Injury to the growing skeleton is common as an isolated event and is also seen in the child with multiple injuries. Nearly 1 of 3 children will have at least 1 fracture during childhood. Pediatricians, primary care physicians, orthopedic surgeons, and emergency room personnel often will need to evaluate and treat fractures and other musculoskeletal trauma in children and, therefore, need an understanding of the basic diagnostic and treatment principles. The patterns and incidence depend on a number of variables including sex, age, climate, and time of year. From birth to 16 years of age, 42% of boys and 27% of girls suffer a fracture. Upper extremity fractures account for two-thirds of childhood fractures, with the forearm being the most common location. The vast majority of these injuries are treated in an outpatient setting.
Most orthopedic injuries present with obvious pain and swelling. At times, decreased use of an extremity or limp may be the only presenting signs. Despite challenges in communications with younger children, methodical and directed palpation will often localize the injury. Screening for symmetry during an exam with a focus on range of motion, pain, swelling, and warmth allows the identification of injuries even in the uncooperative or nonverbal patient. When no reasonable history of injury is present, nonaccidental trauma or musculoskeletal infection also should be considered with the presenting signs of pain and swelling.
Radiographs in at least 2 planes (typically anterior/posterior and lateral) should be obtained in cases with significant signs of injury or duration of symptoms. When bony abnormalities are not readily apparent, a close examination of radiographic soft tissue swelling may help to localize an injury and redirect examination. In younger children, occult fractures are common findings. Common occult fracture locations are the lateral malleolus, evidenced by lateral ankle swelling, and the elbow, in which fat pad signs demonstrate a joint effusion (Fig. 215-1A–C). Three weeks of splint or cast immobilization is appropriate treatment for suspected occult fractures. In older children and adolescents, RICE (rest, ice, compression, and elevation) is appropriate for most soft tissue injuries.
A: Anterior and posterior fat pad positions in a normal elbow. B: Elevation of fat pads secondary to elbow effusion as seen in occult fractures. C: Radiograph with anterior and posterior fat pad signs.
Buckle fractures, also called torus fractures because of a shape similar to the base of a decorative column, are characterized by a buckling of 1 side of the bone while ...