Clavicles are commonly fractured in children, and may occur in newborns during difficult deliveries, presenting in neonates with nonuse of the arm. If the fracture was not initially appreciated, parents may notice a bony callus at age 2 to 3 weeks. In older infants and children, the usual mechanism is a fall onto the outstretched arm or shoulder. Care of the patient with a clavicle fracture is directed toward pain control. Even displaced fractures usually heal well, although patients may have a residual bump at the fracture site. A simple sling is effective and less painful than other methods of clavicle immobilization. Newborns require no specific treatment. Orthopedic consultation in the emergency department (ED) is required for an open fracture (which also requires antibiotics), displacement of the medial clavicle, or a skin-tenting fracture fragment that has the potential to convert to an open fracture. Otherwise, routine follow-up with the PCP is usually adequate.
Supracondylar and Condylar Fractures
The most common elbow fracture in childhood is the supracondylar fracture of the distal humerus. The mechanism is commonly a fall onto the outstretched arm. Children complain of pain on passive elbow flexion and hold the forearm pronated. The close proximity of the brachial artery to the fracture predisposes the artery to injury. Subsequent arterial spasm or compression by casts may further compromise distal circulation. A forearm compartment syndrome (resulting in Volkmann ischemic contracture) may occur.
Radiographs show the injury, but the findings may be subtle. Type I fractures have no displacement or angulation, or may have a posterior fat pad as the only radiographic manifestation of a fracture. Confirmation of a fracture may be seen on an x-ray taken 2 to 4 weeks later, when a periosteal reaction is visible. Type II fractures are angulated, but the posterior cortex is intact, while type III fractures are completely displaced with no cortical contact.
In cases of neurovascular compromise, immediate fracture reduction is indicated. If an ischemic forearm compartment is suspected after reduction, surgical decompression or arterial exploration may be indicated. Outpatient treatment is acceptable for type I fractures after appropriate immobilization. Such children need orthopedic reassessment within 2 to 7 days. Orthopedic consultation and admission is recommended for patients with type II or III fractures. Open reduction with operative pinning is usually required.
Lateral and medial condylar fractures and intercondylar and transcondylar fractures carry risks of neurovascular compromise, especially to the ulnar nerve. These patients have soft tissue swelling and tenderness while maintaining the arm in flexion. Depending on the displacement visualized on x-ray, patients may require open reduction.
Radial Head Subluxation (“Nursemaid’s Elbow”)
Radial head subluxation is a very common injury seen most often in children 1 to 4 years of age. The typical history is that the child was lifted or pulled by the hand or wrist, though 50% have no such history and parents may report a fall or simply that their child refuses to use the arm. The arm is held in adduction, flexed at the elbow, with the forearm pronated. Gentle examination demonstrates no tenderness to direct palpation, but attempts to supinate the forearm or move the elbow cause pain. If the history and examination are strongly suggestive, radiographs are not needed. However, if the history is atypical or there is point tenderness or signs of trauma, radiographs should be obtained.
There are two maneuvers for reduction. The first, the supination/flexion technique, is performed by holding the patient’s elbow at 90° with one hand and then firmly supinating the wrist and simultaneously flexing the elbow so that the wrist is directed to the ipsilateral shoulder. There may be a “click” with reduction, and the child may transiently cry and resist. The second, the hyperpronation technique, is reported to be more successful. The hyperpronation technique is performed by holding the child’s elbow at 90° in one hand and then firmly pronating the wrist while extending the elbow. Usually the child will resume normal activity in 5 to 10 minutes if reduction is achieved. If the child is not better after a second reduction attempt, alternate diagnoses and radiographs should be considered. No specific therapy is needed after successful reduction. Parents should be reminded to avoid linear traction on the arm because there is a risk of recurrence.
Torus fractures, also called buckle fractures, are among the most common pediatric bony injuries and may occur in the radius or ulna. Treatment consists of pain management with NSAIDs, application of a volar splint, and follow-up with the PCP or orthopedics in 1 to 3 weeks.
Fractures of the Radial and Ulnar Shafts
Any metaphyseal fracture with rotational deformity or more than 10 degrees of angulation in children above 8 years of age, or more than 15 to 20 degrees in younger children, requires consultation with an orthopedist to determine the need for reduction. Otherwise, immobilization in a splint with follow-up with orthopedics within 1 week is adequate treatment.
Most diaphyseal forearm fractures warrant urgent orthopedic consultation. Transverse fractures of one or both bones may remain unstable despite attempts at closed reduction. Two fracture-dislocation injuries with especially guarded prognoses are an ulnar fracture with a radial head dislocation (Monteggia’s fracture) and a radial shaft fracture with distal radioulnar joint dislocation (Galeazzi’s fracture).
