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An Approach to Management of Toddler’s Fractures

An Approach to Management of Toddler’s Fractures

by | Jun 2, 2020 | Fractures

Article originally published in latest issue of the Pediatric Society of Greater Dallas newsletter. Written by Gerad Montgomery, M.S.N., FNP-C, and Ray Kleposki, M.S.N., CPNP.

A toddler’s fracture is classified as a tibia shaft fracture in a child age 3 and younger. These patients usually present with either a witnessed or unwitnessed report of low energy trauma to the lower extremity. The mechanism of injury may vary but usually involves some sort of a rotational component. Due to the patient’s age and inability to clearly articulate symptoms or mechanism of injury, these fractures often leave both parents and clinicians anxious and confused. This is confounded by the fact that up to 40% of initial X-rays are negative for obvious bony pathology. To add to the confusion, these fractures usually do not present with swelling or other obvious physical exam findings.

Presentation
The typical patient that presents with this injury is a toddler between the ages of 1 and 3 years with an acute onset of refusal to weight bear or ambulating with a limp.

Three common reports include:

  • History of remote trauma such as a twist and fall.
  • Onset of symptoms after going down a slide with an adult and the patient’s leg getting twisted at the bottom of the slide
  • Unwitnessed incident where patient was playing in another room and eventually found crying on the floor and unwilling to weight bear on the affected extremity.

Regardless of the mechanism, in most cases, the patient will be unable to reliably articulate what caused the injury or where his/her symptoms are arising from. 

Evaluation
When evaluating the patient in this age group, with the presenting complaint of a limp and/or refusal to weight-bear, it is important to consider other conditions that may present in a similar fashion.

Though unlikely, these include:

  • Infection: early presentation of both benign viral infections such as transient synovitis and serious bacterial infections, like osteomyelitis and septic joints, can present with similar initial complaints.
  • Constipation
  • Inflammatory reaction to recent immunizations
  • Chronic or congenital conditions: consider hip dysplasia, cerebral palsy and foot or ankle deformities.

Most of the time, a good history and detailed clinical exam can eliminate dangerous conditions and lead the clinician to an accurate diagnosis. Usually, a step by step exam (starting at the hips and working down to the feet) will reveal pain-free, full range of motion of the hips and knees. This includes classical tenderness to palpation noted over the tibial shaft and pain produced with rotation of the lower leg.  

Treatment
The vast majority of these fractures are stable injuries and treatment is aimed at providing comfort and modifying activities, with the goal of reducing the risk of further injury. Immobilization is appropriate, however a cast is usually not necessary. It has been well documented that a walking boot produces outcomes equivalent to a cast or splint. A removable boot has a lower risk of complications from skin breakdown and higher rate of patient and parent satisfaction. 

Splinting Considerations – When a Boot is Not Available
We frequently see significant skin breakdown after splints or casts used to immobilize patients in this age group. The size of the extremity makes it difficult to properly mold casts/splints in order to prevent friction with skin contact. The most common areas of breakdown are at the back of the heel and anterior crease of the ankle. If you are splinting a patient in this age group, we recommend paying careful attention to the positioning of the foot and ankle and applying extra padding over bony prominences such as the malleoli and at the back of the heel.

The presence of swelling in toddler fractures is minimal and usually not a concern. Therefore, elevation is not a necessary part of the treatment plan, despite the many clinicians and parents who believe that elevation is important for any fracture. While the elevation alone is not harmful, proper elevation techniques should be taught when elevation is recommended.

Proper Elevation – Keep the Heel Off of the Surface
Poor positioning can cause increased pressure leading to skin breakdown. Place a pillow under the calf only, not directly under the knee or heel. Do not assume that immobilization is a benign modality. You must provide the family with warnings and instructions on what to monitor for regarding signs and symptoms of potential complications.

Patient and Family Education
Providing reassurance to the family is a key goal of patient education. These fractures generally heal well with little to no complications in regard to bony healing or future sequela after four to six weeks of immobilization. Additional imaging may be needed in some cases. A child will gradually return to normal activity within a few days of discontinuing activity restrictions and immobilization.
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Learn More About Our Fracture Clinic Walk-In Hours

Learn More About Our Fracture Clinic Walk-In Hours

by | Feb 21, 2020 | Fractures

In many cases, a visit to your pediatrician, urgent care or emergency room is your first stop when your child is hurt. If you are told to follow up with a pediatric orthopedic specialist for a fracture, you can come to the Scottish Rite for Children’s Fracture Clinic during our convenient walk-in hours.

