Nasal injuries

Cite this article as:
Ragavan Navaratnam. Nasal injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33108

13-year-old Freya (she/her) has been tackled in rugby and fell onto her nose. It bled initially and her mother has brought her as it is really swollen and looks wonky. “Is it broken, doctor?”

Nasal injuries in children are frequently encountered in paediatric emergency departments. One third of all nasal fractures occur in children, accounting for 60% of all facial fractures seen in the emergency department. The nose is the second most commonly injured site on a child and is more commonly seen in males. The most common locations of injury to the nose are: the nasal tip, the dorsum, and nasal root region with only 32% of injuries involving the nasal skeleton.

Nasal fractures are more common after three years of age, and unlikely below the first year of life, as the nasal bones are hardly ossified. But the bones aren’t the only thing you need to look out for; nasal obstruction and septal haematomas are important to identify and treat urgently.

History

Nasal trauma in children commonly arises following: falls, contact sports and automobile crashes, typically involving bicyclists or pedestrians. Non accidental injury also must be considered as a potential mechanism.

Important aspects of history should include:

  • mechanism
  • if there was any deformity immediately
  • new-onset nasal obstruction.
  • bleeding
  • anosmia

It is also important to note any previous nasal injury or pre-existing deformity.

Examination

Children with facial trauma are usually apprehensive, so any examination may be limited due lack of cooperation.  Pain relief and play therapy will go a long way. Bleeding and swelling often accompany injuries and can limit a thorough examination. Applying local pressure may be necessary prior to starting a formal examination.

Inspection

The examination should start with inspection of the nose and the surrounding facial structures.  It is important to note:

  • Periorbital bruising in the absence of other orbital findings is suggestive of a nasal fracture.
  • External nasal deformity, epistaxis, oedema, and bruising is highly suggestive of a septal injury. Any deformity more be masked by swelling.
  • A flattened, broad nose with an increase of the inner canthal distance and associated with vertical orbital displacement is suggestive of a naso-orbito-ethmoid fracture. The normal mean inner canthal distance is 16 mm at birth and increases to 25 to 27 mm in the mature female and male face, respectively, although there is ethnic variation.

The intranasal cavity should be assessed with a nasal speculum to exclude a septal injury. A septal haematoma can arise without the presence of any external signs. The septum should be examined for the presence of fractures, displacement, lacerations, discoloration, and abnormal swelling. Don’t forget that the nasal septum may be acutely or chronically deviated so you may need to ask about this in the history. Sometimes looking at an old photo helps.

The key findings suggestive of septal hematoma include:

  • An asymmetrical septum with a blue/red discolouration
  • Swelling of the nasal mucosa that obstructs the nasal passage
  • The size of the mass does not change with the application of topical vasoconstricting agents.

Most times a septal haematoma looks like a blueberry up the nostril.

Palpation

After inspection, the nasal bones should be palpated for tenderness, deformity, mobility and  crepitus, although realistically poking a bruised nose may be too painful to tolerate. It is important to note:

  • Tenderness over the frontal sinus may indicate frontal sinus fractures.
  • Tenderness to palpation of the tip of the nose may be suggestive of a septal hematoma
  • Tenderness and instability on palpation of the anterior nasal spine from beneath the upper lip may indicate a significant septal injury.
  • Malocclusion is suggestive of a midfacial Le Fort fracture.

It is important to exclude an associated skull fracture which may be indicated by the presence of clear fluid in the nasal cavity. A fracture through the cribriform plate can result in a CSF leak. In an ideal world you can test for beta-2-transferrin (present only in CSF, perilymph, and aqueous humor), but I have yet to hear of EDs which offer this.

The signs and symptoms of nasal septal injury may evolve during the 24 to 72 hours after injury. Children with nasal trauma should be safety-netted to return if anything changes after they go home.

Investigations

A history and clinical examination should more than suffice in guiding the management of children with nasal injuries. In simple nasal injuries, imaging adds very little. Plain radiographs are of very limited benefit as the majority of the nose in children in cartilaginous and therefore poorly visualised on x-rays.

In injuries associated with more worrying features i.e. CSF leak or malocclusion, CT imaging is the modality of choice due to the risk of a Le Fort fracture or a base of skull injury.

Classification

A number of classifications systems have been proposed for nasal injuries. The first and most widely quoted was based on the pattern of injury sustained and the direction of force applied. More recently, a classification system based on pathological findings was proposed. This second classification system has been adapted, to incorporate clinical findings as opposed to the  pathologic patterning of injury.

Table showing 6 types of nasal injury
Classification of nasal injuries

A complicated fracture is classified as a Type II to Type IV  fracture with CSF rhinorrhea, airway obstruction, septal haematoma, crush injury, numbness, severe displacement or midface involvement.

Treatment

The management of nasal trauma in infants and children depends upon their age, the degree of nasal obstruction, and associated injuries. Children with nasal trauma should maintain upright posture to prevent the formation and facilitate the resolution of any associated oedema and hematoma. Patients who have no symptoms, minimal swelling, and no septal deviation or hematoma do not need specific follow-up.  Ensure adequate analgesia is given and appropriate advice when to return (on-going bleeding, evolving nasal obstruction, worsening pain).

Epistaxis – Most acute nasal bleeds respond to direct pressure over the anterior nose. Encourage the child to pinch their own nose but if they are unable, asking a parent to perform this has the added benefit of helping reduce the patient’s anxiety. During simple compression, position the child upright and sit them forward. This will help avoid possible aspiration of blood. Distraction and play therapy during compression are useful. In the majority, bleeding is controlled within 5 – 10 minutes.

If direct pressure fails to control bleeding, a number of management options are available but are rarely needed in the emergency department. These include:

  • Nasal packing. Tamponading the bleeding point can be very effective but can be very distressing to children. Sedation is often required to facilitate the procedure. It is advisable to seek an ENT opinion before packing a child’s nose, especially if this is traumatic.
  • Topical vasoconstrictors. These can be very effective but are not without risks. They are most commonly used in the theatres by the ENT surgeons. Options include topical phenylephrine or oxymetazoline. After application of a vasoconstrictor, direct pressure should be applied for at least 5 minutes before reassessing for further bleeding.
  • Tranexamic acid.
  • Cautery. In the emergency department, chemical cautery is commonly used, predominately in the adult population. Typically 75% silver nitrate is used to arrest bleeding. Cauterisation is undertaken around the bleeding point. Cautery works most effectively on dry areas so direct cautery of a bleeding point is often unsuccessful until the surrounding area has been treated. Care must be taken to avoid the skin and it is paramount the child is calm and cooperative, which may necessitate sedation. Make sure you don’t cauterise both sides of the septum.

Children presenting with possible fractures or obvious deformity should be reviewed by an ENT specialist; generally this can wait a few days. In the very young, injuries resulting in nasal obstruction should be referred urgently as young children are obligate nasal breathers.

As mentioned previously, swelling and oedema can make an accurate assessment difficult. As such, an immediate referral of a child with a broken nose but no features of airway compromise may not be needed. Children can be referred to an outpatient clinic for review but should be seen within in five to seven days. Short delays in definitive management of up to a week have been shown to have little impact on long term outcome. However, delays over seven days can make reduction of fractures more challenging, largely due to the active growth centres in a child’s nasal bones promote rapid healing.

Potential complications of nasal injuries

A number of potential complications can arise as a result of nasal trauma, particularly if there is a fracture. The most common complication is obstruction. This is often due to either soft tissue swelling or a deviation of the septum following an injury. Persistent obstruction following an injury is more likely due to septal deviation and therefore requires assessment by an ENT surgeon.   

Poor cosmesis following healing is a common problem reported by patients and is a valid concern for many parents. Recent work has shown that those sustaining fractures at a younger age compared to those that had none, had no differences in functional outcomes but were likely to suffer with deviations of the septum, bumps or humps in the nasal bridge and saddle formation.  Ensuring a timely referral to a surgeon may help reduce the incidence of a poor aesthetic result for the patient.

A septal haematoma that is not promptly dealt with can result in a septal abscess or necrosis (and a future flat nose). Though infection can remain localised, cases of intracranial infection via tracking through the cavernous sinus have been reported. Cavernous sinus thrombosis is also a recognised complication of septal haematomas. Damage to the cribiform plate with a resulting CSF leak is also a potential avenue for intra-cranial infection.

Rarer complications but still clinically important include:

  • Lacrimal duct obstruction
  • Maxillary hypoplasia
  • Naso-oral fistula
  • Anosmia. If this occurs following trauma, it very rarely returns.

Take homes

A clever history and examination are key.

Ensure you examine the inside of the nose especially for a septal haematoma

Adequate analgesia and distraction will make examination much easier

Radiological investigations have little use in simple injuries.

Direct pressure for at least 10 minutes should stop most cases of epistaxis.

Make sure, if referring to clinic, the child is seen within a week.

You have examined Freya and she has no signs of obstruction, no septal haematoma and her bleeding as stopped. She does seem to have a deviated septum however, so you discharge her with advice for simple analgesia, safety-netted and referred her for rapid access ENT clinic within seven days.

References

Baek HJ, Kim DW, Ryu JH, Lee YJ. Identification of Nasal Bone Fractures on Conventional Radiography and Facial CT: Comparison of the Diagnostic Accuracy in Different Imaging Modalities and Analysis of Interobserver Reliability. Iran J Radio. 2013 Sep; 10(3): 140–147.

Beck R, Sorge M, Schneider A, Dietz A. Current approaches to epistaxis treatment in primary and secondary care. Dtsch Arztebl Int. 2018 Jan; 115(1-2): 12–22

Béquignon E, Teissier N, Gauthier A, Brugel L, De Kermadec H, Coste A, Prulière-Escabasse V. Emergency Department care of childhood epistaxis. Emerg Med J. 2017;34(8):543

Burnius M, Perlin D Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am. 2006;53(2):195

Caglar B, Serin S, Akay S, Yilmaz G, Torun A, Adibelli ZH, Parlak I. The accuracy of bedside USG in the diagnosis of nasal fractures. Am J Emerg Med 2017 Nov;35(11):1653-1656.

Calder N, Kang S, Fraser L, Kunanandam T, Montgomery J, Kubba. A double-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngol Head Neck Surg. 2009;140(5):670

Elden LM, Potsic WP. Otolaryngology trauma. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1663.

Hester TO Campbell JP. Diagnosis and management of nasal trauma for primary care physicians. J Ky Med Asoc. 199795(9):386

Higuera S, Lee E I, Cole P, Hollier L H, Jr, Stal S. Nasal trauma and the deviated nose. Plast Reconstr Surg. 2007;120(7, Suppl 2):64S–75S

Hoppe IC, Kordahi AM, Paik AM, Lee ES, Granick MS (2014) Age and sex-related differences in 431 pediatric facial fractures at a level 1 trauma center. J Craniomaxillofac Surg 42(7):1408–1411

Joseph J, Martinez-Devesa P, Bellorini J, Burton MJ. Tranexamic acid to help treate nosebleeds. Cochrane review. 2018

Lkas Anschuetz B, KaiserN, Dubach P, Caversaccio M lun nasal trauma in children:a frequent diagnostic challenge. Euro Arch Oto-Rhin-Larng.2019. 276; :85-91

Lopez MA, Liu JH, Hartley BE, Myer CM. Septal hematoma and abscess after nasal trauma. Clin Pediatr (Phila). 2000;39(10):609

Precious DS, Delaire J, Hoffman CD. The effects of nasomaxillary injury on future facial growth. Oral Surg Oral Med Oral Pathol. 1988; 66:525-530.

Puricelli MD, Zitsch RP. Septal Hematoma Following Nasal Trauma. J Emerg Med. 2016 Jan;50(1):121-2.