Carpal bone injuries are rare in young children, and gain frequency in older children and adolescents, when athletic pursuits generate greater force. The scaphoid fracture requires a high index of suspicion. Snuffbox tenderness and tenderness of the lateral wrist with axial compression of the thumb warrant application of a thumb spica splint and follow-up with an orthopedist, even when radiographs show no scaphoid fracture.
Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis (SCFE) is more common in obese children, with a peak incidence between ages 14 and 16 years (11 and 13 years in girls). Clinically, the child presents with pain at the hip or referred to the thigh or knee. With a chronic SCFE, children complain of dull pain in the groin, anteromedial thigh, and knee, which becomes worse with activity. With walking, the leg is externally rotated and the gait is antalgic. Hip flexion is restricted and accompanied by external rotation of the thigh. Acute SCFE is due to trauma or may occur in a patient with preexisting chronic SCFE.
The differential includes septic arthritis, toxic synovitis, Legg–Calvé–Perthes disease, and other hip fractures. Children with SCFE are not febrile or toxic and have normal white blood cell counts and erythrocyte sedimentation rates. Obtain bilateral hip radiographs in any adolescent with hip pain. Bilateral anteroposterior and frog-leg lateral radiographs of the hips are preferred. Medial slips of the femoral epiphysis will be seen on anteroposterior views, whereas frog-leg views detect posterior slips. In the anteroposterior view, a line along the superior femoral neck should transect the lateral quarter of the femoral epiphysis, and will not if the epiphysis is slipped.
The management of SCFE is operative. Immediate non-weight-bearing upon diagnosis is important and admission for surgical pinning is typical. The main long-term complication is avascular necrosis of the femoral head and premature closure of the physis.
All femoral shaft fractures should prompt emergent orthopedic consultation. In infants and nonambulatory children with femoral fractures, evaluation for nonaccidental trauma is warranted. In young children who are injured, femur fractures rarely cause hypotension. When hypotension is present, searching for another serious hemorrhagic injury is key.
Fractures of the Distal Femoral Physis
Fractures through the distal femoral physis are uncommon yet carry a significant complication rate. The popliteal artery lies close to the distal femoral metaphysis and may be injured along with the peroneal nerve. In these cases, immediate orthopedic evaluation is needed.
Often, there is a history of the kneecap “popping” out of place. Reduction is performed by extending the affected knee while gently “lifting” the patella medially into place. After reduction, radiographs are obtained to evaluate for fracture. A knee immobilizer and crutches are provided, and follow-up is with orthopedics.
The toddler’s fracture is an isolated spiral fracture of the distal tibia in a toddler. The typical mechanism is external rotation of the foot with the knee flexed. Clinically, there is often refusal to bear weight, and usually pain with palpation and rotation of the distal tibia, although swelling may be minimal or absent and occasionally there is no tenderness. Obtain radiographs with standard and oblique views of the leg in the limping toddler, even in the absence of physical examination findings. Radiographically, a fracture line may be noticed at the distal third of the tibial shaft. If a toddler’s fracture is clinically suspected and initial radiographs are negative, immobilization and no immobilization are both management options with follow-up in 1 week for repeat x-rays and/or bone scan or MRI. The leg should not be in a circumferential cast if the diagnosis is not clear. For fractures evident on radiograph, immobilize the leg in a long leg splint or above knee cast with adequate flexion for car seat use and provide orthopedic follow-up within 72 hours for definitive casting if not done in the ED.
Distal tibial Salter–Harris types I and II fractures are the most common tibial fractures in children. If any significant displacement is evident, closed reduction and immobilization are usually sufficient ED management. The Salter–Harris type III fracture of the distal tibia typically requires open reduction when there is displacement. The Tillaux fracture is a Salter–Harris type III fracture through the anterolateral physis: it is usually managed surgically. The triplane fracture is a Salter–Harris type IV fracture. A computed tomography scan is warranted, and management is usually surgical.
Most nondisplaced fractures of the metatarsals and phalanges can be managed by immobilization in a posterior short-leg splint and follow-up with an orthopedist. Significantly displaced fractures of the metatarsals and phalanges, as well as those of the great toe, that have intra-articular involvement may require fixation, although this can typically be done on an outpatient basis. Fractures of the base of the fifth metatarsal are common with inversion injuries of the ankle as in adults. The evaluation of ankle injuries should therefore include radiographs of the foot when there is tenderness over the fifth metatarsal bone.