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Top 10 Things to Know about Pediatric Fractures

Top 10 Things to Know about Pediatric Fractures

by | Oct 31, 2022 | Fractures

These are key messages from a lecture provided as part of a free, monthly education series offered for Medical Professionals. Gerad Montgomery, M.S.N., FNP-C, is a certified family nurse practitioner and director of the Scottish Rite for Children Orthopedics Fracture Clinic in Frisco, Texas.

Download the PDF.
 
Watch Top 10 Things to Know about Pediatric Fractures on-demand.
 
Alternatively, you can access the full pediatric fracture care lecture on our Medical Professionals playlist where he also addresses questions from the audience including these:

  • What are your thoughts on the use of X-rays or advanced imaging in an urgent care or outpatient setting before sending to a pediatric musculoskeletal expert?
  • Would you recommend putting in a hematoma block for pain control before referring to a specialist?
  • Do you have guidelines for return-to-sport or load management after fracture?
  • What do you tell parents that wonder if their child needs an X-ray?

#10 A Methodical Exam Is Your Best Tool 

Perform a methodical exam every time, the same way. It may not be easiest, but it is the best tool.

  • X-rays and history should augment a good step-by-step physical exam.
  • Age-appropriate exam may include the parent assisting to help maintain comfort.
  • Encourage pointing to the injured area with “one finger at one spot.”
  • Then, examine the contralateral side first.
  • Always examine the joint above and below.

#9 Don’t Miss Signs of a Non-accidental Trauma  

More than half of children who die from non-accidental trauma have a history of prior maltreatment. Know your resources and obligations. Listen closely to the story and vigilantly observe for signs and red flags such as:

  • Inconsistent history
  • Unwitnessed trauma
  • Fracture doesn’t match story (i.e., femur fracture in non-ambulatory child)
  • Multiple fractures in various stages of healing – skeletal survey
  • Skin stigmata – bruises, burns

#8 X-Ray Views Matter

Poor alignment during X-rays can cause you to miss a fracture. Despite the patient’s discomfort, it is important to insist on good alignment and at least two views.
 
Learning how to describe a fracture over the phone when you are discussing a referral. Terms to use include:

  • Open vs. closed
  • Proximal vs. distal
  • Angulated – apex volar vs. apex dorsal
  • Shortening
  • Displaced vs. non-displaced

# 7 Not All Fractures Require a Cast   

Don’t let the treatment be worse than the injury. In some cases, immobilization may not be necessary. Depending on the condition, an alternative to a cast, such as a boot or a splint, may provide appropriate immobilization and allow early motion and an easier option for treatment.

#6 Splints and Casts Are NOT Benign  

When a cast or splint is indicated, here are key messages for patient education to prevent complications like skin breakdown:

  • Elevate the extremity for the first three days after the splint/cast is applied.
  • Never place anything inside of the splint.
  • DO NOT attempt to remove and re-apply a splint without help from a health care provider.
  • Monitor for signs and symptoms of neurovascular compromise.
  • Teach them how to check this and what to do should an issue occur (cap refill, sensation changes, increasing pain, proper elevation)
  • DO NOT get your splint or cast wet. Call your health care provider immediately if it does.

#5 Pediatric Fracture Patterns

Know the pediatric bony anatomy and fracture patterns. Though complete fractures are possible with higher mechanism injuries, incomplete fractures are more common on the pediatric population.
 
An open physis may look to some like a fracture. Additionally, an open physis may also hide a fracture that you don’t want to miss. Any injury near the physis may benefit from an earlier referral to ensure no growth disturbance.

#4 Most Pediatric Fractures Can Be Managed Without Surgery   

The Pediatric Orthopaedic Society of North America (POSNA) states on its website, “The standard of care for the treatment of pediatric forearm fractures remains nonoperative treatment with closed reduction and casting. An acceptable functional outcome with closed treatment is the rule in a majority of fractures.”
 
Our pediatric fracture clinic sees hundreds of children with fractures each week. Very few of these children require operative care for their fractures. Staffed with pediatric-focused nurses, medical assistants and orthopedic cast technicians, our clinic also has full-time, certified child life specialists. They are experts at providing developmentally appropriate education and support before, during and after diagnosis, care and complex in-clinic procedures.