Rohrich RJ, Adams WPJr, Nasal fracture management: minimizing secondary nasal deformities, Plast. Reconstr. Surg. 2000, 266-273

Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations.Laryngoscope. 2004;114(2):255

Stucker FJ Jr, Bryarly RC, Shickley WW. Management o nasal trauma in children. Arch Oolaryngol. 1984: 110 (3): 90

Thomson CJ, Berkowitz RG. Extradural frontal abscess complicating nasal septal abscess in a child. Int J Pediatr Otorhinolaryngol. 1998;45(2):183

Wu KH, Tsai FJ, Li TC, Tsai CH, Peng CT, Wang TR. Normal values of inner canthal distance, interpupillary distance and palpebral fissure length in normal Chinese children in Taiwan. Acta Paediatr Taiwan. 2000;41(1):22. 

Yoon HY, Han DG. Delayed Reduction of Nasal Bone Fractures Arch Craniofac Surg. 2016 Jun; 17(2): 51–55

Fracture hide and seek

Cite this article as:
Carl van Heyningen and Katie Keaney. Fracture hide and seek, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32819

Another winters morning. You are freshly vaccinated, caffeinated and ready for another ED shift. Your first patient is a return visit. A 7 year-old who fell onto his shoulder at school a week ago. You read your colleague’s previous assessment. On examination there was no bony tenderness and the x-ray report of the right clavicle was normal. Yet today there’s a lump over the collar bone and he’s no longer using his arm normally. Has something been missed?

X-ray interpretation is a complex human enterprise vulnerable to a wide variety of errors. The extent of missed diagnoses has been estimated to be as high as 15-20% 1,2.

There are two principle types of error:

  • Perceptual errors – those where the abnormality is simply not seen
  • Cognitive errors – where the abnormality is seen but its significance is not appreciated

You might think that such errors can simply be avoided through education, better imaging techniques and training. Yet since the 1960’s, despite doubtless advances in technology and improvements in medical practice, the rate of radiological errors has remained almost unchanged.

So what do we do? Admit defeat? Never!

Instead, let’s journey inwards and analyse these errors, why we make them and how we can improve ourselves and our approach to avoid missing fractures in children with injuries.

Causes of error

Perceptual errors are the most common and are due to many factors including:

  • Clinician fatigue
  • Distractions from colleagues and the working environment – the extrinsic cognitive load
  • High workload
  • Satisfaction of search (spotting one abnormality then failing to look for any more)

There is a reason your friendly radiologist is sat quietly in a dark room with a cup of coffee – a world away from a noisy, busy accident and emergency department. Consider yourself and your environment when reviewing an x-ray. Just as with prescribing, respect reviewing x-rays.

Even with the best conditions, what the eye sees the brain doesn’t always spot. Consider the now infamous Invisible Gorilla experiment that earned Christopher Chabris and Dan Simons an Ig-Nobel Prize in 2004. Participants were asked to watch a video and count the number of times the ball was passed between players. What they failed to notice was the large hairy simian playing the game. The brain failed to recognise what the eyes clearly saw.

The selective attention test

Cognitive errors occur for a whole host of reasons. Some of these include:

  • Lack of knowledge (e.g. how to interpret x-ray findings, ossification centres, etc.).
  • Lack of clinical information (e.g. history or examination)
  • Faulty reasoning (e.g. fracture identified but not cause of pain)
    • True positive, misclassified
  • Complacency (e.g. fracture identified but from separate injury)
    • False positive finding
  • Satisfaction of report (e.g. reliance on radiology report discourages further analysis).
  • Satisfaction of search (e.g. finding one fracture discourages search for another).  

Then there are our own cognitive biases which may also influence our interpretation…

Anchoring bias– early focusing on one feature of the image so neglecting or misinterpreting the rest of the information

I’ve found the distal radius fracture so that is the diagnosis”. The scaphoid fracture is then missed).

Availability bias– recent experience of a diagnosis/presentation makes you more likely to diagnose the same condition

I saw a pulled elbow the other day, it looks the same”. May miss ulnar dislocation.

Confirmation bias– looking for evidence to support your hypothesis and ignoring evidence against

It looks like a simple ankle sprain, I think that X-ray must be fine”. Can miss fractured fibula.

Outcome bias– opting for the diagnosis associated with the best patient outcome/prognosis

If there is a vertebral fracture, we will have to immobilise this child. It probably isn’t that”.

Zebra retreat– history and findings are in keeping with a rare diagnosis but the diagnostician is afraid to confirm this

As Dr Cox says, if you hear hoofbeats look for horses not zebras” …sometimes it’s a zebra!

Finally, no article on medical error would be complete without reference to the good old Swiss Cheese Model. We are but one step in a sequence of events that can either prevent or lead to error. For our example case, consider the following…

Graphic showing swiss cheese model of errors
Errors were made

Can I have some examples please?

Most fractures in children are easy to spot however some may present with subtle findings, especially when they involve the epiphyseal growth plate.

Examples of where most missed fractures occur are shown below:

Common but low risk as well as rare but high risk missed fractures

Many fracture patterns are unique to children. The paediatric skeleton is more elastic, more porous, and has a relatively stronger periosteum. That makes it uniquely vulnerable to torus fractures, buckle fractures, plastic bowing and greenstick fractures. Knowing to look for such subtleties sets paediatric fracture diagnosis apart. That coupled with odd growth plates and ossification centres explains, in part, why fractures are more easily missed in children5.

There is a subtle angled fracture of the distal radius. Compare this with the normal (middle) and healing (right) – taken from Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003). 

A subtle angulated fracture of the proximal radius taken from Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003). 

Plastic bowing deformity of the left radius and ulna taken from George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855

Plastic deformity of the radius with upward bowing (arrows) taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

A subtle greenstick fracture of the distal ulna taken from George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855

Note the upward plastic deformity of the right clavicle with the left for comparison taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

The leftmost image shows an obvious spiral fracture. The Toddler’s fracture in the middle image is not apparent until the line of sclerosis appears with healing taken from Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). 

A Salter-Harris 1 fracture of the distal radius. Look at the widened growth plate compared with the ulna taken from Jadhav, S.P., Swischuk, L.E. Commonly missed subtle skeletal injuries in children: a pictorial review. Emerg Radiol 15, 391–398 (2008). 

We have seen how even with the benefit of the patient in front of us and the luxury of radiology reports that we are vulnerable to making mistakes. Yes, we need to first know our ischial spine from our olecranon (our arse from our elbow), but we also need to train ourselves in techniques to avoid perceptual and cognitive traps.

So how do we prevent them?

Reducing missed fractures in children

Sadly the evidence is lacking and largely focuses on the performance of radiologists. Approaches centred solely on education and training are insufficient. Slowing down strategies, group decision-making and feedback systems are, as yet, an unproven step in the right direction. Checklists, however, have a growing evidence base in improving performance despite their poor popularity.

Whether or not you are a fan of the ‘Checklist Manifesto’, less controversial are principles around workplace culture and communication. Facing up to errors, avoiding blame and frequently just talking with colleagues (the clinician, the radiographer, the radiologist, the patient) remains incredibly important.

What else?

Systems-level thinking

A growing number of healthcare trusts now implement peer learning systems. Rather than being punitive, such groups create collective opportunities to teach using diagnostic catches as well as misses. At Leicester Royal Infirmary, Education Fellow Sarah Edwards set up one such weekly group teaching session for A&E staff. It gave them the opportunity to review images with the support of a Consultant Radiologist.

Evidence also supports “double-reading” to reduce the misses. At the Royal London Hospital, we are supported by our Radiology colleagues who review all images from our paediatric emergency department within 24 hours. Furthermore, within our ED we foster a culture of learning from each other through openly sharing learning points without risk of embarrassment and most (if not all) x-rays are reviewed by two or more clinicians to share knowledge and experience.

Such principles underpin the Irish National Radiology Quality Improvement (QI) programme. Through standard setting and measuring performance they pursue a cycle of continued quality improvement.

Individual level thinking

Michael Bruno, Vice Chair for Quality and Chief of Emergency Radiology at Penn State University says “there’s a very simple fix for errors of thinking- cognitive biases.… you must force yourself to ask really open-ended questions…. what else, how else, where else could a finding be… force your mind back open again.

To be more technical, lets consider the “dual process theory of reasoning.” In radiology, automatic system 1 processes typically enable immediate pattern recognition. In contrast deliberate system 2 reasoning enables less obvious abnormalities to be detected. Normally there is a dynamic oscillation between these to forms of thinking. The lesson is not to eliminate type 1 processing, which is prone to mental shortcuts and mistakes, but instead to be aware of our own thinking with the ability to deliberately “turn on” our type 2 brain when needed.

This discipline is termed metacognition or meta-awareness. 

For those who find such talk nebulous, there a number of practical steps that come recommended from Andrew J. Degnan (Department of Radiology at Children’s Hospital of Philadelphia).

Maintain a healthy skepticism

Reflect on your diagnostic process, challenge your interpretation forensically and question yourself objectively.

Use a structure or checklist

Structured reports help radiologists. Find your own repeatable techniques and approach each x-ray systematically, including “review areas” that are often overlooked. 

Consider the clinical findings

What is your pre-test (pre-x-ray) probability? How confident were you in your clinical assessment? Is the x-ray a rule-in or rule-out? Marrying up a thorough history and examination with a careful focus on the relevant radiographic area often bears reward.

Injuries that are missed because of failure to image are typically because the injury was poorly localized or because of the presence of other injuries distracted attention from the injured part.”

Mind your environment

Are you fatigued? Have you had a break? Clearing your mind for even a moment can actually improve overall efficiency. A quiet work space. A few minutes away from distraction. These will all empower your type 2 thinking.

Mitigate, mitigate, mitigate

Mistakes happen. Telling parents about uncertainty is critical to them re-presenting if their child’s soft tissue injury or sprain is not improving. Importantly, this is not the same as forgoing responsibility. Yet if your routine practice includes quality safety netting, discussing cases with your friendly radiologist and chasing up on cases you may not prevent mistakes but you might minimize the harm that comes from them.

What happened with our case?

A repeat x-ray was done but again no fracture was evident. Yet to examine there was an un-deniable lump mid-clavicle. In view of persistent pain and continued non-use of the limb (right arm) the child was discussed with the radiologist who agreed upon ultrasound. Ultrasound confirmed early callus formation and a break in the cortex that was not visible on X-ray. The child went home in a sling for outpatient follow up.

Take home messages  

  • Missed fractures are more common in children and not necessarily subtle
  • Know what to look for and how to look for it
  • Process is important, don’t forget history and examination
  • Communicate clearly, speak frequently with your radiographer and radiologist

Selected references

1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(5 suppl):S2–S23.

George MP, Bixby S. Frequently Missed Fractures in Pediatric Trauma A Pictorial Review of Plain Film Radiography Radiol Clin North Am 2019 Jul57(4)843-855. – Images 3,5 in carousel

Hernandez, J.A., Swischuk, L.E., Yngve, D.A. et al. The angled buckle fracture in pediatrics: a frequently missed fracture. Emergency Radiology 10, 71–75 (2003) – Images 1,2 in carousel

Jadhav, S.P., Swischuk, L.E. Commonly missed subtle skeletal injuries in children: a pictorial review. Emerg Radiol 15, 391–398 (2008). – Image 8 in carousel

2. Wachter RM. Why diagnostic errors don’t get any respect: and what can be done about them. Health Aff (Millwood) 2010;29(9):1605–1610.

5. Smith J, Tse S, Barrowman N, Bilbao A, (2016). P123: Missed fractures on radiographs in a paediatric emergency department, CJEM, 18 (S1), S119-S119

Swischuk, L.E., Hernandez, J.A. Frequently missed fractures in children (value of comparative views). Emerg Radiol 11, 22–28 (2004). Images 4,6,7 in carousel

Further reading

Brady AP. Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging. 2017;8(1):171-182. 

Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 2014;202(3):465–470.