Our Fracture Clinic is open Monday – Friday. Bring your X-ray images on a disc and arrive at our Frisco campus between 7:30 to 9:30 a.m. No appointment needed.

If you have not had X-rays for the child’s new injury, that is okay too. Parents can call 469-515-7200 to request an appointment.

Learn more about our Fracture Clinic.

Get to Know our SRH Staff: Kat Petty, Fracture Clinic

Get to Know our SRH Staff: Kat Petty, Fracture Clinic

by | Jul 15, 2019 | Fractures

What is your role at the hospital? What do you do on a daily basis? 
I am the R.N. coordinator for the Fracture Clinic at our Frisco campus. I coordinate patients’ needs (orders, medications, supplies, phone calls) and manage the overall flow of the clinic. 
The clinic serves patients that have been injured and may have a fracture. We have walk-in clinic hours from 7:30 – 9:30 a.m., as well as scheduled appointments throughout the day. It’s a busy place!
What led you to Texas Scottish Rite Hospital for Children? How long have you worked here?
I have been here for exactly two years. When I was looking to transfer out of the hospital setting, I came across a job posting for Scottish Rite Hospital. I did one of my nursing school clinicals at the hospital back in 2010 and I remembered how great of an experience that was. The building was a happy place, the employees were friendly and of course the popcorn smell wafting through the building left an impression on me!
 
What do you enjoy most about Texas Scottish Rite Hospital for Children?
I really enjoy making a difference in children’s lives. Bonus, the management is unlike any I have worked for!
 
What was your first job? What path did you take to get here?
My very first job was when I was 14. I was a daycare worker at a facility that also doubled as a themed party event center on the weekends. My specialty was dressing up as Snow White.
 
What do you like to do in your spare time?
Read, spend time with my husband, feed people, craft, travel, volunteer at my church and plan events.
 
Three words to best describe you:
Patient, considerate, disciplined
 
What would you do (for a career) if you weren’t doing this?
I would be a home decorator or a professional crafter!
 
What’s the most adventurous thing you’ve ever done?
When I was 19, I did a leadership internship and participated in an event called E.S.O.A.L. – Emotionally Stretching Opportunity Of A Lifetime. 
 
This event was fashioned after the Navy Seals boot camp training. For 96 hours, with little to no sleep, we hiked for what felt like a million miles and ran rounds and rounds of obstacle courses. I ate some pretty interesting things (think live mealworms with ketchup and ice cream) and stayed really dirty as we rolled down hills and waded through mud pits. Through the nights, we had sleep-wake cycles: seven minutes to sleep with a rude awakening to jump in a pool of ice water. I’m proud to say that I lasted to the end (only 25% of us made it to the finish line). To date, the hardest and most adventurous thing I have ever done!

An Injury Not to Ignore: Hand & Finger Fractures in Young Athletes

An Injury Not to Ignore: Hand & Finger Fractures in Young Athletes

by | Jan 29, 2019 | Fractures

Believe it or not, hand and finger injuries in kids, especially young athletes are very common. In fact, almost 20 percent of the injuries we see in the Fracture Clinic are hand related injuries. For children, these injuries can occur in a number of ways. For athletes, some of the more common mechanisms we see are from a finger getting struck by a ball, a hand getting stepped on or a finger getting caught in a jersey. While most injuries to the hand or fingers will get better with some time, rest and immobilization, others may require more extensive care or even a surgery to correct alignment or restore function. As the parent of a young athlete, it is important to know when to seek medical treatment.

Recognizing a hand injury in a child is not always easy and may require the attention from an expert who specializes in caring for patients whose bones are still developing. Sometimes, X-rays can appear normal and exam findings can be subtle making it easy to miss or ignore injuries to the hand. If rest is not healing the injury, it is important to know the signs and symptoms where being evaluated by a pediatric specialist is necessary.

