Common Orthopedic Injuries in the Pediatric ED Part II
Common Orthopedic Injuries in the Pediatric ED – Part II
Authors:
Lilliane M. Sarraff, MD, Fellow, Department of Emergency Medicine, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA.
Christopher J. Haines, DO, FAAP, FACEP, Assistant Professor of Emergency Medicine and Pediatrics, Drexel University College of Medicine; Director, Department of Emergency Medicine and Medical Director, Critical Care Transport Team, St. Christopher's Hospital for Children, Philadelphia, PA.
Peer Reviewer:
John Santamaria, MD, FACEP, Affiliate Professor of Pediatrics, University of South Florida School of Medicine, Tampa, FL.
Although lower extremity fractures are much less common than upper extremity fractures in children, the correct diagnosis and management of this type of injury is critical. In the second part of this series the authors review common lower extremity fractures, fractures common in abused children and the diagnosis and treatment of radial head subluxation. Children are much more likely to sustain fractures rather than ligamentous injuries and identification of injuries and timely management will maximize an optimal outcome. Awareness of certain unique pediatric fractures such as the triplane juvenile fracture and the juvenile Tillaux fracture will allow for prompt treatment and referral. The authors also provide a table encompassing guidelines for ED management and treatment of common pediatric orthopedic injuries. (See Table 1.)
The Editor
Table 1. Guidelines for ED Management and Treatment / Splinting of Common Pediatric Orthopedic Injuries
Fracture Type Radiograph Views ED Management Treatment/Splint
|
Upper Extremity and Clavicle |
|||
|
Clavicle |
AP, cranial/caudal tilt view |
Outpatient follow up unless fracture is open, neurovascular injury, significant degree of angulation and/or displacement >2 cm in older child |
Sling (1-4 wks) or figure of eight wrap; orthopedic follow-up for children who participate in athletics |
|
Elbow Supracondylar (Gartland) Type I Types II & III Lateral condyle |
AP in extension, lateral with 90° of flexion, oblique AP in extension, lateral with 90° of flexion, oblique AP in extension, lateral with 90° of flexion, oblique |
Outpatient follow up Orthopedic consultation Closed or open reduction Inpatient orthopedic management; surgical repair |
Posterior long arm splint with the elbow in 90° of flexion with forearm in a neutral position; orthopedic follow up within 3-5 days Long arm immobilization while waiting for orthopedic consultation Long arm immobilization while waiting for orthopedic consultation |
|
Distal radius/ulna fracture Night stick (Midshaft ulnar fracture) |
Wrist AP, lateral (+/- forearm and elbow) Forearm: AP and lateral (+/- elbow, wrist) |
Outpatient follow up unless fracture is open, neurovascular injury, orthopedic consultation for significant displacement, angulation > 10° (> 6 years), angulation > 15° (< 6 years of age) Outpatient follow up unless fracture is open, neurovascular injury, angulation > 10° (> 6 years of age), angulation > 15° (< 6 years of age); orthopedic consultation for angulation > 10 |
Volar splint with a sling Orthopedic follow up in < 1-2 weeks Posterior long arm splint Orthopedic follow up in < 1-2 weeks |
|
Monteggia (Ulnar fracture with radial head dislocation) |
Forearm: AP and lateral Elbow views, (+/-wrist) |
Orthopedics consult Closed or open reduction |
Long arm immobilization while waiting for orthopedic consultation |
|
Galeazzi (Radial shaft fracture with disruption of the radioulnar joint) |
Forearm: AP and lateral (+ elbow, wrist) |
Orthopedic consultation Closed reduction |
Long arm immobilization while waiting for orthopedic consultation |
|
Colles (Distal radius fracture with dorsal displacement of the distal segment and volar angulation) |
Forearm: AP and lateral (+ elbow, wrist) |
Outpatient follow up unless fracture is open, neurovascular injury, rotational deformity, >40° angulation, severe displacement; If not suitable for outpatient care, orthopedic consultation for closed or open reduction |
Long arm posterior or sugar tong splint Orthopedic follow up in 3-5 days If orthopedic consultation is required, long arm immobilization while waiting for orthopedics |
|
Smith (Distal radius fracture with volar displacement of the distal segment and dorsal angulation) |
Forearm: AP and lateral (+/- elbow, wrist) |
Outpatient follow up unless fracture is open, neurovascular injury, rotational deformity, >10° angulation, severe displacement; if not suitable for outpatient care, orthopedic consultation for closed or open reduction |
Long arm posterior or sugar tong splint; orthopedic follow up in 3-5 days If orthopedic consultation is required, long arm immobilization while waiting for orthopedics |
|
Lower Extremity |
|||
|
Toddler Fracture (Spiral tibial shaft fracture) |
AP, and lateral (+/- oblique views) |
Outpatient follow up unless fracture is open, neurovascular injury |
Long leg posterior splint; orthopedic follow up in 3-5 days |
|
Femur |
AP, lateral + knee and pelvis |
Immediate orthopedic consultation |
Immobilization while waiting for orthopedics; consider traction techniques |
|
Ankle |
|||
|
Triplane Juvenlle Fracture (Complex tibial physis fracture occurring in three planes) |
AP, lateral, mortise (+ CT scan) |
Immediate orthopedic consultation |
Short or long immobilization while waiting for orthopedics; short or long leg immobilization |
|
Juvenile Tillaux Fracture (Salter-Harris type III fracture of the distal tibia) |
AP, lateral, mortise (+ CT scan) |
Immediate orthopedic consultation |
Short or long leg immobilization while waiting for orthopedics |
Additional Notes:
- Any NV injury, deficit, open or multiple fractures should be evaluated in the ED by orthopedics.
