Accurate Reporting of Pediatric Fractures A Guide for Orthopedic Consultation Kapi’olani Medical Center For Women And Children’s Emergency Department Children's Orthopaedics of Hawaii, LLC Displaced lateral condyle fracture Avoid giving predictions to the family about Accurate description of the fracture (radial side; capitellum) are intra-articular injuries is the most important factor in determining the need for since they involve the joint surface. These what the orthopedic management will be once immediate orthopedic care. In describing the fracture to commonly require surgery if displaced, but the the orthopedist is involved. Delayed surgical the orthopedic surgeon, please include the following: urgency of the orthopedic referral is based on the intervention or delayed casting is sometimes patient’s neurovascular status. Site of injury : Which bone(s) are affected? the preferred management option. Parents What part is broken? Proximal / Midshaft / Distal may be unhappy with this if they are initially Fracture pattern: Transverse (broken straight across) led to expect immediate intervention. Oblique (slanted or diagonal break) Spiral (“twisted” break) Splinting an extremity is an easy office skill Comminuted (shattered) Non-displaced Early casting may have a higher complication rate Angulation present? (i.e. Is the fracture bent?) lateral condyle compared to later casting. Splinting provides excellent initial fracture Degrees and direction of angulation. care until orthopedic surgery can see the patient. Displacement present? (i.e. Has the fracture shifted?) 1. Obtain splinting material such as Approximate percentage of displacement. plaster, Ortho-glass, Scotchcast, Sam Medial epicondyle fracture: Partially displaced medial (ulnar side) epicondyle Is any shortening present? How much? splint, or even an IV board. Is this fracture open? (skin intact over the fracture) fracture. This is not as serious and can be placed in a splint and referred to orthopedics electively. 2. Cut an appropriate length of Neurovascular status intact? splinting material. Distal radius fracture. 3. Pull out the padding to cover Buckle (or torus) type. the sharp edges of the fiberglass. Minimal angulation. This can be placed in a volar splint and sling. Non-urgent referral to orthopedic surgeon. Fiberglass Fiberglass Angulated edges edges 25 degrees, apex Supracondylar Fractures exposed covered by points to the left padding 1 cm Type I supracondylar (non-displaced) 4. Lay the fiberglass out and apply 25 ° fracture. No Angulated water. Shortened valgus angular 25 degrees AND Displaced by 1 cm deformity. Apply Displaced 80% 50% to the right a posterior elbow splint, sling, and refer to orthopedics. o )20 R 5. Then roll it in a dry towel to C Type II supracondylar remove moisture. fracture. Mid-ulna fracture. Approximately 20 degrees angulation. The apex is AP view shows valgus Optional: You could wrap the pointing toward the volar side (confirm the apex clinically). No angulation (5 degrees). extremity in cast padding or any displacement. Radial head [R] is dislocated (it should be aligned with Lateral view shows the the capitellum [C]). Ulna fractures are frequently associated with radial apex of the angulation fluffy material for extra padding. head dislocation (the Monteggia injury). (30 degrees) pointing However, Ortho-glass and anteriorly. Scotchcast come pre-wrapped in sufficient padding. Type III supracondylar fractures are 6. Here is an example worse, showing greater degrees of valgus of a simple volar forearm deformity and a higher risk for neurovascular splint. Hold the splinting Non-displaced, spiral fracture compromise. material on the volar surface of the mid-femur. This view of the forearm rolling the shows minimal angulation. distal end in the palm. Elbow 7. Roll an elastic ossification wrap over the centers can resemble fracture forearm and splint. The splint material Other views are needed to fragments. This X-ray determine angulation in other shows all the will mold to fit the planes. ossification centers extremity nicely. in the elbow which ossify in the sequence CRITOE: (C) capitellum (R) radial head Comminuted (I) internal epicondyle (shattered, multiple (T) trochlea fragments) of the (O) olecranon DONE !! distal tibia. No (E) external angulation. epicondyle Other splint types: Apply splint material, then roll an elastic bandage Salter-Harris fractures over this. The splint material will mold nicely to fit the extremity. involve the physis (growth Transverse fracture of plate) of long bones. Types the distal radius which 1, 2, 3, 4, 5 are diagramed is 100% displaced, here. Since the physis is shortened (over- not ossified, a fracture riding) approximately through the physis cannot 2 cm, and angulated Rad be visualized on X-ray with the apex of the easily. angulation pointed toward the ulnar side of the forearm. The Non-displaced distal ulna fracture with 20 distal ulna is fractured degrees of angulation. The apex of the in two places. The angulation points toward the radial side of epiphysis of the ulna the forearm. Salter-Harris type II fracture (arrow) is displaced Ulna of the distal radius involving the Volar forearm splint (behind the radius on the lateral view). There is also a “greenstick” metaphysis into the physis. There is a Posterior elbow splint fracture of the distal 1/4th of the ulna which is angulated slight degree of angulation with the apex Sugar tong elbow splint approximately 20 degrees with the apex pointing toward the ulnar and point toward the radial side of the dorsal sides of the forearm. Posterior short leg ankle splint forearm. Stirrup or sugar tong ankle splint For more fracture images, info, and downloadable copies of this poster, visit: www.hawaii.edu/medicine/pediatrics.