Michael A. Bruno, Eric A. Walker, and Hani H. Abujudeh, Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction, RadioGraphics 2015 35:6, 1668-1676 

Martino F., Barbuti D., Martino G., Cirillo M. (2012) Missed Fractures in Children. In: Romano L., Pinto A. (eds) Errors in Radiology. Springer, Milano.

Miele V., Galluzzo M., Trinci M. (2012) Missed Fractures in the Emergency Department. In: Romano L., Pinto A. (eds) Errors in Radiology. Springer, Milano.

Wang CC, Linden KL, Otero HJ. Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 2017;33(3):200-207.

Distal femoral physeal fractures

Cite this article as:
Sinead Fox. Distal femoral physeal fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31852

Marcus is a 13-year-old boy who sustained an injury to his right leg during a rugby match, describing a hyperextension injury at the knee during a tackle. He is brought to your ED via ambulance. He is complaining of a significantly painful right leg which is quite swollen and exquisitely tender at the distal thigh and knee. Marcus is treated using advanced paediatric trauma protocols and no other injuries are identified. The injury to his leg is a closed injury and his distal neurovascular status is intact. An IV cannula is inserted. IV Morphine is administered for pain and an above knee back-slab is applied to splint the injury. An X-ray is suspicious for a Salter Harris type III fracture to his distal femur. Marcus is kept nil by mouth and referred to the orthopaedic team for urgent review.

Epidemiology

Distal femoral physeal injuries are uncommon. They represent approximately 7% of lower extremity injuries in children and less than 1% of all paediatric fractures. Although rare, distal femoral physeal fractures have a high incidence of long-term complications. These injuries must be considered in patients with open physes to avoid misdiagnosis as collateral ligament injuries and minimise the risk of complications.

Anatomy

Bones

The epiphysis of the distal femur is the first epiphysis to ossify and is present at birth. From birth to skeletal maturity the distal femoral physis contributes 70% of the growth of the femur and 37% of the growth of the lower extremity. The distal femoral physis has an average growth of 1.0 cm/year, making it the fastest growing physis. Growth ceases at a mean skeletal age of fourteen years old in girls and sixteen years old in boys. Compared with ligamentous structures, the physis is generally considered weaker within joints of children, therefore most periarticular injuries involve the growth plate.

Muscles

Both heads of the gastrocnemius and plantaris muscles originate just proximal to the physis of the distal femur.

Ligaments

The collateral ligaments of the knee attach distal to the physis at the level of the epiphysis of the distal femur. The ACL and PCL attach to epiphysis at the intercondylar notch and can be injured.

Blood supply

The popliteal artery is an important vessel in this area and can be prone to injury. It is important to undertake a careful neurovascular exam in children with confirmed or suspected distal femur fractures. Although rare, injury to the popliteal artery can result in loss of lower limb viability.

Nerves

The sciatic nerve divides into the peroneal and tibial nerves proximal to the popliteal space. 

Mechanism of injury

Distal femoral physeal injuries can be caused by hyperextension of the knee, with or without varus or valgus strain, or can occur by direct impact to the area. In the days of horse drawn wagons, this injury was coined ‘wagon-wheel injury’ or ‘cartwheel injury’ because it occurred when children attempted to jump onto a moving wagon and the leg became entrapped between the spoke of the moving wheel. Nowadays, most distal femur fractures are as a result of significant trauma such as motor vehicle accidents or sports related trauma. This is especially true for children between the ages of 2-11 years old, however less force is required for physeal disruption in infants and adolescents.

Children with underlying conditions such as neuromuscular disorders, joint contractures, difficult deliveries, or nutritional deficiencies can be more predisposed to distal femur physeal injuries.

Evaluation

Children with distal femur fractures will have significant pain and may be quite anxious, especially if assessment is undertaken in a resus situation. Make sure to follow advanced trauma protocols and ensure the child has had adequate analgesia.

Children with distal femoral physeal fractures generally present with pain, swelling and tenderness to the distal femur or knee and an inability to weight bear. Displaced separation of the distal femoral epiphysis may produce clinical deformity. Abrasions or lacerations of the overlying soft tissues may be a clue to the mechanism of injury or to an open fracture. Children with distal femur fractures may hold the knee in a flexed position due to hamstring muscle spasm. There may be varus or valgus knee instability on exam also.

A careful neurovascular exam of the lower limb including pulses, colour, temperature and motor and sensory status should be undertaken. Swelling in the popliteal space may be a sign of a vascular injury which requires urgent orthopaedic intervention. Although rare, injury to the popliteal artery is most commonly associated with an anterior displacement of the epiphysis or a posterior spike at the fracture site. The use of doppler ultrasound may be helpful in evaluating circulation distal to the injury but one of the most important screening tools for a vascular injury is measurement of the ankle-brachial index ratio.

The ankle-brachial index ratio involves comparing differences in systolic BP between the lower and upper limb. The cuff systolic blood pressure of the ankle should be >90% of the arm’s (brachial) systolic blood pressure. If the ankle’s cuff systolic blood pressure is <80-90% of the arm’s cuff systolic pressure, further investigation with a flow doppler ultrasound or arteriogram may be indicated.

If either the ankle-brachial index ratio or clinical exam suggest a vascular injury, then formal imaging with CT angiography should be carried out as soon as possible and repair of any defect to revascularize the distal limb must be undertaken as soon as possible but certainly within 6 hours of the initial injury. Urgent referral to orthopaedics is essential.

Evaluate the patient for signs and symptoms of compartment syndrome.

Assessing for compartment syndrome – the 5 Ps

  • Pain – the most important indicator.  Often diffuse and progressive, not resolved by analgesia, worsened by passive flexion of the injury.
  • Pallor – assess distal to the injury.  Dusky or cool skin (compared to the other side) or delayed capillary return.
  • Pulse – weak or absent pulse indicates poor perfusion,
  • Paralysis – assess active movement of the toes and foot.  This may cause pain, but the purpose is to assess ability to move.
  • Paraesthesia – ask about pins and needles or a feeling of the leg/foot “falling asleep”.  Assess sensation with light touch or using an object such as a pen lid.

Any concerns about potential compartment syndrome must be escalated to an ED or orthopaedic senior without delay as this is a time-critical situation.

Injury to the peroneal nerve can be caused by anterior or medial displacement of the femoral epiphysis. The nerve can become stretched resulting in neurapraxia. Spontaneous recovery can be expected following reduction or fixation of the fracture. The exception to this is a transected nerve in association with an open injury which requires urgent orthopaedic input.

Testing motor and sensory function of the lower limb

Radiology

Most distal femur fractures can be identified on plain X-ray. AP, lateral and oblique views are recommended. Stress radiographs for suspected physeal injury are no longer routinely performed, MRI or ultrasound have replaced stress views in this setting. CT may be necessary for evaluation of intra-articular extension and to define fracture fragments to plan fixation.

Classification

The standard Salter Harris (SH) classification is used to describe distal femoral physeal fractures.

Salter Harris Type I (SHI)

A SHI fracture is a separation through the distal femoral physis. A non-displaced SHI fracture may be difficult to diagnose on X-Ray. A slight fleck of bone adjacent to the physis, a slight widening of the growth plate, or other irregularities of the physis can indicate a SHI fracture of the distal femur. Sometimes diagnosis is only made or confirmed during follow up when subperiosteal new bone formation along the adjacent metaphysis is identified on subsequent X-rays.

Non-displaced SHI fractures should be suspected when knee tenderness is localised circumferentially to the distal femoral physis. To help guide examation it is helpful to know that when the knee is in extension the waist of the patella overlies the distal femoral physis. Gentle varus/valgus stress to the knee may elicit pain.

Patients who have tenderness of the growth plate and are unable to weight bear should be treated as having a presumptive physeal fracture and should be casted and referred to a fracture clinic for follow up. If in doubt, seek advice by discussing your clinical findings with orthopaedics.

Distal femoral epiphyseal widening. Courtesy of Orthobullets.com

Salter Harris Type II (SHII)

Distal femoral physeal fractures are most commonly SHII fractures. This fracture pattern is characterised by an oblique fracture that extends across the metaphysis of the distal femur. The metaphyseal corner that remains attached to the epiphysis is called a Thurston-Holland fragment.

Salter Harris II fracture of the distal femur. From Orthobullets.com

Salter Harris Type III (SHIII)

A SHIII fracture involves the physis and extends vertically through the epiphysis. These injuries can be produced by valgus stress during sports activities and may have an associated injury to the cruciate ligaments.

Salter Harris Type IV (SHIV)

SHIV fractures of the distal femur are uncommon. This injury pattern involves a fracture that extends vertically through the distal femoral metaphysis, physis and exits through the articular surface of the epiphysis.

Salter Harris Type V (SHV)

SHV fractures occur when the physis is crushed. This injury is rare and similar to SHI fractures in that they are often diagnosed retrospectively, when growth disturbance is observed following injury to the knee.

Management

Non-operative

Non-operative management may be considered in the case of non-displaced fractures. The injured leg is immobilised in a long leg cast for 4-6 weeks. Close clinical follow up by orthopaedics is essential to minimise complications.

Operative: closed technique

Closed reduction and percutaneous fixation followed by casting is used in cases of displaced SHI or SHII fractures. Some SHIII and SHIV fractures may be treated in this manner if anatomical reduction can be achieved. Again, the patient is followed closely post-operatively by orthopaedics to monitor for complications.

Operative: open technique

Open reduction internal fixation (ORIF) is indicated in the case of SHIII and SHIV fractures with weightbearing articular involvement or in the case of irreducible SHI or SHII fractures.

Complications

Growth arrest and arthritis

Any physeal fractures of the distal femur can be complicated by growth arrest. SHI and SH II fractures in other areas of the body usually have a low risk of growth arrest but in the case of distal femoral physeal fractures even minimally displaced SHI and SHII type fractures should be followed closely for physeal injury leading to growth arrest.

A complete growth arrest can lead to limb length discrepancies. A partial growth arrest can lead to angular deformities at the knee. SHIII and SHIV fractures that heal with displacement can produce post-traumatic arthritis because of their joint surface involvement. The risk of these complications can be minimised by maintaining anatomical physeal alignment and close follow up following non-operative and operative treatment.

Popliteal artery injury, peroneal nerve palsy and compartment syndrome

Although rare, vascular injuries can be associated with anterior displacement of the epiphysis or a posterior spike at the fracture site. Some studies have suggested that peroneal nerve palsy is observed in approximately 7.3% of distal femoral physeal fractures and compartment syndrome is noted in approximately 1.3% of these injuries.

Classic metaphyseal lesions

While discussing distal femur fracture patterns, it is important to mention classic metaphyseal lesions (CML). These fractures, also known as ‘bucket handle fractures’ or ‘corner fractures’, are highly specific for non-accidental injury (NAI) in children <1 year old. CMLs are most common in the tibia, femur and proximal humerus and can result from shearing forces applied to these long bones, which causes avulsion of the metaphysis. Shearing forces can be produced by holding a child by their trunk and shaking them causing their limbs to move back and forth. Any fracture in a non-mobile child should raise suspicion for NAI but be vigilant for the subtle findings of CMLs on X-ray. If you have concerns regarding NAI, escalate your concerns to the most senior clinician, contact the relevant social work / safeguarding department and discuss fracture management with the orthopaedic team. Refer to local hospital guidelines to give you an idea of what teams the child should be admitted under and what investigations should be carried out. See these DFTB resources related to child safeguarding for more information: skeletal surveys and NAI and safeguarding module facilitator guide.

Metaphyseal corner fracure of the distal femur. Courtesy of Orthobullets.com

The orthopaedic team review Marcus and a CT of his distal femur and knee is ordered to evaluate the degree of intra-articular extension and to define fracture fragments to plan fixation. Following CT he undergoes open reduction and internal fixation (ORIF) of the SH III fracture to distal femur and he is discharged home after a couple of days in a long leg cast. He will be closely monitored in fracture clinic during his recovery to minimise the risk of complications.