- If orthopedics consultation is required or patient is being transferred to a tertiary care facility for further management (sedation with reduction or operative repair), the patient should be made NPO.
- Patients with suspected fractures should receive medication for pain control as soon as feasibly possible. Patients with obvious deformity should receive expedited pain control utilizing IV or institution specific medication regimens.
- Radiographic imaging should generally include the joint above and below.
- Splinting of the joint above and below will provide the optimal patient comfort and decreased the likelihood of additional injury.
- Fractures that should raise suspicion for non-accidental trauma include:
○ Posterior rib fractures, metaphyseal bucket handle or corner fractures, bilateral long bone fractures, complex skull fractures, and spinous process fractures
Physeal Fractures
Salter Harris Description ED Management Treatment
|
I Fracture through the physis |
Immobilization, ice, elevation and outpatient referral; orthopedic consultation for any displacement |
Orthopedic follow up in < 1 week |
|
II Fracture through the physis and metaphysis |
Immobilization, ice, elevation and outpatient referral with minimal displacement Orthopedic consultation if significant displacement |
Orthopedic follow up in < 1 week unless significant displacement needing closed or open reduction |
|
III Fracture through physis and epiphysis (intra-articular) |
Immobilization, ice, elevation, orthopedic consultation |
Management per orthopedics, may required closed or open reduction |
|
IV Fracture through the epiphysis, physis, and metaphysis (intra-articular) |
Immobilization, ice, elevation, orthopedic consultation |
Management per orthopedics, may required closed or open reduction |
|
V Physeal crush injury |
Immobilization, ice, elevation, orthopedic consultation |
Management per orthopedics, may require operative intervention |
Subluxation of Radial Head
|
Reduction Type |
Technique |
|
Supination/pronation reduction |
Hold the elbow of the affected extremity with one hand while the thumb of the hand palpates the radial head. Simultaneously, use the opposite hand to supinate the wrist and then completely move the elbow into a flexed position. |
|
Hyperpronation/flexion reduction |
This method is performed in a similar fashion to the supination/flexion technique; however, the forearm of the child is moved into a hyerpronated position and then the elbow is moved into a flexed position. |
Introduction
Fractures of the lower extremities in pediatrics occur less commonly than fractures to the upper extremities. Tibial and fibular diaphyseal fractures are the most common pediatric lower extremity fractures,1 and fractures of the femur and ankles are less common. The mean age of presentation for lower extremity fractures is 8 years of age.2,3
Clinical Presentation. Most lower extremity fractures in children result from high-energy traumatic mechanisms such as recreational activities and sports. Children with lower extremity fractures are usually older, and as a result are able to localize their pain. In addition to localized pain, children with lower extremity fractures will frequently present with swelling, deformity, and an inability to bear weight.
Femoral Shaft Fractures
Femur fractures are common in pediatric patients. They occur most commonly in the femoral shaft (> 60%).4,6 The mechanism of injury is variable and differs based upon age and the amount of energy involved. The energy needed to sustain a femur fracture is generally moderate to high. The most common mechanism by age includes the following: falls (1-5 years), pedestrian injury (6-9 years), and motor vehicle collisions (adolescents).4-6 In addition, any femur fracture occurring in a child younger than 2 years of age should raise the clinician's suspicion for nonaccidental injury.