#3 Pediatric Bone Remodeling Is Remarkable    

Pediatric bone is structurally different than adult bone in the following ways:

  • Less dense/more porous
  • Increased elasticity
  • Tend to break in “patterns” (greenstick, torus/buckle, plastic deformation, complete, etc.)
  • Thick periosteum
  • Potential to remodel

These characteristics make remodeling “easy” in young patients. Fractures in these conditions have greater remodeling potential with:

  • Patient is younger in age
  • Fracture is closer to the physis
  • More growth remaining in the adjacent physis

Learn more about how Scottish Rite for Children is helping to define evidence-based care for treating clavicle fractures and how the outcomes in operative and nonoperative care are similar.

# 2 Not All Fractures Are an Emergency

Every fracture does not need to be treated in the emergency setting. This can save stress and use of expensive resources. A study of more than 200 cases has shown this can cause unnecessary anxiety and increased pain due to increased number of assessments before definitive care with pediatric orthopedic specialist.
 
Be familiar with your resources to manage and refer accordingly.

  • Safely immobilize with sling, boot or splint.
  • Provide crutches, when indicated

Educate the patient and family:

  • Pain control
  • Warning signs
  • Elevation
  • Immobilization and proper education
  • Appropriately timed referral to pediatric orthopedics

Examples of orthopedic emergencies that can’t wait include, but are not limited to:

  • Open fractures
  • Neurovascular concerns
  • Severe swelling
  • Severe clinical deformity
  • Slipped capital femoral epiphysis (SCFE)
  • Femur fractures
  • Pain uncontrolled with over-the-counter medications

#1 You Are Treating the Patient AND the Parents!

Majority of second opinions are requested to provide clarity, not necessarily a different treatment. Here are suggestions to optimize the conversations at the first visit:

  • Spend extra time with the family. This may reduce frustration and duration of subsequent visits.
  • Discuss expectations and timelines for both treatment and healing.
  • Map out what to expect at subsequent visits.
  • Identify and address questions or complications right away. Pediatric injuries are not always straightforward, and you must be able to explain things in ways that parents will understand and trust your diagnosis and treatment. 

Montgomery emphasized the important role that patient and family education plays in pediatric fracture care. “If that family leaves your office and the family does not feel comfortable with your plan, you’ve lost,” he says. “We spend a lot of time with families to make them comfortable.”

Wrist Complaints You Shouldn’t Ignore – Fracture Clinic Tips

Wrist Complaints You Shouldn’t Ignore – Fracture Clinic Tips

by | Aug 31, 2021 | Fractures

Falling onto an outstretched hand can often cause injuries to the ulna and/or radius, or the long bones in the arm. The most common injuries are called both bone forearm fractures (BBFA) or buckle fractures. Sometimes, the carpals, the smaller bones in the wrist, may be injured instead. When the hand is turned slightly inward during a fall, the scaphoid bone is most likely to be injured.

“In some cases, early X-rays of a painful wrist may not show an obvious fracture,” nurse practitioner in the Fracture Clinic Ray Kleposki, M.S.N., CPNP, says. “A detailed physical exam of the wrist is important to evaluate for a small fracture in the scaphoid or other bones.”

Scaphoid injuries tend to be slow to heal, so early intervention is important and can help to prevent future complications. Kleposki has helpful advice to parents about what to look for following a fall onto an outstretched hand. “If there is a concern for a scaphoid fracture, or if the wrist pain after a fall has not gotten better in more than a week, we recommend a specialized X-ray series to evaluate for a scaphoid fracture or other diagnosis,” Kleposki says.

Falling down and getting a few bruises comes naturally as kids play and learn new skills! Parents can rest easy knowing that experts at Scottish Rite for Children are here to help when a child breaks a bone or when a seemingly minor injury bothers a child longer than a few days.

Learn more about the multi-disciplinary care in our Fracture Clinic.