References

Amick A. (2019, Oct 7). Non-Accidental Trauma. [NUEM Blog. Expert Commentary by Riney C]. Retrieved from: http://www.nuemblog.com/blog/nonaccidental-trauma.

Ilharreborde, B., Raquillet, C., Morel, E., Fitoussi, F., Bensahel, H., Penneçot, G.F. and Mazda, K. (2006). Long-term prognosis of Salter–Harris type 2 injuries of the distal femoral physis. Journal of Pediatric Orthopaedics B15(6), pp.433-438.

Kareem, S., Shirley, E. and Skaggs, D. (2020). Distal Femoral Physeal Fractures- Pediatrics. Retrieved from: https://www.orthobullets.com/pediatrics/4020/distal-femoral-physeal-fractures–pediatric

McKenna, S.M., Hamilton, S.W. and Barker, S.L. (2013). Salter Harris fractures of the distal femur: Learning points from two cases compared. Journal of investigative medicine high impact case reports1(3), p.2324709613500238.

Price, C.T (2020). Extra-Articular Injuries of the Knee. Retrieved from: https://teachmeorthopedics.info/extra-articular-injuries-of-the-knee/

Wall, E.J. and May, M.M. (2012). Growth plate fractures of the distal femur. Journal of Pediatric Orthopaedics32, pp.S40-S46.

Fibula fractures

Cite this article as:
Shah Rahman. Fibula fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31860

Romesh, a 6 year old boy, was playing on some monkey bars at school when he slipped, and landed on his legs, and has been unable to weight bear since. The bars were approximately 1m high, and on examination, positive findings include an area of bruising over the lateral aspect of the right lower leg and marked tenderness on palpation.

Incidence

Isolated fibula shaft fractures are rare. More commonly, they are associated with tibia fractures, or with an ankle fracture affecting the distal fibula.

How might the patient present?

History

The mechanism is key to the injury pattern identified:

  • Direct trauma to the lateral aspect of the lower leg resulting in a transverse or comminuted fracture.
  • Twisting injuries producing a spiral fracture.
  • Repeated stress such as in long-distance runners can cause a fatigue fracture, usually just above the inferior tibiofibular ligament. Think of the cross-country running teenager who usually wouldn’t present but has new lower leg pain or antalgic gait

Examination

  • The normal process of look, feel, move is a good step after an initial history. Always examine the knee and the ankle as well as evaluating for other areas of injury. Gait is a useful assessment, as isolated fractures are likely to be treated conservatively.

Investigations

  • X- ray is the initial imaging modality of choice
  • Point of care ultrasound could be used to confirm the presence of a fracture, but given the risk of other associated bony injuries, patients will still require imaging.
  • Patients with complex injuries involving other bones or joints may warrant cross sectional imaging
  • Does the history match the injury – is there a risk for NAI?

Classification

Fibula fractures are classified by fracture type, whether there is an associated tibial fracture, whether they’re displaced or not and whether they’re open or closed,

  • Displacement i.e. 0-50% displaced, >50% displacement with bony contact, or fully displaced
  • Open/Closed
  • Greenstick type patterns can occur
  • Toddler’s fracture (Spiral fracture of the tibia) may uncommonly have an associated fibula fracture

Treatment

  1. Analgesia
  2. Remove significant contaminants from open wounds and administer antibiotics early
  3. Isolated shaft fractures – treat with either a supportive dressing, a cast or a boot
  4. As the fibula is rarely fractured in isolation, the need for surgical management (such as open reduction and internal fixation) if usually dictated by that of any associated tibial fractures

Potential complications

As with any fracture, union issues (delayed, malunion and non-union) is a risk, made worse if there’s infection. Compartment syndrome is a risk, but is more relevant if there is an associated tibial fracture. Be suspicious of an isolated spiral fracture at the proximal fibula; it may be associated with a distal tibia fracture, called a Maisonneuve fracture. These do poorly with conservative treatment, meaning the ankle must be imaged in those with an apparently isolated fracture of the fibula to prevent a missed tibial fracture. Although rare, these can occur in older adolescents with closed physes.

Ensure associated nerves (common peroneal if the fibular neck is fractured), arterial territory (the anterior tibial pulse) and lateral collateral ligament is intact with normal function. The lateral collateral ligament joins the femur and fibula, so whilst not as important as the other collateral ligaments, if damaged, it has a high co-incidence of stiffness or pain in other areas such as knee, ankle and foot can delay full rehabilitation.

Do not miss…

  • Compartment syndrome
  • Other associated fractures – namely at the ankle and tibia
  • Fibular head dislocation – the mechanism is usually a fall on a flexed knee, and can be managed with closed or open reduction.

And a bit of trivia

Some patients can be born without a fibula (fibula hemimelia). This will be picked up on ultrasound screening or on newborn screening, but may be relevant for those patients who haven’t presented to healthcare or have migrated.

Romesh was given loading doses of paracetamol and ibuprofen, as well as intranasal diamorphine. His lower leg x-ray, which also included ankle views, and his right lower leg shows a minimally rotated spiral distal tibia fracture and proximal fibula fracture – a Maisonneuve. He was taken to the emergency trauma list and managed with open reduction and internal fixation.

References

Emergency Care of Minor Trauma in Children, 1st Edition, Davies F

Lecture Notes Orthopaedics and Fractures, 4th Edition, Duckworth T and Blundell CM

Essential Orthopaedics and Trauma, 5th Edition, Dandy DJ and Edwards D

Foot and toe injuries

Cite this article as:
Taskin Kadri. Foot and toe injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32663

A child’s foot is significantly more cartilaginous than an adult foot, making foot fractures an uncommon injury in children. Foot fractures constitute about 5-8% of paediatric fractures. Evaluation and management of a paediatric foot injury requires an understanding of paediatric anatomy, a careful history, clinical examination, and potentially radiography.

Normal anatomy

The foot is anatomically divided into 3 sections: hindfoot, midfoot and forefoot.

The hindfoot includes the talus and calcaneus. The inferior surface of the talus is more prone to avascular necrosis due to its retrograde blood supply. The part of the calcaneus most prone to fracture is its large posterior facet.

The midfoot includes the navicular, cuboid and the three cuneiform bones.

The forefoot includes the metatarsals and phalanges.

Evaluation of foot injuries

History

The following specific enquiries should be made about the injury:

  • The mechanism of injury (high/low velocity, twisting, compression, direct blow)
  • Characteristics of pain (worse at the time of injury vs late onset)
  • Location of pain
  • Consistency and plausibility of the history, excluding concerns about non-accidental injury
  • The effect of the injury on the child (limping, the distance the child can move)
  • The efficacy of pain relief

Examination

Clinical examination should be tailored to the history.

Look

For external skin abrasions or obvious open fractures.

Feel

Palpation of the bones: tarsals, metatarsals, toes and the base of the 5th metatarsal.

Palpation for tenderness along the ligaments: deltoid ligament on medial side and anterior talofibular, calcaneofibular and posterior talofibular ligaments on the lateral side.

Move

The active movement should be followed by passive movement as much as pain allows.

The usual range of movements are: subtalar eversion (15-20°), subtalar inversion (35-40°), forefoot adduction (20°), forefoot abduction (10°), 1st metatarsal phalangeal (MTP) flexion (45°), 1st MTP extension (70-90°) and free motion of lesser toes.

Neurovascular examination

Two pulses: dorsalis pedis and posterior tibial.

Five sensory nerves: saphenous (medial calf and hindfoot), superficial peroneal (dorsum of the foot), deep peroneal (1st dorsal webspace), sural (lateral foot) and posterior tibial nerve (plantar foot and heel).

Imaging

The Ottawa foot rules can be applied to children. The rules have 97-100% sensitivity in paediatric injury investigation. According to the rules, x-rays of the foot are required if the child is unable to weight bear both immediately after the injury and in the ED, plus bony tenderness over the base of 5th metatarsal or the navicular.  

Accessory ossicles

Accessory foot ossicles can cause pain as a result of stress injuries. The navicular ossicles, arise either on the medial side of (os tibiale externum) or on the lateral tubercle of the navicular bone (os trigonum).

Os tibiale externum

This is an ossification centre that arises at the site of the tibialis posterior tendon on the medial side of the navicular bone. It becomes an accessory bone when it fails to fully ossify.  It is present in 4-14% of patients.

The usual presentation is in adolescence when the patient has pain from overuse, especially in athletes.

Os tibiale externum

Examination may reveal pes planus (flat foot). This happens as the tibialis posterior tendon, maintaining the medial longitudinal arch, attaches to the accessory bone rather than the navicular bone.

Investigations include plain films and, occasionally, MRI scan.  

Treatment is initially conservative with orthotics and casting. The ossicle is excised if these measures fail to resolve the pain.

Os trigonum

This is present in 10-25% of the population. It is often associated with heel pain in ballet dancers due to repetitive microtrauma.

Hindfoot fractures

These are rare, constituting only 0.008% of all paediatric fractures. Children usually present after falling from height or after a motor vehicle injury. The talus can be fractured in multiple places including avulsion fracture.

Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org. From the case rID: 77140

‘Snowboarder’s fracture’ is a fracture of the lateral process of the talus. The mechanism of injury involves dorsiflexion and inversion.

Do not miss: Snowboarder’s fractures are often misdiagnosed as an ankle sprain. If not evident on x-ray, a CT or MRI should be performed if there is clinical suspicion. Think carefully about the mechanism.

Calcaneus fractures typically occur due to axial loading and are frequently associated with vertebral compression fractures. Radiography should include AP, lateral and axial views. The axial view offers a better view of the fracture.

Treatment of talus and calcaneus fractures is dependent on the degree of displacement.

  • Non or minimally displaced avulsion fractures, or extra-articular fractures should be managed in a posterior short leg splint and should be non–weight bearing with crutches for 3 to 4 weeks.
  • Displaced fractures require reduction, by an orthopaedic surgeon, followed by immobilisation with a splint or cast. Severely displaced, comminuted or intra-articular fragments may require ORIF.

Midfoot fractures

These are also rare fractures and usually result from severe blunt injury. Most fractures are avulsion or stress fractures and are associated with other injuries.

Treatment depends on the severity of displacement of the fracture and associated injuries.

  • Non or minimally displaced fractures (the majority of these fractures) can be treated with a walking cast.
  • Displacement of the fracture fragment greater than 2mm should be managed with reduction and stabilisation before immobilisation.

Midfoot fractures have minimal long term sequelae.

Forefoot fractures

Forefoot fractures represent about 60% of paediatric foot fractures and can result from either direct or indirect trauma. They are easily missed: about 41% are missed due to high energy trauma causing other significant injuries.

Lisfranc fracture

Lisfranc fractures occur due to axial loading with forced plantar flexion (commonly seen in bicycle or horseback riders where a foot gets caught in a pedal or stirrup) or with a crush injury.

Clinical examination

  • Tenderness over the dorsum of the foot with swelling and inability to bear weight.
  • Plantar bruising is a consistent sign and if present should raise suspicion of the injury.  

Diagnosis is made with a weight bearing x-rays (as the fracture may not be evident on non-weight bearing views) – AP, lateral and oblique radiographs of the foot. The normal alignment of the foot should have the 2nd metatarsal aligning with the intermediate cuneiform on the dorsoplantar view and the 3rd metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms to the 2nd metatarsal. Disruption of this ligament leaves the foot unstable and hence it is an important not to miss this injury. Due to the ligament attachment, there is often associated fracture of the bases of the 1st or 2nd metatarsal in a Lisfranc injury.

https://emergencymedicineireland.com/

Treatment depends on the degree of severity of the injury.

  • Partial tears with < 2mm malalignment require immobilisation or a walking boot for 4-6 weeks. The patient should be referred to orthopaedic surgeons within 3-5 days due to the high rate of late complications.
  • More severe injuries require operative treatment with internal fixation.