Physical Exam. Pediatric patients with femur fractures will present with moderate to severe pain, which is dependent upon the extent of fracture. Generally, children will be unable to walk, and will present with significant deformity at the site. Physical exam should focus on neurovascular status as well as an assessment for an open versus closed fracture. Although femur fractures may result in a moderate amount of blood loss, an isolated closed shaft fracture should not result in an acute drop in hematocrit levels. Any sign of hemodynamic instability associated with femur fracture should prompt a search for additional sources of blood loss.4-6
Imaging. Patients with suspected femur fracture should be evaluated with anteriorposterior and lateral radiographic views of the femur. In addition, both knee and pelvis film should also be obtained. (See Figure 1.)
Figure 1. Femoral Shaft Fracture
Image courtesy of St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Management. The initial ED treatment should include pain management, immediate immobilization, and orthopedic consultation. Treatment of femur fractures varies by age group as well as type of fracture. This includes casting with traction or immediate operative fixation using internal or external devices.5 Newborns and infants (< 6 months of age) with femur fractures often can be treated successfully in a Pavlik harness, whereas children between the ages of 6 months and 5-8 years are usually immobilized with a spica cast. The treatment options for older children include external skeletal traction, external fixation, and internal fixation.
Toddler Fracture
Dunbar and colleagues first described a toddler fracture in 1964. It was described as a subtle, non-displaced, oblique fracture of the distal tibia in children 9 months to 3 years of age.2,4,5 This fracture is the result of rotational injury to the lower leg (tibia) and does not usually involve the fibula.
Mechanism of Injury. The mechanism of injury is frequently unknown or unwitnessed, as this fracture occurs in children who are mobile with minimal verbal ability. In cases in which the mechanism is known, the injury is often the result of a fall involving the lower extremity with an associated twisting component.2,4,5
Clinical Presentation. The majority of children with this fracture type present to the emergency department (ED) with a limp or refusal to bear weight. Clinical signs of this injury may be subtle, and include minor swelling, pain with range of motion, and tenderness with palpation.4,5
Imaging. A patient with a suspected toddler fracture should be evaluated with anteroposterior and lateral radiographic views of the tibia and fibula. In addition, if there is a high degree of suspicion with physical exam, oblique views of the tibia should be obtained, as this may be the only view in which a fracture is visible.1,2,4,5 A fracture consistent with this pattern appears as a non-displaced spiral fracture of the tibial metaphysis. (See Figure 2.) If radiographic evaluation is negative for fracture, a nuclear bone scan may be used as an adjunct in certain clinical settings.
Figure 2. Toddler Fracture
Image courtesy of St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Management. Initial ED management includes pain management and immobilization. The preferred method of immobilization for a child with a known or suspected toddler fracture is a short or long leg cast for 3-4 weeks.4 In circumstances where immediate casting is unavailable, posterior short or long leg splinting will serve as a bridge until orthopedic follow-up is available. These fractures are stable, and the resultant treatment is completed mainly for comfort. This fracture type is completely healed in 3-4 weeks.
Ankle Fractures
Ankle injuries are among the most common orthopedic injuries seen in the ED. They commonly occur as a result of sports injuries and high-velocity non-motorized vehicles (skateboards, scooters). In comparison to the typical pattern of ankle sprain in older adolescents/adults, children with open growth plates tend to sustain fractures secondary to ligamentous strength being greater than bone strength.7-9 In skeletally immature children, the most common acute injury of the ankle is a Salter-Harris type I fracture of the distal fibula.9
Anatomy. The ankle joint consists of three bonesthe tibia, fibula, and talus. It is a true mortise joint, and moves only in one plane (plantar flexion to dorsiflexion).8-10 The talar dome is wedge-shaped, with the anterior aspect of the talus being wider than the posterior aspect. When dorsiflexed, the ankle is more stable and allows for less rotation because the wider anterior aspect of the talus is engaged within the mortise. When in plantar flexion, the posterior, narrow aspect of the talus becomes engaged in the ankle mortise with resultant vulnerability to crushing and twisting injuries.8 The distal tibial physis begins to appear at 6-24 months of age and asymmetrically ossifies at approximately 14 years of age.