Wrist Complaints You Shouldn’t Ignore – Fracture Clinic Tips

Wrist Complaints You Shouldn’t Ignore – Fracture Clinic Tips

by | Aug 31, 2021 | Fractures

Falling onto an outstretched hand can often cause injuries to the ulna and/or radius, or the long bones in the arm. The most common injuries are called both bone forearm fractures (BBFA) or buckle fractures. Sometimes, the carpals, the smaller bones in the wrist, may be injured instead. When the hand is turned slightly inward during a fall, the scaphoid bone is most likely to be injured.
“In some cases, early X-rays of a painful wrist may not show an obvious fracture,” nurse practitioner in the Fracture Clinic Ray Kleposki, M.S.N., CPNP, says. “A detailed physical exam of the wrist is important to evaluate for a small fracture in the scaphoid or other bones.”

Scaphoid injuries tend to be slow to heal, so early intervention is important and can help to prevent future complications. Kleposki has helpful advice to parents about what to look for following a fall onto an outstretched hand. “If there is a concern for a scaphoid fracture, or if the wrist pain after a fall has not gotten better in more than a week, we recommend a specialized X-ray series to evaluate for a scaphoid fracture or other diagnosis,” Kleposki says.

Falling down and getting a few bruises comes naturally as kids play and learn new skills! Parents can rest easy knowing that experts at Scottish Rite for Children are here to help when a child breaks a bone or when a seemingly minor injury bothers a child longer than a few days.

Learn more about the multi-disciplinary care in our Fracture Clinic.

“Walk It Off, It’s Just an Ankle Sprain.”…. Or Is It? – Fracture Clinic Tips

“Walk It Off, It’s Just an Ankle Sprain.”…. Or Is It? – Fracture Clinic Tips

by | Aug 24, 2021 | Fractures

The ankle is one of the most commonly injured body parts in children of all ages. An ankle sprain usually occurs when the ligaments, which support the three ankle bones, are stretched beyond their normal limits. This often occurs when the ankle is twisted or rolled inwards. When this happens, the ligaments can stretch or even tear, and oftentimes a “pop” is reported to be heard or felt at the time of the injury. When a child or adolescent with open growth plates twists or rolls their ankle, it can actually result in a fracture of the growth plate rather than a sprain to the ligament.

Ray Kleposki M.S.N., CPNP, a Scottish Rite for Children Fracture Clinic Nurse Practitioner, tells us, “An evaluation by a pediatric orthopedic specialist can help to prevent potential complications. Usually X-rays are required to make a diagnosis and treatment will depend on multiple factors, including the specific type of injury and age of the patient.”

An ankle sprain is an injury to one or more of the ligaments which support the ankle joint. Ligaments connect bones and hold a joint together. Ankle sprains are one of the most common sports injuries but can happen anywhere.

How does it occur?

Any movement that causes the ligaments of the ankle to stretch farther than they naturally can, may cause an ankle sprain. Examples include:

  • Twisting or turning injury during a step or landing.
  • Fall or near fall on an uneven surface.
  • Unsteadiness from a sudden change in direction.

What are the symptoms?

  • Tenderness or pain
  • Limp or pain with walking
  • Aching
  • Swelling
  • Bruising or discoloration

How is it diagnosed?

An ankle sprain is best diagnosed by a health care provider. A detailed history and physical exam will be performed. In some cases, X-rays or other imaging may be ordered to evaluate for injuries to the bones or other tissues.

How long will this injury last?

Recovery time varies and depends on the child and the severity of the injury. A child may recover in a few days, weeks or months. Rehabilitation to strengthen and stabilize the ankle, and to reduce the risk of another injury, plays an important role during the recovery from an ankle sprain.

How is it treated?

To improve pain and swelling:

  • Limit activity since pain may increase with activity.
  • PRICE: Protect, Rest, Ice, Compression and Elevation.
  • Non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen (Advil®, Motrin®) or naproxen sodium (Aleve®) may be taken as needed for pain.

Depending on the sprain, the health care provider may or may not advise formal rehabilitation immediately. Treatment goals for recovery and prevention are to restore these:

  1. Motion and flexibility
  2. Strength
  3. Balance, proprioception and stability

When can my child return to normal activities and sports?
This decision is made based on the severity of the injury, the child’s age and activity level. A gradual functional return to activity and sports can be made once:

  • cleared by provider.
  • pain and swelling are gone.
  • able to walk without pain or limp.
  • ankle has full motion, and strength is the same as on the other ankle.
  • balance is restored.