There is a high rate of residual pain in children with a Lisfranc injury.

Metatarsal fractures

Metatarsal fractures are associated with athletic activity and are becoming more common. The 5th metatarsal is the most commonly fractured metatarsal in paediatric patients. It can result from twisting, repetitive stress or direct trauma. 1st and 5th metatarsal fractures can be isolated whereas 2nd-4th metatarsal fractures often occur along with other metatarsal fractures. It is a frequently missed fracture on a radiograph.

Children younger than 5 years of age are more likely to be injured by a fall from height and fracture the 1st metatarsal. Older children are more likely to fracture it from falling from a standing position, during sports and tend to fracture the 5th metatarsal.

Pseudo-Jones fracture

A Pseudo-Jones fracture is an avulsion fracture of the base of the 5th metatarsal resulting from a twisting injury of the foot. The examination will reveal focal point tenderness. The patient should be immobilised for 3-4 weeks in a weight-bearing cast.

Treat with a short walking boot or hard sole shoe for 6 weeks. Follow-up with orthopaedic surgeons.

Jones fracture

The Jones fracture is a fracture of the metaphyseal-diaphyseal junction at the base of the 5th metatarsal bone. It is the most common of metatarsal fractures (40%), representing about 25% of all paediatric foot fractures.

Jones fracture (metaphyseal-diaphyseal junction fractures of the 5th metatarsal).

Fractures at or distal to the metaphyseal-diaphyseal junction require 6 weeks in a non–weight bearing cast, with crutches. All patients should be referred to orthopaedic surgeons as there is a high incidence of delayed union of the fracture. Many of these patients will require ORIF subsequently.

The apophysis of the base of the 5th metatarsal appears at age 10 for girls and at age 12 for boys. An unfused apophysis runs longitudinally whereas pseudo-Jones fracture runs transversely.

Normal apophysis of the 5th metarasal (note it runs longitudinally rather than transversely). Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 8802

Toe fractures

Toes fractures are one of the most common fractures in the paediatric population. Phalangeal fractures constitute about 3-7% of all physeal fractures and are usually Salter-Harris I or II injuries. They are more common in boys than girls and are mostly closed in nature.

The patient may present with localised tenderness to the toe, a limp or inability to bear weight. Nail bed bleeding and bleeding from or around the nail fold should prompt the possibility of an open fracture through the nail bed. Alignment, rotation and neurovascular status should be checked.

Fractures of the 2nd-5th toes are usually treated by buddy strapping and weight bearing as much as possible. Healing can take up to 3-4 weeks. A hard-soled shoe or walking boot may be used for patient comfort. Follow-ups with orthopaedic surgeons can cease 3 weeks after the injury. If there is possible injury to physis then follow-up should continue for 1-2 years to detect abnormal growth.

The big toe

The big toe plays an important part in bearing weight. Fractures of the big toe are therefore managed slightly differently.  Salter-Harris III or IV fractures of the proximal phalanx of the hallux are often intra-articular.

Urgent orthopaedic consultation for closed or open reduction for K wiring if:

  • more than one third of the joint surface is involved or
  • displacement is more than 2-3mm

In other cases, toe platform cast or a walking boot is used.

The epiphysis of the proximal phalanx of the 1st toe is sometimes bipartite, simulating a Salter-Harris III fracture. If there is no tenderness on the 1st toe, no treatment is indicated.

Phalangeal open fractures require thorough irrigation and debridement in addition to antibiotics to avoid osteomyelitis.  A nail-bed injury to the germinal matrix will require surgical repair.

Long term complications include growth arrest and angular deformities from physeal injury, degenerative joint disease from intra-articular fractures and osteomyelitis from open fractures.

References

Boutis K: Paediatric metatarsal and toe fractures. Up to Date 2019

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].

Eiff, M. and Hatch, R. Fracture management for primary care and emergency medicine. Elsevier.

Halai, M., Jamal, B., Rea, P., Qureshi, M. and Pillai, A., 2015. Acute fractures of the pediatric foot and ankle. World Journal of Pediatrics, 11(1), pp.14-20.

Horner K and Tavarez M, 2016. Paediatric Ankle and Foot Injuries. Clin Pediatr Emerg Med, 17 pp. 38-52

Juliano, P., 2018. Lateral Talar Process Fractures – FootEducation. [online] FootEducation. Available at: <https://footeducation.com/lateral-talar-process-fractures/> [Accessed 4 April 2021].

Malanga, G. and Ramirez – Del Toro, J., 2008. Common Injuries of the Foot and Ankle in the Child and Adolescent Athlete. Physical Medicine and Rehabilitation Clinics of North America, 19(2), pp.347-371.

Metaizeau, J. and Denis, D., 2019. Update on leg fractures in paediatric patients. Orthopaedics & Traumatology: Surgery & Research, 105(1), pp.S143-S151.

Smit, K. Foot Fractures – Phalanx | Pediatric Orthopaedic Society of North America (POSNA). [online] Posna.org. Available at: <https://posna.org/Physician-Education/Study-Guide/Foot-Fractures-Phalanx> [Accessed 4 April 2021].

Shoulder examination

Cite this article as:
Mark Webb. Shoulder examination, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31287

Johnny is five. He fell onto his outstretched arm and now is sat in your ED, crying and holding his shoulder adducted. Triage has been ace and given him analgesia so he is adequately comfortable before you examine him.

Joint examinations can be easily remembered by “look, feel, move” and special tests. It’s important that in addition to the joint you’re interested in that you also examine the joint above and below.

Look

  • Deformity
  • Swelling
  • Atrophy: Asymmetry  
  • Wounds
  • Bruising
  • Skin tenting (typically clavicular fractures, whereby the bony fragment is causing pressure on the skin and thought to cause skin necrosis, although this is controversial) 

A chaperone may be needed to expose the joint adequately in older children.

Feel

Feel for warmth, which could indicate septic arthritis.

From the front:

Start medially at sternoclavicular joint

Anatomy of the acromio-clavicular joint

From the back:

  • Scapula: spine, supraspinatus, infraspinatus muscle

Neurovascular assessment:

  • Check for distal pulses: brachial/ radial.
  • Always check the regimental patch for axillary nerve injury and document it.

Move

Assess for range of motion, both active and passive.

Girl flexing and extending at shoulder showing range of movement

Flexion: 180 degrees. Raise arm forward up until they point to the ceiling.

Extension: 45-60 degrees. Stretch the arm out behind them.

Girl showing range of adduction and abduction at the shoulder

ABduction: 150-160 degrees. Put arms out to the side like an aeroplane’s wings and then bring them above their head to point to the ceiling.

ADduction: 30-40 degrees. Put arms out to the side like an aeroplane’s wings and move them in front of their body so they cross over.

Girl showing range of internal and external rotation

External rotation: 90 degrees. Tuck their elbows to their side and swing the hands out.

Internal rotation: 70-90 degrees. Tuck elbows to the side and bring their hands across their tummy.

Scapula winging: Ask the child to push against the wall or your hand. If the scapula wings out this suggests long thoracic nerve pathology.

Some special tests

It is easy to get lost in the number of special tests when examining the shoulder and the trick is to perform those most relevant to the patient in front of you. Many are to test the integrity of the rotator cuff tendons, i.e. Supraspinatus, Infraspinatus, Teres minor and Subscapularis. (SITS)

Girl performing Apley scratch test

“Appley Scratch” test: (1) Ask the child to reach behind their back to touch the inferior border of the opposite scapula (internal rotation and aDDuction) and then (2) reach behind their head to touch the superior angle of the opposite scapula (external rotation an Abduction). A positive test of pain indicates tendinitis of the rotator cuff, usually supraspinatus.

Girl performing empty can test

Empty can test: Ask the child to hold their arm raised parallel to the ground and then point their thumbs towards the ground as if they were holding an empty can (this rotates the shoulder in full internal rotation while in abduction). Then push down on the child’s wrist while asking them to resist. A positive test is pain or weakness, suggestive of supraspinatus tear or suprascapular nerve neuropathy.

Girl performing lift off test

Lift off test: The child stands and places the back of their hand against their back. Put your hand against theirs, palm to palm, and ask them to push against you. A positive test is pain or weakness, indicating subscapularis muscle pathology.

Girl and boy performing scarf test

Scarf test: Ask the child to wrap their arm over the front of their neck reach down over their opposite shoulder towards the scapula (like a scarf). Pain over ACJ when doing this indicates ACJ pathology.

Although the standard approach to limb examination involves a LOOK, FEEL and MOVE (and special tests) structured assessment, in reality, if a young patient has a significant injury, a more pragmatic approach is needed. An X-ray may be warranted before a more thorough exam. This doesn’t mean that you can get away without a documented range of motion exam (even if you explain it is limited by pain) and neurovascular assessment.

Back to Johnny. You noticed a deformity over the middle third of the clavicle, but no skin tenting. He was neurovascularly intact and range of movement only marginally reduced by pain, so you discharged him with a broad arm sling and follow-up (or not) according to your local guidelines.

Selected references

Carson, S., Woolridge, D.P., Colletti, J. and Kilgore, K. (2006) Pediatric upper extremity injuries. Pediatric Clinical North American: 53(1) pp. 41-67

Chambers, P.N., Van Thiel, G.S. and Ferry, S.T. (2015) Clavicle Fracture more than a theoretical risk? A report of 2 Adolescent cases. The American Journal of Orthopedics. 44(10) 

https://fpnotebook.com/Ortho/Exam/ShldrExm.htm [Accessed April 2019]

McFarland, E.G., Garzon-Muvdi, J., Jia, X., Desai, P. and Petersen, S.A. (2010) Clinical and diagnostic tests for shoulder disorders: a critical review. British Journal of Sports Medicine. 44(5) pp. 328-32.

NationwideChildrens.org/Sports-Medicine

https://shouldercomplexgocatsnmu.weebly.com/range-of-motion.html [Accessed April 2019]

Proximal humeral fractures

Cite this article as:
PJ Whooley. Proximal humeral fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31855

“Slow down!” Joel’s mom shouts at him as he whizzes past on his scooter. Joel turns to answer and doesn’t see the curb which he hits, goes flying and puts out his hand to stop himself. Mom is already running to find him holding his arm.

Proximal humeral fractures are uncommon, accounting for less than 5% of all paediatric fractures. The anatomic characteristics of the proximal humerus can explain the various fracture presentations, complications and outcomes.

Anatomy

Ossification centres

The proximal humeral physis has three ossification centres. Head, lesser tuberosity and greater tuberosity. The capital centres appear at 3 months whereas the two others appear at 1 year of age and fuse between 3 & 5 years to produce tuberosity ossification. By the time the child’s 6, the capital and tuberosity centres fuse into a single proximal epiphyseal centre. At this point it acquires a characteristic ‘tent’ or inverted V shape. This results also in a double contour that can complicate the interpretation of the images. The proximal physis accounts for approximately 80% of the longitudinal growth of the entire bone.

Periosteum

This thick sleeve of periosteum is present along the shaft and limits fracture displacement and promotes healing.

Nerves

The axillary nerve, which supplies the sensory innervation to the regimental badge area, is at potential risk in displaced proximal humeral fractures. However, axillary nerve damage is rare, the majority being only a temporary neuropraxias.

Epidemiology

Proximal humeral fractures show an early modest peak at 10-14 years of age, account for up to 3.5% of all fractures, followed by return to low levels in young adults and then a second increase in later adulthood.

These fractures account for a third of all humeral fractures in neonates and are the second most common birth injury after clavicular fractures.  However, they are still rare, occurring in only 0.03 per 1000 births.

The pattern of injury varies with age. Metaphyseal proximal humeral fractures are proportionately higher in pre-pubertal children, compared to a higher proportion of epiphyseal separation in adolescents.