Salter Harris Type I Fracture of Distal Fibula
This fracture type represents 5% of all pediatric fractures and 15% of all physeal injuries.11 Fractures of the distal fibula and tibia occur most commonly in children between the ages of 10 years and 15 years, with the incidence higher among males. The mechanism of injury for this fracture is commonly supination and inversion of the foot and ankle.7
Physical Exam. Children with a distal fibular Salter-Harris type I fracture present with swelling and tenderness in the region of the lateral malleolus.8-10 Specifically, children will have point tenderness over the fibular growth plate (approximately 2-3 centimeters above the tip of the malleolus). In addition to tenderness, they will have difficulty bearing weight on the affected extremity.
Imaging. Radiographs for the evaluation of suspected distal fibular fracture should include anteroposterior, lateral, and mortise views. Additionally, radiographs of the tibia, fibula, and foot may be needed to assess for associated fractures. As with other Salter-Harris type I fractures, radiographic views of the ankle may not display a visible fracture. However, radiographs will show soft tissue swelling adjacent to the physis and/or a slight widening of the physis.10 As a result of the typical pattern of minimal radiographic findings, skeletally immature children presenting with distal fibular point tenderness should be treated as a Salter-Harris type I fracture.4,8,10
Management. The initial ED management should include pain control and immobilization with a short leg posterior splint. In addition, these patients should be referred to orthopedics as outpatients and given instructions for non-weight-bearing on the affected extremity. At follow-up with orthopedics, these patients will be immobilized with a short leg walking cast. Any patient with angulation or displacement should have an orthopedic consultation. This casting will generally be left in place until the child is able to bear weight without pain.42
Triplane Juvenile Fractures
A triplane fracture is a unique physeal injury that occurs during the closure of the growth plate. The fracture pattern is directly dependent upon a combination of force applied and the degree to which the growth plate is open. This fracture type occurs when the medial physis of the tibia is closed, usually around 12-14 years of age. It is called "triplane" because the injury has three components (coronal, sagittal, and transverse). (See Figures 3-4). Physical exam findings consistent with this fracture include significant pain and extensive swelling with an associated inability to bear weight on the affected side. Initially, standard radiographs of the ankle should be obtained. However, additional computed tomography (CT) imaging with three-dimensional reconstruction is frequently necessary to define the exact fracture configuration.7,36,38,42-44 (See Figures 5-6.) The treatment of triplane fractures includes immediate orthopedic consultation for operative repair followed by immobilization.
Figure 3. Triplane Juvenile Fracture, AP View
Image courtesy of Archana Mallick, MD, St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Figure 4. Triplane Juvenile Fracture, AP View
Image courtesy of Archana Mallick, MD, St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Figure 5. Triplane Juvenile Fracture, CT Coronal View
Image courtesy of Archana Mallick, MD, St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Figure 6. Triplane Juvenile Fracture, CT Sagittal View
Image courtesy of Archana Mallick, MD, St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Juvenile Tillaux Fracture
A juvenile Tillaux fracture is a Salter-Harris type III fracture of the distal tibia. This fracture tends to occur in older adolescents during the closure of the distal tibial physis. (See Figures 7-8.) It occurs when the anteroinferior tibiofibular ligament avulses a fragment of bone corresponding to the portion of the distal tibial physis that is still open. On physical exam, these patients will have significant swelling and tenderness at the anterior lateral joint line. As this is a complex ankle fracture similar to the triplane fracture, CT scan imaging (Figure 9) is often needed to evaluate the degree of displacement and extent of fracture.7,36,38,42-44 Immediate orthopedic consultation should be obtained; provide pain medication and immobilization while waiting for orthopedics.
Figure 7. Juvenile Tillaux Fracture, AP View
Image courtesy of Archana Mallick, MD, St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Figure 8. Juvenile Tillaux Fracture, Oblique View
Image courtesy of Archana Mallick, MD, St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Figure 9. CT of Juvenile Tillaux Fracture
Image courtesy of Archana Mallick, MD, St. Christopher's Hospital for Children Radiology Department, Philadelphia, PA
Other Pediatric Considerations
Nonaccidental Fractures. Fractures are a common presentation of nonaccidental trauma and the astute clinician should always include this mechanism as a cause for injury. When evaluating fractures, the clinician should consider the age of presentation, mechanism, and fracture type, as certain patterns may be consistent with possible nonaccidental injury. Specifically, fractures in a child younger than 1 year of age or a child who is not ambulatory should prompt additional investigation and raise a concern for nonaccidental trauma.12 In addition, specific patterns, including posterior rib fractures, metaphyseal bucket-handle or corner fractures (see Figure 10), bilateral long bone fractures, complex skull fractures, and spinous process fractures should raise suspicion for nonaccidental injury.7 In regard to the mechanism of injury, nonaccidental injury should be considered in cases in which a detailed history of the mechanism of injury is inconsistent with the history or the child's developmental stage. (See Table 2.)