Some general “redflags” with finger injuries include:

  • Hearing or feeling a “pop” or “crack” at the time of the injury.
  • Seeing significant swelling immediately after the injury occurs.
  • Noticing differences compared to the same finger on the other hand. Seeing bleeding or drainage at or around the nailbed.
  • Inability to move, straighten or bend the finger or a joint more than two days after the injury.

Gerad Montgomery, M.S.N., FNP-C, tells us that most pediatric hand and finger injuries can be managed with immobilization in a cast or splint. However, when there is significant displacement of fracture, injuries to ligaments and tendons or damage to the nailbed, surgery may be needed.

Advice for parents of young athletes

  • Teach proper techniques with catching, hitting or throwing a ball.
  • Discourage grabbing a shirt or jersey in fast-moving games like football or tag.
  • Encourage athletes to be aware of surroundings during team sports.

  • Insist that athletes wear proper protective sports equipment when appropriate.
  • Never ignore an injury to the hand or fingers. Though it may be tempting to “push through the pain” and keep playing, these injuries can have serious consequences if they are overlooked. Don’t wait to have it evaluated by a medical professional.

Learn more about fracture care at Scottish Rite for Children in Frisco.

What You Need to Know About Getting a Cast Removed

What You Need to Know About Getting a Cast Removed

by | Dec 5, 2018 | Fractures

The experts in our Fracture Clinic specialize in caring for broken bones. Depending on the child and the nature of the injury, a cast may be needed to treat the break. Learn more about our Fracture Clinic, located at our Frisco campus, and what it is like to have a cast removed. Watch the video. When you arrive:
  • Check in at the Fracture Clinic desk and complete a health history questionnaire.
  • A Child Life specialist can be available to talk with you, to make sure the experience is smooth and enjoyable, plus they can prepare you for what to expect.
  • The cast technician will let you look at the tools beforehand and will explain what is going to happen.
During the removal:
  • You can wear head phones, if you are sensitive to loud sounds.
  • Some people even think it tickles.
After the cast comes off:
  • Try not to scratch the skin.
  • Blot warm water on the area if the skin itches.
  • You can use lotion on the skin, but not right away. Speak with your provider before using lotion.
  • A follow up X-ray may be needed.
  • Your provider will then examine you, to confirm the bones are properly healing.
Learn more about our Fracture Clinic and walk-in hours or call 469-515-7200 to schedule an appointment.
Our Fracture Clinic Is Here to Help

Our Fracture Clinic Is Here to Help

by | Sep 30, 2016 | Fractures

A young gymnast’s experience with our Fracture Clinic

When Riley broke her arm during a front handspring at the gym, she and her mom were both afraid that she would need surgery. Thankfully, a friend at her gym told them exactly where to go for expert fracture care. On their first visit to Scottish Rite Hospital, they met with Gerad Montgomery, a certified pediatric nurse practitioner who specializes in nonoperative fracture care. He explained to them that surgery was not the only option for Riley’s injury. After discussing the pros and cons of each treatment option and getting answers to all of their questions, Riley and her mother decided to continue care without surgery. Fractures like Riley’s can be challenging to manage and often require a series of several specialized casts to keep the bones aligned correctly and allow them to heal.

Riley tells us she has gotten lots of questions about her cast, which was specially molded to help align her bone. “I tell people my bones are sticking out,” Riley said with a smile as she talked about the bulges from spacers in the cast. Then, she laughed saying she assures them that her bones are fine.

“When I called to ask about some feelings Riley was describing, Gerad asked to speak directly with her about what she was feeling,” her mom explained. She and Riley thought this was a great example of the outstanding service they received from the moment they met the Fracture Clinic team.

Riley is now back in the gym and able to participate in some activities. She is still wearing a cast, since the healing process takes time. “She’s happy this doesn’t keep her out of her training,” her mom and former coach tells us. “In pediatrics and sports medicine, we look for ways to keep kids engaged in their activities; we know this is good for them physically and psychologically,” Gerad says.

Bumps and bruises are sometimes a normal part of kids being kids. However, if your child breaks a bone, you can call our Fracture Clinic directly at 469-515-7200.

To learn more about our Fracture Clinic on our North Campus, visit our Fractures page.