As with any fracture, be aware of the potential of a non-accidental cause. These fractures, can be associated with physical abuse.

Mechanism of Injury

Indirect

Proximal humeral fractures in non-newborns commonly result from a fall backwards onto an outstretched hand with elbow extended and wrist dorsiflexed or a direct blow to the lateral aspect of the shoulder. Pathological fractures  can occur as the humerus is a common location of bone cysts and other benign lesions. This might occur with minimal trauma.

Birth injuries

The upper arm can be hyperextended or rotated during delivery, occurring more commonly in infants of diabetic mothers and with shoulder dystocia.

Clinical Evaluation

Newborns

Typically, a newborn with a proximal humeral fracture will hold their arm in extension. Consider these fractures if a history of birth trauma is given. If noted, then infection, clavicle fracture, shoulder dislocation and brachial plexus injuries need to be ruled out. These little ones may be irritable, particularly when the upper limb is moved.

Children and adolescents

As with other upper arm fractures, the typical presentation is with pain, dysfunction, bruising and swelling with a painful range of movement. Displaced fractures result in significant anterior swelling and altered shoulder appearance relative to the contralateral side.

A detailed distal neurovascular examination is needed including evaluation of the radial, ulnar, median, axillary and musculoskeletal nerves. Be particularly vigilant for any axillary nerve deficit with decreased sensation over the regimental badge area and loss of the deltoid muscle function (shoulder ABDuction).

Radiology

Proximal humeral fractures are identified on routine AP and axillary views of the humerus. If there is clinical concern of a dislocation then dedicated shoulder views should also be taken. If there is tenderness over the physis and no obvious fracture, a suspicion of a Salter Harris (SH) I fracture can be made. Imaging the contralateral humerus may be helpful to determine if there is any widening of the physis.

Patterns of fracture

There are two variations of proximal humeral fractures: metaphyseal and epiphyseal separation.

  • Metaphyseal fractures (70%) usually occur at the surgical neck, although can also occur at the metaphyseal-diaphyseal junction, typically a transverse or short oblique fracture. These fractures typically occur in 5-12 year olds.
  • Epiphyseal fractures (30%) occur in the under 5s and over 12s. The type of epiphyseal fracture depends on skeletal maturity.

SH I fractures are less common and can be seen at all ages before growth-plate closure, most commonly in <5 year olds.

SH II fractures are the most common type, chiefly in adolescents over the age of 12.

SH III & IV fractures are exceedingly rare.

A metaphyseal fracture at the surgical neck of the humerus
Epiphyseal Salter Harris II fracture of the proximal humerus in a 6 year old

Pathological fractures

40% of pathological fractures involve the proximal humerus. The leading cause is a unicameral bone cyst, as this lesion develops in the proximal humerus in 51% of cases. Other causes are aneurysmal bone cysts, non-ossifying fibromas, fibrous dysplasia and bone malignancies.

Displacement

If a proximal humeral fracture displaces, it usually does so in a varus direction, with the humeral head moving medially and posterior to the shaft. This occurs due to pectoralis major traction pulling the distal segment medially, while the rotator cuff and deltoid pull the proximal component superiorly in a tendency towards flexion and external rotation. Displacement is often absent or minimal in 40% of metaphyseal fractures, but is more common in epiphyseal injuries, occurring in up to 85%.

Proximal humerus fracture in an 11 year old with varus deformity

Classification

The Neer-Horowitz classification is the most frequently used classification system for this type of fracture. It divides the proximal humerus into 4 parts, classifying fracture by the degree of displacement as well as the fracture line, consisting of:

  1. Humeral head
  2. Greater tuberosity
  3. Lesser tuberosity
  4. Humeral shaft

One-part fractures involve 1 – 4 undisplaced parts (<1cm AND <45 degrees)

Two-part fractures account for 20% of proximal humeral fractures, involving 2 – 4 parts, 1 of which is displaced (i.e. >1cm OR >45 degrees)

  1. Surgical neck – most common
  2. Greater tuberosity – often seen with anterior shoulder dislocation. A lower threshold for displacement (>5 mm) has been proposed.
  3. Anatomical neck
  4. Lesser tuberosity

Three-part fractures account for 5% of proximal humeral fractures and involve 3 – 4 parts, 2 of which are displaced (i.e. > 1cm OR > 45 degrees)

  1. Greater tuberosity and shaft displaced with respect to lesser tuberosity and articular surface which remain together.
  2. Lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together.

Four-part fractures are uncommon, occurring in less than 1% of proximal humeral fractures. They involve more than 4 parts, 3 of which are displaced (i.e. >1 cm OR > 45 degrees with respect to the 4th). Four-part fractures require operative reduction.

Management

Initial treatment

Displaced fractures can be very painful so ensure pain is addressed with adequate analgesia.

The aim of immobilisation is to keep the elbow by the side, flexed to 90 degrees with the forearm against the torso. A simple sling is sufficient plus / minus a swathe for younger ages. Straps and adhesive tape can be used as described by Durrajer. Other options include a shoulder immobiliser or a U-shaped coaptation splint.

Neurovascular status must be checked before and after immobilisation.

Orthopaedic consultation should be obtained if there is:

  • associated shoulder dislocation
  • intra-articular (SH IV) fracture
  • completely displaced fracture in a child over 12 years.
  • associated neurovascular compromise
  • open fracture (rare)
  • evidence of compartment syndrome

Definitive Treatment

Newborns usually have SH I fractures, which have an excellent prognosis. A sling and a swathe is sufficient for up to 4 weeks. The primary role of follow up is to ensure there is no brachial plexus injury.

Children and adolescents with minimally displaced fractures are usually managed with a sling or shoulder immobiliser. Gentle pendulum exercise is started between weeks 2 to 4 post injury and active range of movement at 4 to 6 weeks. We would expect near to normal function by 2 months.

Significantly displaced fractures in children 12 and under should be treated with a U-slab, sling and swathe.

Acceptable angulation

  • < 5 years – any degree is allowed as proximal humeral fractures in young children have excellent remodelling potential.         
  • 5 to 12 years – 40 to 70 degrees of angulation is acceptable
  • >12 years – up to 40 degrees of angulation or 2/3 displacement.

Operative

Fractures in which immobilisation would result in unacceptable alignment are managed with closed reduction +/- fixation. Open reduction and internal fixation (ORIF) is indicated if acceptable reduction is not possible due to soft tissue interposition. Most commonly this is caused by the long head of biceps tendon, but can also be caused by the joint capsule, infolded periosteum and deltoid muscle. ORIF is also indicated in open fractures, compound fractures and intra-articular displacement of the fracture.

Complications

Complicated are rare in children, but when do occur are more common in older children, with shortening of the humerus due to physeal damage. This usually has no functional affect. Radiographic malunion can occur but rarely has any functional affect.

Non accidental injury

And finally, as with any fracture, it is imperative that a mechanism inconsistent with an injury or fracture in an otherwise healthy child should prompt escalation and involve the child protection team.

Joel’s x-ray shows a proximal humeral fracture through the surgical neck, with 20 degrees of angulation. He’s placed in a shoulder immobiliser and followed-up in fracture clinic, where he’s advised to start gentle pendulum exercises after a couple of weeks. Two months later he’s back on his scooter, helmet on, flying down the pavement without a care in the world.

References

LA. Landin. Epidemiology of the children’s fractures. J Pediatric Orthop B. 1997;6(2):79

E.J. Ortiz, M.H. Isler, J.E. Navia, R. Canosa, Pathologic fractures in children. Clin Orthop Relat Res, 432 (2005), pp. 116-126

MW Shrader et al, Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23(4);431

Pectoral girdle, shoulder region and axilla | Clinical Gate

Toddler fracture

Cite this article as:
Rhiannon McClaren. Toddler fracture, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31170

A 2-year-old girl, Aila, presents to the emergency department with her mother. She had been running around at childcare playing with her friends when she fell over. She is upset, has refused to walk since and won’t weight bear on her right leg. On examination, there is no obvious swelling or deformity and on palpation and axial loading it appears that her pain is most likely localised to her right lower leg, but it’s hard to be sure.

A toddler’s fracture is a non-displaced spiral fracture of the distal two-thirds of the tibial shaft, with an intact fibula, occurring in children generally between the ages of 9 months and 3 years. The periosteum remains intact. It was first described in 1964 by Dunbar et al. It is thought to be due to new stresses on the bone due to increasing ambulation.

History and examination

The mechanism is usually trivial, a trip or a fall, and often involves a twisting mechanism. Sometimes a specific story of trauma is difficult to elicit. More commonly children present unwilling to bear weight or limping with non-specific examination findings. They may be tender to palpation of the tibia, have pain with dorsiflexion of the ankle or pain with gentle twisting of the lower leg. All joints of the lower limb should be examined. It is always worth examining both lower limbs as gait can be difficult to assess in toddlers and may be misleading regarding the side of the injury.

As part of a thorough history and examination, any history of fever, weight loss, recent illness, or recurrent presentations with minor injuries should be elicited. The child should have their spine and neurology examined as well as any bruising, petechiae, warmth and swelling of joints, and puncture wounds on the soles of the feet documented.

Imaging

Initial x-rays may show a non-displaced spiral fracture of the tibia, however, a fracture may not be seen despite multiple views. AP and lateral views should be adequate in children, however, an oblique view may help. A repeat x-ray in 1 week usually shows sclerosis or periosteal reaction. 

AP and Lateral of lower limb
Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 9317
Periosteal reaction and callus formation in healing toddlers fracture
Case courtesy of Dr Sebastian Tschauner, Radiopaedia.org. From the case rID: 49123

But, a plain film x-ray may not be where it ends. Ultrasound is being explored as a possible diagnostic tool for toddler’s fracture, as sonography is used more and more for diagnosis of long bone fractures in children. The idea’s not a new one; a case report of three children in England in 2006 demonstrated that Point of Care Ultrasound Scan (POCUS) could be used to diagnose toddler’s fracture where initial x-rays did not show any fractures. They used the appearance of an elevated periosteum and a layer of low reflectivity superficial to the tibial cortex which suggests a fracture haematoma as a way of diagnosing an occult fracture. 

Cortical breach seen on ultrasound
Ultrasound image showing cortical breach in a toddler’s fracture. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

A recent pilot study by Carsen et al comparing ultrasound to radiographic diagnosis of toddler’s fractures looked at 27 children presenting with suspected toddler’s fractures. Five children had confirmed toddler’s fractures and of these five, three were identified correctly by x-ray at initial presentation and the other two were diagnosed with repeat x-ray at follow up appointments. All five children had their toddler’s fracture correctly identified using POCUS at their initial presentation. 

Radiograph showing Toddler fracture
AP x-ray of the same toddler’s fracture seen on ultrasound. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

Although there are limited studies evaluating the use of POCUS in the diagnosis of toddler’s fractures, the small number of studies and case studies available are promising. As a point of care test in someone with appropriate training, this is a convenient potential diagnostic tool, particularly given the potential to reduce radiation exposure for children.

Management

Toddler’s fractures do not need to be reduced and the management is largely supportive for 3-4 weeks. Standard treatment is a long leg back slab followed by a long leg walking cast. 

A number of retrospective studies have looked at rates of immobilising toddler’s fractures when the diagnosis is either confirmed or presumed. They show that children with confirmed toddler’s fractures are more likely to be immobilised. But… a series of 75 children with radiographic evidence of toddler’s fractures, by Schuh et al., looked outcome following a variety of treatments (cast/splint, controlled ankle movement boot, or no immobilisation). Those not immobilised had fewer follow up appointments and fewer repeat radiographs. Skin breakdown was reported in 17% of children, all of whom were in a splint or cast. Schuh et al. also found that children who were not immobilised walked much earlier than those who were immobilised in a controlled ankle movement (CAM) boot or splint. It was a mean of 4.1 days for the little ones not immobilised compared to 27.0 days for the smallies in a boot and a whopping 27.5 days for those in a cast or splint.  