Figure 10. Corner Fracture and Bucket Handle Fracture
Corner fracture of left distal femur metaphysis
Right distal humerus bucket handle fracture
Yamamoto L, Inaba A, DiMauro R. Radiology cases in Pediatric Emergency Medicine. Medical Center for Women and Children, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine 1996; Vol. 4, Case 2. Available at www.hawaii.edu/medicine. Used with permission
Table 2. Signs of Possible Non-accidental Injury
Classic red flags for non-accidental injury in the history include:
- Changing details with the caretaker's repetition of the story
- Details inconsistent with findings on physical exam:
► Findings of additional injuries or more severe injuries than described
► Injuries described as self-inflicted or inflicted by another child
► Injuries not compatible with developmental stage of the child
- Significant lapse in seeking care for injuries
- Seeking care at different health care facilities with each presentation
Classic red flags for non-accidental injury on physical exam include:
- Multiple injuries and multiple types of injuries at different stages of healing
- Poor hygiene or poor caretaker-child interaction
- Pathognomonic injuries:
► Posterior rib fractures
► Spiral fractures (non- ambulatory children)
► Metaphyseal fracture (bucket handle), scapular and spinous process fractures
► Sternal fractures
- Patterned injuries:
► Hand imprint
► Cigarette burns
► Grill marks or loop marks
Radiography. For any child younger than 2 years of age who is potentially abused or has a suspicious fracture, a complete skeletal survey is required. A single film such as a "babygram" (an anteroposterior view of the entire child on one film) is not an acceptable alternative, because it may miss more subtle evidence of child abuse. A skeletal survey consists of the following: AP and lateral views of the extremities in total, AP and lateral views of thoracolumbar spine, and AP and lateral views of the skull. Optimally, all positive findings should be evaluated in at least two planes and additionally, oblique views may be necessary to reveal a suspected fracture not apparent on the biplane views.
Radionuclide skeletal scintigraphy (bone scan) may be useful as a screening tool for child abuse, secondary to its sensitivity for rib, spine, and subtle diaphyseal trauma, which may not be evident on plain films. As with any diagnostic test, bone scanning has limitations in that symmetric fractures and epiphyseal-metaphyseal fractures can be missed. Another future potentially useful tool to evaluate the injuries of abuse is ultrasonography, especially for areas with incomplete ossification.
Radial Head Subluxation. Also known as "nursemaid's elbow," radial head subluxation is the most common upper extremity injury in children younger than 6 years of age. The peak incidence occurs between 1 year and 3 years of age. Although this injury occurs most commonly in toddlers it may occur from infancy into the early school-age years.1,14 The typical mechanism of injury is abrupt longitudinal traction on a pronated wrist or hand with resultant sliding of the annular ligament over the radial head.14 This results in the interposition of the annular ligament between the radial head and capitellum.12 Although this is the most common mechanism, the astute ED physician should include this injury in their differential diagnosis, as children will frequently present with an unknown mechanism with associated decreased use of the affected extremity.
The diagnosis of radial head subluxation is clinical and may be made with a careful history and physical examination. Children with this injury type will generally present without tenderness or swelling. However, when present, tenderness or swelling should increase the clinician's suspicion for fracture. When being evaluated for possible radial head subluxation, the child will frequently hold the affected arm close to the body and resist attempts to move it.1 In addition, children presenting with this injury will appear to have minimal pain when resting comfortably. Initially, the evaluating physician should approach the child in a gentle, non-threatening fashion and without movement of the elbow examine for and exclude point tenderness. After exclusion of point tenderness, the extremity should be assessed for signs of swelling which is not typical of a nursemaid's elbow.
