to review the treatment and outcomes of consecutive series of distal humerus fractures in adolescents and to compare outcomes between patients treated with percutaneous skeletal fixation and those treated with open reduction and fixation.

The objective of the study was to evaluate the efficacy (length of stay in the emergency department and failure rate of Bier's block) and safety profile (death and major complications) of Bier's block in its use for manipulation and reduction of paediatric forearm fractures.

The objective of this study was to determine if high body mass index increases the risk of loss of reduction following closed reduction and casting for displaced concomitant fractures of the radial and ulnar shafts in pediatric patients.

The aim of this study is to evaluate the utility of point-of-care ultrasound for diagnosing distal forearm fractures in pediatric emergency departments.

The primary outcome of the study was the proportion of proximal humerus fractures, initially treated non-operatively, for which displacement or angulation on follow-up radiographs led to a change to operative treatment.

The purpose of this study was to investigate the use of MRI in diagnosis and therapeutic decision in minimally displaced lateral condyle fractures in children.

The aim of this study was to evaluate the role of ultrasound (US) as a point-of-care triage tool for pediatric wrist injuries with limited training.

This study aimed to assess shoulder function in adolescents following shortened clavicle fracture and compare operative versus non-operative treatment.

Understanding national treatment trends will provide important insight into variations in regional treatment standards and help identify areas for improvement in value in care delivery.

The current study was conducted to answer 2 questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation : 1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? 2) Is there a difference in the rates of major sedation-related complications?

The purpose of this investigation was to characterize capitellar fracture patterns in children and adolescents and to assess early clinical and radiographic treatment outcomes.

The objectives of the study were to examine the test performance characteristics of point-of-care ultrasound for nonangulated distal forearm injuries in children and compare to x-ray with respect to pain, caregiver satisfaction, and procedure duration.

The primary aim of this study was to determine if a cohort of physicians with little or no previous experience with US could, after a short training program, safely exclude forearm fractures in children.

The primary objective of this study was to evaluate the ability of MRI to determine whether the fracture line is complete or incomplete in cases of non-displaced lateral humeral condyle fractures in children.

A retrospective case-controlled study was conducted to determine whether obesity is an independent risk factor for the failure of closed reduction and casting.

The aim of the study was to analyze the influence of immobilization time on functional outcome.

The purpose of this investigation was to characterize the functional outcomes of children and adolescents treated for scaphoid fractures.

Primary outcome of this study was the difference in active range of motion between a conventional forearm-based ulnar gutter or hand-based thermoplastic splint.

This study describes fractures revealed by magnetic resonance imaging (MRI) in a prospective population of children and adolescents with posttraumatic radial-sided wrist tenderness, and compare the diagnostic value of radiographs and computed tomography (CT) with that of MRI.

The main objective was to determine the proportion of children referred to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who subsequently did not deviate from this reassessment strategy.

This study presents the results of managing children's fracture of the distal forearm in the ED using intranasal diamorphine and Entonox to allow manipulation and discharge on the same day.

The purpose of this retrospective study was to describe our strategy and to determine the guidelines of therapeutic consensus.

The purpose of this study was to analyze the clinical utility and cost of the week 4 radiograph following closed treatment of pediatric forearm fractures.

This study aimed to assess the improvement in documented neurological examination for children presenting with upper limb fractures following introduction of a simple guideline.

The primary objective was to assess if a computerized pop-up reminder increased splint application before X-ray in pediatric emergency department patients with deformed upper limb fractures.

This study aimed to investigate whether the mechanical properties of Softcast are sufficient to stabilize a paediatric forearm fracture and protect the patient from further injury against clinically defined failure parameters.

The objectives of this study were to determine how often X-rays are obtained after splinting of non-displaced fractures to identify if postsplinting X-rays change treatment management in the ED, and identify if there are medical complications at follow-up.

The purpose of this investigtion was to evaluate the LOR rate requiring intervention - including either repeat closed reduction or surgical reduction and fixation- following closed reduction and cast immobilization of pediatric greenstick forearm fractures.

The aim of this study is to report the long-term functional outcome of neurological complications associated to pediatric supracondylar fractures.