Another retrospective study by Bauer and Lovejoy of 192 children, aged 9 months to 4 years, meeting criteria for a toddler’s fracture, showed an earlier return to weight-bearing in those immobilised with a CAM boot compared with a short leg cast (2.5 vs 2.8 weeks). Even when considering the seven children in this study who received no immobilisation, none of the fractures shifted. Sapru and Cooper also found that there were no complications with management in or out of a cast.  

There is now a move towards recommending immobilisation in a CAM boot or short leg cast or splint rather than in a long leg cast. Further studies are currently underway so watch this space!

What not to miss

A thorough history and examination should always be taken so as not to miss other diagnosis. If a child is not yet mobile, there must be a high suspicion for non-accidental injury. Fevers warrant consideration of septic arthritis or osteomyelitis. Malignancy and inflammatory conditions should also be considered. 

Aila’s initial x-ray showed a non-displaced spiral fracture of the distal third of her right tibia. She was placed in a long leg back slab and had a follow-up with the local orthopaedic service in the fracture clinic. Four weeks later she is running around and happily playing with her older brother.

 References

Alqarni, N., & Goldman, R. D. (2018). Management of toddler’s fractures. Canadian family physician Medecin de famille canadien64(10), 740–741. 

Bauer, J.M., Lovejoy, S.A. (2019) Toddler’s Fractures: Time to Weight-bear with Regard to Immobilization Type and Radiographic Monitoring. J Pediatr Orthop. Jul: 39(6), 314-317. 

Carsen, S., Doyle, M., Smit, K., Shefrin, A., Varshney, T. (2020) Point-of-care Ultrasound in the Emergency Department may provide more accurate diagnosis of toddler fractures than radiographs: A pilot study. Orthopaedic Proceedings. 102-B

Dunbar, J.S., Owen, H.F., Nogrady, M.B., McLeese, R., (1964) Obscure Tibial Fracture of Infants – The Toddler’s Fracture. Journal of the Canadian Association of Radiologists, Sep;15, 136-144. 

Fox, S. (2013) Toddler’s Fracture. Available at: https://pedemmorsels.com/toddlers-fracture/

Lewis, D. and Logan, P. (2006), Sonographic diagnosis of toddler’s fracture in the emergency department. J. Clin. Ultrasound. 34: 190-194. 

Pattishall, A.E. (2019) An updated approach to toddler fractures. J Urgent Care Med.  Available at: https://www.jucm.com/an-updated-approach-to-toddler-fractures/

Rasuli, B., Gaillard, F. Toddler Fracture. Available at: https://radiopaedia.org/articles/toddler-fracture

Royal Children’s Hospital Guidelines – Tibial Shaft Fractures. Available at: https://www.rch.org.au/clinicalguide/guideline_index/fractures/tibial_shaft_emergency/

Sapru, K., Cooper, J.G. (2014). Management of the Toddler’s fracture with and without initial radiological evidence. Eur J Emerg Med. Dec;21(6), 451-454. 

Schuh, A.M., Whitlock, K.B., Klein, E.J. (2016) Management of Toddler’s Fractures in the Pediatric Emergency Department. Pediatri Emerg Care.  Jul: 32(7), 452-454.

UpToDate – Tibial and fibular shaft fractures in children

Wang, C.C., Linden, K.L., Otero, H.J. (2017) Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 33(3), 200-207. 

Wijtzes, N., Jacob, H., Knight, K., Thrust, S., Hann, G. (2020) Fifteen-minute consultation: The toddler’s fracture. Arch Dis Child Educ Pract Ed. 0, 1-6. 

Head injury – the 4-hour observation clock…

Cite this article as:
Patrick Aldridge. Head injury – the 4-hour observation clock…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32331

You have just seen a 3 year old boy who, one hour earlier, was running along the street, fell over and hit his head. There was no loss of consciousness, no vomiting and he’s running around the Emergency Department (ED) completely unaware of ‘social distancing’ practices. On examination he’s got a small forehead abrasion but nothing else concerning. The parent was initially concerned (so came to ED) and now wants to go home.

You think this is sensible and speak to your senior who advises that you observe him for 4 hours post-injury. You think he’s got a ’trivial head injury’ with no risk factors and ask why they need to wait a further 3 hours in ED. ‘That’s what we do’ comes the reply…

Paediatric head injuries, arguably, make up a significant proportion of children attending hospital. It’s been suggested and subsequently shown  that a fair proportion could be sent home by a competent nurse at triage even during a worldwide pandemic…

PREDICT have done some wonderful work recently with their ‘Guideline for Mild to Moderate Head injuries in Children – Algorithm’ (2021) – answering questions I have often wondered myself. However, I personally feel the two most ground-breaking of all these recommendations appear to have been glossed over. This may be because they are soooo obvious, simplistic and pragmatic but that makes me love them even more…

Trivial head injuries

Children with trivial head injuries do not need to attend hospital for assessment; they can be safely managed at home’. 

  • How many children in your own experience fall (boom boom) into this category and attended for review?
  • How much money and time (the families and the health services) could be saved if these children stayed at home?

A lot’ would be the assumption for both of these questions. However, this is currently an evidence void in need of answers.

Extended observation OR discharge

It is made very clear that children who do not fall into one of the assorted risk categories have ‘no need for observation’ aka discharge home.

  • No need to stop, pass go or take up sacred ED seating until 4 hours after their medically innocuous injury (agreed, to a parent an injury may not have been innocuous but by medical head injury rules it is).
  • The child stays for no longer than it took to see and assess them. This may be a hard practice to change in many ED’s.

4 hours

How many paediatric head injuries in your own clinical practice do you or someone else say/write the immortal words “Observe 4 hours from injury’? 

Do all the children observed for 4 hours across the world require this?

How many children, that you have seen in your practice, have deteriorated?

Why does this practice exist and what is the evidence base?

Well, there is a clear consensus on who should be observed for 4 hours from injury. In the UK, the National Institute for Health and Care Excellence (NICE) Head injury: assessment and early management CG176, 2014 – – suggests children with the following require observation for at least 4 hours from the injury:

  • Loss of consciousness lasting more than 5 minutes (witnessed)
  • Abnormal drowsiness
  • Three or more discrete episodes of vomiting
  • Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object)
  • Amnesia (antegrade or retrograde) lasting more than 5 minutes

The latest PREDICT guideline is slightly more prescriptive (especially around age groups) and suggests those with the following risk factors need observation for up to 4 hrs…

But why 4 hours? Why not 3 hours, as someone previously suggested with wheeze?  Why observe them at all and just CT the lot? Well, at the end of the day this is all about risk stratification. A CT scan is not without risk (that small thing called radiation?) and the actual number of abnormal CT’s (ciTBI/TBI-CT) has been shown to be quite low (2.3%) in a large group (19 920) of children with head injuries.  We want to scan those children deemed ‘high risk’ who are more likely to have an abnormal scan not those deemed medium/low risk who are less likely to have an abnormal scan.

The evidence for 4 hours

What evidence is 4 hrs observation based on? Umm, not a lot. Like many practices in medicine, it’s based on consensus and pragmatism. Many institutions follow a 4 hour target for patients to be admitted or discharged from the emergency department. Children with asthma/wheeze seem to require inhalers every 3-4 hours until discharge too and there are, no doubt, countless other examples within the medical world. Four hours observation post-injury is the consensus view and currently established practice from experts with specialist knowledge in this field. It probably came about when you had to sell your kidney to the Radiologist to get a CT scan and radiation doses delivered per scan were a lot higher than present ‘modern’ machines. It was easier to just observe the child and if they deteriorated you could then more easily argue for a scan. This is my best guess but is probably not far from the mark. Could this time be shortened in these at risk groups? Probably. But trying to research this would, no doubt, be an ethical minefield.

The clock is ticking…

There are a small select group of children with head injuries who require a period of observation post-injury, as suggested by national guidelines, decision rules and clinical gestalt. I would argue many children in ED’s across the world that are observed for ‘4 hours post-injury’ do not fall into any of the categories mentioned above and the root cause for observation being clinician preference based on defensive or outdated practice. This is understandable in those who see children infrequently, but should this be accepted going forward?

In the COVID-era we are living through, I believe there will be an increased focus on reducing unnecessary hospital footfall, ED crowding and time in a potentially risky environment. One potential quality improvement project would be to look at your own institution – how many children stay ‘4 hours post-injury’ and how many really needed to…?

Carpal injuries

Cite this article as:
Sian Edwards. Carpal injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.29050

Injuries to the hands are extremely common in children and are a frequent reason for their attending the ED. While common, their management can be limited by difficulties in proper assessment as well as a paucity of evidence to guide treatment. That said, documented outcomes remain typically excellent so it seems we must be doing something right! Generally, training is provided with an adult focus, and while some principles from adult trauma can be applied, it is not uniform. As our post on radiographic findings demonstrates, the bones of children are different. This is significant because we know that missed injuries or delays in appropriate treatment can lead to long term loss of function; further compounded by the science that children heal faster and therefore our window for intervention is considerably shorter. Therefore, accurate assessment coupled with appropriate initial management and timely referral if necessary are essential.

As is not uncommon in the paediatric arena, evidence specific to this population is limited although it is stated that carpal fractures in children are being increasingly reported . Perhaps this is as we, as clinicians, get better at diagnosis and radiologists therefore see more and so naturally become more adept at interpreting them. Regardless of radiographic findings, diagnosis is primarily through clinical examination. 

While not exclusive to the teenage population, we can expect the majority of carpal injuries to occur in the older child; as children age, become braver and take on more activities with an increased likelihood of higher velocity falls. Falling onto an outstretched hand, otherwise widely known as a FOOSH injury, is a common mechanism, accounting for 30% of non-scaphoid carpal injuries.

Before we get in to it, we can take a moment to re-familiarise ourselves with the bones of the hand and wrist.

The carpus

The carpal bones are the eight bones of the wrist that articulate the forearm with the hand – this in itself seems confusing as they are quite clearly situated in what we call the hand but go with it. They are divided into the proximal and distal rows, collectively known as the carpus. Proximally we have scaphoid, lunate, triquetrum, pisiform and distally, trapezium, trapezoid, capitate, hamate. The carpal bones develop through the course of childhood and should all be visible on X-ray by approximately 8 years of age.

Literature suggests that carpal fractures account for around 8-19% of all hand injuries worldwide; as we’ve already touched on, the majority will be scaphoid fractures and ED’s are pretty used to dealing with these – they even get their own series of x-rays – for that reason, this post will give some time to carpal fractures NOT including the scaphoid.

What are we looking for on x-ray?

While the AP view allows clear visualization of all of the carpal bones and would appear the ‘easier’ view, particularly to those less experienced with interpreting these x-rays, the lateral view is good for assessing the distal wrist, carpal bones and proximal metacarpals – it can appear confusing at first due to the overlapping bones. Regardless, both radiographs must be evaluated together. As always, we are tracing each individual bone looking for obvious breaks in the cortex before then looking for uniformity of the joint spaces; abnormally widened spaces are often indicative of ligamentous injury however abnormally narrow spaces are often the result of radiographic projection rather than injury. It is often helpful to sit back from the image and see it in its entirety as well as a close-up view.

Image adapted from a case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 37947

Recommended questions to ask when looking at the carpal bones:

  • Is the scapho-lunate distance less than 2mm wide? – if NO then suspect a tear of this ligament.
  • Is there a bony fragment lying posterior to the carpal bones? if YES, then suspect triquetral fracture.
  • Is there a bone sitting in the cup of the lunate? If NO, think carpal dislocation involving the lunate.

After the scaphoid bone, the triquetrum is the most commonly fractured bone in isolation with the trapezoid bone being the least frequently fractured. Each will now get it’s moment to shine as we take a minute to go through them.