The classic reduction technique is the supination/flexion procedure. The provider performs this procedure by initially holding the elbow of the affected extremity with one hand while the thumb of this hand palpates the radial head. Simultaneously, the provider utilizes the opposite hand to supinate the wrist and then completely move the elbow into a flexed position. Published success rates for the supination/flexion method of reduction range from 80% to 92%.14 An alternative method is the hyperpronation/flexion procedure. This method is performed in a similar fashion to the supination/flexion technique; however, the forearm of the child is moved into a hyerpronated position and then flexed. Published studies examining the success rate of this technique have displayed a successful reduction rate as high as 97%. In addition, the hyperpronation technique has been shown to be effective when the supination/flexion technique has failed.14 During reduction attempts, providers should feel the classic click of the radial head sliding into the annular ligament. If the reduction has been successful, a child should begin using his or her arm within a few minutes.
As the diagnosis of radial head subluxation is clinical, radiographic imaging is not routinely necessary. However, if the history and physical examination are consistent with radial head subluxation and repeated attempts at reduction have failed, radiographic evaluation should be completed. If the radiographic evaluation is negative for fracture, the child should be placed in a posterior long arm splint and have orthopedic follow-up arranged within 24 to 72 hours.12,14
Recurrence of radial head subluxation is not uncommon. Parents should receive education regarding the mechanism of injury and instructions regarding avoidance of utilizing extremities as a means to pick a child up.
Conclusion
Pediatric fractures are commonplace in the ED. Emergency physicians should be aware of the difference in pediatric anatomy and fracture patterns, common pitfalls, and need for the careful assessment of neurovascular status. Although some injuries may require orthopedic consultation with procedural sedation and reduction or operative repair, the skilled emergency physician can successfully manage the majority of pediatric fractures.
References
1. England SP, Sundberg S. Manage-ment of common pediatric fractures. Pediatr Clin N Am 1996; 43:991-1012.
2. Gholve, PA. Lower Extremity Fractures. In: Kielgman RM, et al, eds. Nelson's Textbook of Pediatrics. 18th ed. Philadelphia: Saunders; 2007:682.
3. Mubarak SJ, Kim JR, Edmonds EW. Classification of proximal tibial fractures in children. J Child Orthop 2009;3:191-197.
4. Hart ES, Luther B, Grottkau BE. Broken bones: Common pediatric lower extremity fractures-Part III. Orthopaed Nurs 2006;25:390-407.
5. Thompson GH. Fractures of the Tibia and Fibula. In: Green NE, Swiontkowski ME, eds. Skeletal Trauma in Children. 4th ed. Philadelphia: Elsevier; 2008:405-576.
6. Loder RT, O'Donnell PW, Feinberg JR. Epidemiology and mechanisms of femur fractures in children. J Pediatr Orthop 2006; 26:561-566.
7. LaBella CR. Common acute sports-related lower etremity injuries in children and adolescents. Clin Ped Emerg Med 2007;8:31-42.
8. Crawford A. Fractures and Dislocations of the Foot and Ankle. In: Green NE, Swiontkowski ME, eds. Skeletal Trauma in Children. 4th ed. Philadelphia: Elsevier; 2008:16:507-584.
9. Polyzois VD, Vasiliadis E, Zgonis T. Pediatric fractures of the foot and ankle. Clin Podiatr Med Surg 2006;23:241-255.
10. Malanga GA, Ramirez-Del Toro JA. Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am 2008;19:347-371.
11. Overly F, Steel DW. Common pediatric fractures and dislocations. Clin Ped Emerg Med 2002;3:106-117.
12. Della-Giustina K, Della-Giustiina DA. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 1999;17:895-922.
13. Mathison JD, Agrawal D. General principles of fracture management: Fracture patterns and description in children. www.uptodate.com/home/index.html. Accessed June 14, 2010.
14. Carson S, Woolridge DP, Colletti J, et al. Pediatric upper extremity injuries. Pediatr Clin N Am 2006;53:41-67.
Although lower extremity fractures are much less common than upper extremity fractures in children, the correct diagnosis and management of this type of injury is critical. In the second part of this series the authors review common lower extremity fractures, fractures common in abused children and the diagnosis and treatment of radial head subluxation. Children are much more likely to sustain fractures rather than ligamentous injuries and identification of injuries and timely management will maximize an optimal outcome. Awareness of certain unique pediatric fractures such as the triplane juvenile fracture and the juvenile Tillaux fracture will allow for prompt treatment and referral. The authors also provide a table encompassing guidelines for ED management and treatment of common pediatric orthopedic injuries.Subscribe Now for Access
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