How can future ankle injuries be prevented?

Restoring and maintaining ankle strength and mobility are both vital in preventing repeat ankle injuries.
Here are several additional ways to protect the ankle:

  • Wear proper fitting shoes, tied correctly, for activities.
  • Learn and perform strength and neuromuscular exercises a few times a week.
  • Stretch before and after activity.
  • Focus on form and proper technique.
  • Work with a knowledgeable coach familiar with proper training for growing athletes.
  • Consider an ankle brace or ankle taping to provide support.

The Fracture Clinic in Frisco is open Monday – Friday from 7:30 a.m. to 4:30 p.m. The clinic accepts walk-in patients between 7:30 a.m. and 9:30 a.m.

Learn more about our Fracture Clinic.

Jump! Flop! Bounce! Break.

Jump! Flop! Bounce! Break.

by | Apr 20, 2021 | Fractures

As things get back to normal, we’re seeing an influx of orthopedic injuries from trampolines and bounce houses. We thought you would like some quick tips for making them as safe as possible.

  • Allow one child to jump at a time.
  • Separate the big kids from the younger kids.
  • Supervise at all times.
  • Consider the equipment:
    • Are there mats around the trampoline?
    • Is there a net?
    • Are the springs intact and covered?
  • Consider the environment:
    • Are there a lot of distractions for the supervising adult or the jumpers?
    • Are there safety protocols in place for all participants?

Most common injuries from these activities:

  • Fractured (broken) tibia, the lower leg bone.
    • Proximal tibia fractures occur at the top of the bone close to the knee.
    • Tibial shaft fractures occur in the middle of this long bone.
  • Buckle fracture of the forearm. Learn more here [link to blog].
  • Elbow fracture or dislocation.

Though kids are resilient and heal well from these injuries, we want to keep them safe. Kids under 5 are at a greater risk of injury and count on their parents to protect them in these environments.

Learn about our Fracture Clinic. It’s open weekdays and has morning walk-in hours.

Buckle Fracture – Important Things Parents Should Know

Buckle Fracture – Important Things Parents Should Know

by | Oct 15, 2020 | Fractures

In our Fracture Clinic at the Frisco campus, our team cares for various types of fractures – from simple to complex. It is important to be seen by a pediatric specialist when your child gets injured because treating growing bones is different than treating adult bones.

The distal radius buckle fracture is one of the most commonly seen fractures in our patient population. These fractures heal well with splint immobilization for four weeks. In general, the patient seen in our clinic do well with this type of fracture and are able to return to full activity quickly after splint removal. 

What is a buckle fracture?
A buckle fracture or torus fracture is a break in the bone. One side of the bone may buckle or bend upon itself without breaking the other side of the bone. Pediatric bones are softer and more flexible than adult bones, therefore this is a very common injury for children. It can also be called an incomplete fracture.

Generally, buckle fractures occur in the distal radius portion of the wrist and occurs when falling on the hand. Often this injury occurs from a fall on outstretched hand, or “FOOSH.”

What are the symptoms?

  • Wrist pain following a fall.
  • Mild to moderate wrist swelling.
  • Limited range of motion in the wrist or forearm following the injury.

How is a buckle fracture diagnosed?
A detailed history and physical exam will be performed. In many cases, X-rays will be used to see if the arm is fractured/broken.

What is the treatment?
A removable wrist splint is worn for four weeks. The splint helps protect the bone and keep it still to allow for adequate healing. It is important to wear the splint for the full time, even after the pain is gone. The splint should only be taken off with parent’s help during showering/bathing and for a daily skin check. 

What to expect following treatment:

  • Buckle fractures typically heal within four weeks from the injury.
  • No follow-up appointment is needed in most cases.
    • Tenderness, weakness and stiffness may last for one to two weeks following the splint removal.
  • It is important to have full strength and full range of motion, without pain, before returning to activities.
  • There is no evidence of issues with growth, function, ability or stability after these injuries.

Learn more about the Fracture Clinic.