Wrist torus fractures in children are a frequent reason for Emergency Department (ED) visits. Torus fractures traditionally were treated with a backslab cast in the Children's ED and then referred to the Fracture Clinic. Guidelines were developed in order to standardise the care for children who attended the ED with a torus fracture. All patients who were seen & treated by the Advanced Nurse Practitioner (ANP) over a one year period with a diagnosis of a torus fracture were treated with immobilisation in a softcast. 119 patients met the criteria for inclusion. There were no adverse events recorded and no patient required subsequent visits to the Fracture Clinic. There was a cost savings of 18,596 as compared with the normal referral pathway to the Fracture Clinic.

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

The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluroscoppy in determining successful realignment of pediatric forearm fractures.

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

The purpose of this study was to find out whether below-elbow casts cause equal limitation of pronation and supination but with higher comfort level, compared with above-elbow casts.

The objective of this study was to determine the diagnostic accuracy of pediatric emergency physicians in diagnosing clavicle fractures by bedside ultrasound.

This study aimed to determine whether the use of a prefabricated splint is as effective as a cast in the recovery of physical function.

The objective of this study 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.

Based on the results of a postal questionnaire and a prospective randomised trial, this study descibes a simple treatement for a torus fracture of the distal radius, which saves both time and money.

This publication provies an evidence-based pathway can help prevent this overtreatment, reduce unnecessary radiation exposure and decrease the financial burden on families and the healthcare system.

The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures 47 minutes of emergency department arrival.

To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013).

The objective of our study was to determine if overweight and obesity were associated with increased desaturations during procedural sedation compared with patients of healthy weight.

This study aims to determine whether a pathway designed to facilitate the use of intranasal (IN) fentanyl for long-bone fractures will expedite the delivery of pain medication, decrease the total length of emergency department (ED) stay, and provide faster analgesia compared with intravenous (IV) morphine.

The purpose of this study was to investigate if outcomes or complications differ between two management methods.

Following closed reduction and initial casting of pediatric forearm fractures, loss of reduction (LOR) occurs in 5% to 75% of fractures. We hypothesized that the sugar-tong splint would be an acceptable method for initial immobilization to prevent LOR in distal, mid-shaft, and proximal pediatric forearm fractures.

The primary objective was to determine the accuracy of US, performed by a Dutch EP, compared with conventional radiography, in diagnosing distal forearm fractures in children. As a secondary objective, differences in pain scores during the performance of both US and plain radiography were determined.

Buckle fractures are the most common wrist fractures reported in the paediatric age group. National Institute for Clinical Excellence (NICE) recommends using a non-rigid immobilisation with no follow up for these patients and appropriate discharge advice. A telephone survey was conducted to assess the variation in practice in Irish hospitals regarding the mpediatrianagement of buckle fractures.

The purpose of this study is to determine the predictive value of clinical suspicion for scaphoid fracture in children aged 4 to 11 years, to look at the efficiency and practicality of current management of children presenting to the emergency department, and to help quantify the burden of the treatment strategy of immobilization for 10 to 14 days on clinical grounds despite negative or equivocal x-rays on presentation.

The purpose of this study was to characterize management of supracondylar humerus fractures (SCHFs) at a level 1 trauma center and identify factors contributing to divergence in management from American Academy of Orthopedic Surgeons (AAOS) the Appropriate Use Criteria (AUC) recommendations.

The primary objective of this trial is to assess whether or not the long-term functional outcome in remodeling patients is inferior to patients receiving closed reduction and K-wire pinning.

To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children.

We compared the epidemiology of children's forearm fractures treated with fracture reduction to those not treated with reduction, hypothesizing that high weight status would be significantly associated with need for reduction.

To measure the effectiveness of a set of interventions in improving the rate and timeliness of analgesic medication administration, as well as appropriate backslab immobilization (application of a moldable plaster or fiberglass splint), in a pediatric ED.

Objective: To evaluate the effectivness of the Low Risk Ankle Rule in reducing the frequency of radiography in children with ankle injuries.

Objective: To determine the criterion validity of three rules for predicting clinically important ankle fractures in children.

Objective: To examine the costs and consequences of implementing the Low Risk Ankle Rule.

Objectives: To determine the sensitivity and specificity of the Ottawa Knee Rules when they were applied to children, and to determine post hoc whether use of the rules would reduce the number of knee radiographs ordered.

Objectives: To determine the sensitivity and specificity of the Ottawa Ankle Rules in children and to determine the potential change in x-ray utilization.

To determine the frequency of SH1DF using magnetic resonance imaging (MRI) and compare the functional recovery of children with fractures identified by MRI vs those with isolated ligament injuries.