Triquetral

Triquestral
Triquetral bone

Triquetral fractures usually occur on the dorsal aspect of the bone and are often the result of perilunate fracture dislocation as well as fracture of distal radius and ulna; they account for about 20% of all carpal fractures and are regularly missed.  These may occur by means of impingement from ulnar styloid, shear forces or avulsion from strong ligamentous attachments. The usual mechanism is a FOOSH whilst in ulnar deviation, and less commonly a direct blow to the dorsum of the hand. It is best seen on a lateral projection where the avulsed flake of bone may be seen lying posteriorly to the triquetrum – look for pooping duck sign on the image.

Image adapted from a case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 16046
Case courtesy of Dr Matt Skalski, Radiopaedia.org. From the case rID: 57109

Hamate

The hamate

Hamate fractures are rare, only accounting for approximately 2% of carpal fractures, potentially due to under reporting. They generally don’t happen in isolation, often being associated with dorsal fracture dislocation of 4th and 5th carpometacarpal (CMC) joints, ulnar nerve injury and flexor tendon rupture, especially of 4th and 5th fingers. Common mechanisms are from blunt trauma e.g. fist punch, falls and through impact from racquet sports.

Image adapted from a case courtesy of Andrew Murphy, Radiopaedia.org. From the case rID: 46110

Capitate

Capitate

Like hamate fractures, capitate fractures are also frequent injuries which seldom occur in isolation. A capitate fracture is uncommon, accounting for approximately 1.3% of carpal fractures and can be associated with a scaphoid fracture. It is uncommon to have a combined capitate-hamate fracture. The primary mechanism is a FOOSH with the wrist in hyperextension. Injury can result in ‘scaphoid capitate’ syndrome (1-2% incidence) where the capitate actually rotates by 180o – this latter presentation will need open reduction.

Image adapted from a case courtesy of Dr Bahman Rasuli, Radiopaedia.org. From the case rID: 65954

Lunate

Lunate

Lunate fractures account for about 1% of carpal fractures, and like its predecessors rarely occur independently. They are associated with injuries to the distal radius, carpus or metacarpals. Subluxations / dislocations of the carpus are most commonly centred around the lunate bone and key to their detection is the apple, cup, saucer analogy- the cup of the lunate should never be empty – the distal radius, lunate and capitate articulate with each other in a straight line on the lateral radiograph, so when examining the image, if the capitate (apple) is not sitting in the cup of the lunate on the saucer of the radius then injury is present. Failure to recognise this anatomy means that dislocations are often overlooked. Where scapho-lunate ligament injury has occurred, missed diagnosis can lead to chronic pain around the joint due to its instability. In the younger population, surgery will be considered to restore full function and relieve pain.

Normal capitate – lunate – radius alignment. Image adapted from a case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 37947
Perilunate dislocation. Image adapted from a case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 46714
Image adapted from a case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 70427

More commonly, injury can occur at the scapho-luncate ligament – on x-ray, expect to see a widened joint space which is often referred to as the “Terry Thomas” or “Madonna” sign (named for the gap between the front teeth) demonstrating such injury. While conservative management may often be trialled, surgical reconstruction can be needed.

Image adapted from a case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 46695

Trapezium

Trapezium

Trapezium fractures comprise between 3% and 5% of all carpal fractures and <1% of all hand injuries; they can occur in isolation or in combination with another carpal bone e.g. fracture of the 1st metacarpal base and/or subluxation or dislocation of the 1st carpometacarpal (CMC) joint although this is extremely rare. They are often the result of high energy trauma, usually involving axial loading force. Isolated trapezium fractures can be easily missed on x-ray due to the overlying bones, particularly on AP view.

Image adapted from a case courtesy of Amanda Er, Radiopaedia.org. From the case rID: 74739

Pisiform

Pisiform

Pisiform fractures account for 0.2% of all carpal fractures and of those, half are in association with other carpal injuries; rarely it may dislocate without fracture and displace radially. Its rarity is attributed to the sturdy ligaments that encase it.

Image adapted from a case courtesy of Dr Garth Kruger, Radiopaedia.org. From the case rID: 29263

Trapezoid

Trapezoid bone

Trapezoid fractures are incredibly rare, with only about 10 cases reported in the literature. Their anatomic location and stable articulation with the 2nd metacarpal together with their strong ligamentous attachments to neighbouring carpal bones are thought to be responsible for the low incidence of fracture.

Image adapted from a case courtesy of Dr Bruno Di Muzio, Radiopaedia.org. From the case rID: 46412

So how do we manage these injuries?

Inevitably there will be some local differences, but the general principles are:

  • Closed manipulation can prove difficult and often unsuccessful so orthopaedic review is required if displacement exists.
  • If no displacement, and no concern about ligamentous injury, then conservative management is often indicated. There is frequently no requirement to formally immobilise so analgesia may be the only treatment. 
  • If carpal subluxation is suspected, always refer to the orthopaedic team for specialist evaluation. If you are unsure, the literature discusses obtaining a radiograph of the uninjured hand to use as comparison – this is not always a well received request so do consider utilising your local reporting radiologist, and if unavailable or in doubt then refer for follow up.

The take home

So, what essentially is our take home message? We need to keep in mind that carpal fractures, dislocations and ligamentous injuries do occur in children, albeit rarely. We need the ability to recognise the ‘normal’ so we can pick out the ‘abnormal’. As with all injuries, diagnosis should be mainly clinical with the x-ray being our confirmation. As cannot be said enough, if it presents like a fracture, or considerations of acute injury like swelling and pain inhibit your ability to confidently exclude it, then treat it as such and refer onwards to the specialists that can!

References

Armstrong M and Oyinkansola Adeogun BS (2009). Tendon injuries in the Pediatric Hand. The Journal of Craniofacial Injury. 20(4) : 1005-1010.

El-Feky M and Weerakkody Y (a). Trapezium fracture, accessed from https://radiopaedia.org/articles/trapezium-fracture?lang=gb accessed on 30/06/2020.

El-Feky M and Weerakkody Y (b). Pisiform fracture accessed from https://radiopaedia.org/articles/pisiform-fracture?lang=gb accessed on 30/06/2020.

Filho, R. L. R. et al. (2020). Capitate and Hamate Fracture. Case Study. Ortopedia, traumatologia, rehabilitacja. 22(2), pp. 143–149. doi: 10.5604/01.3001.0014.1185.

Foley K and Patel S (2012). Fractures of the scaphoid, capitate and triquetrum in a child: a case report. Journal of Orthopaedic Surgery. 20(1): pp 103-104.

Hacking C and Knipe H (). Carpometacarpal joint dislocation accessed from https://radiopaedia.org/articles/carpometacarpal-joint-dislocation?lang=gb accessed on 12/06/2020

Hacking C and Radswiki et al. Triquetral Fracture. Accessed from https://radiopaedia.org/articles/triquetral-fracture?lang=gb accessed on 30/06/2020.

Kam MLW, Sreedharan S, Teoh LC and Chew WYC (2011) ‘Severe Isolated Trapezoid Fracture:: A Case Report’, Hand Surgery, 16(2), pp. 185–187. doi: 10.1142/S0218810411005321.

Kose, O., Keskinbora, M. and Guler, F. (2015) ‘Carpometacarpal dislocation of the thumb associated with fracture of the trapezium’, Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology, 16(2), pp. 161–165. doi: 10.1007/s10195-014-0288-9.

Maloney E, Zbojniewicz A, Nguyen J, Luo Y and Thapa M (2018). Anatomy and injuries of the paediatric wrist: beyond the basics. Pediatric Radiology. 48 : pp764-782.

Murphy A and Knipe H. Hamate fractures. Accessed from https://radiopaedia.org/articles/hook-of-hamate-fracture?lang=gb accessed on 30/06/2020.

Raghupathi AK, Kumar P (2014). Nonscaphoid Carpal Injuries – Incidence and associated injuries. Journal of Orthopaedics. II: 91-95.

Rasoli, S., Ricks, M. and Packer, G. (2012) ‘Isolated displaced non-union of a triquetral body fracture: a case report’, Journal of medical case reports, 6, p. 54. doi: 10.1186/1752-1947-6-54.

Shah S, Rochette L and Smith G (2012). Epidemiology of pediatric hand injuries presenting to United States emergency departments, 1990-2009. Journal of Trauma and Acute Care. 72(6) : pp 1688-1694.

Wahba G and Cheung K (2018). Paediatric hand injuries: clinical review. Canadian Family Physician. 64: pp 803-810.

Humeral shaft injuries

Cite this article as:
PJ Whooley. Humeral shaft injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.29682

Six-year-old Rosie was running in from the back yard when she just tripped over the skateboard that her mum had told her to tidy up. She landed directly onto her left arm. She was brought to the ED and it was noted she was unable to extend her left wrist and she had pins and needles over the back of her hand. 

Humeral shaft fractures are uncommon, accounting for less than 10% of paediatric fractures. Children have a great ability to remodel and heal with little or no deformity despite significant displacement and angulation therefore most of these fractures can be managed with simple immobilization. 

Anatomy

The thick periosteal sleeve of the humerus limits the displacement of humeral fractures and promotes excellent healing. The main anatomical feature that is important to remember is the radial nerve, which curves around the back of the mid humerus and is at risk of injury. That said, injuries of the radial nerve secondary to humeral fractures are rarely associated with long-term deficits with the majority being temporary neuropraxia.

Mechanism of injury

Neonates – hyper extension or rotation as they pass through the birth canal. The typical fracture is a transverse midshaft fracture. 

Older children – Fall on an outstretched hand (FOOSH), a direct blow to the upper arm or high energy trauma such as a motor vehicle collision. 

Adapted from Orthobullets.com 

Pathological fracture – suggested when a midshaft humeral fracture occurs after only minimal trauma. The humerus is a common site for bone cysts and other benign lesions. These occur most commonly in children 3-12 years of age. 

Case courtesy of Dr. Hani Makky Al-Salam, Radiopaedia.org. From the case rID: 13537

Non accidental injury – Is the mechanism inconsistent with the injury or is there a fracture in a healthy child younger than 3 years? This should raise concern for child abuse. These fractures can be transverse fractures from a direct blow or an oblique or spiral fracture caused by traction with humeral twisting. 

Evaluation

These injuries often present with mid arm pain and swelling. If a humeral fracture is present with no visible deformity, it is typically minimally displaced. 

Determine if there is any distal neurovascular compromise (check out the elbow examination post for some top tips on neurovascular assessment in upper limb injuries). Vascular injuries are extremely rare but midshaft fractures are associated with radial nerve injuries in 5% of fractures. This will be evident with paraesthesia / numbness in the dorsum of the hand between the 1st and 2nd metacarpal and motor deficit with reduced thumb and wrist extension and reduced forearm supination. 

Radiology

Typical Anterior-posterior (AP) and lateral views are sufficient. A prominent vascular groove in the distal humerus is commonly seen on plain film and should not be confused with a fracture line. 

Case courtesy of Kellie Grant, Radiopaedia.org. From the case rID: 39526

Describing humeral fractures

There are four key descriptors of humeral fractures:

  1. Anatomical location: proximal, middle or distal third
  2. Fracture pattern: spiral, short oblique, transverse or comminuted
  3. Degree of displacement and angulation
  4. Presence of soft tissue damage: is the fracture open or closed?

Analgesia and immobilisation

Give early analgesia. These are sore and children often require opiate analgesia such as intranasal fentanyl or diamorphine, which are safe to give if there is no facial trauma or signs of head injury present. 

Immobilization in a sling and swathe or shoulder immobilizer enhances patient comfort and reduces the chance of further fracture displacement. Be sure to check for and document any neurovascular deficit pre and post immobilization.

Infants – sling and a swathe for 4 weeks is sufficient regardless of the degree of displacement.

Older children – In incomplete fractures then a sling and swathe, a collar and cuff sling or a shoulder immobiliser can be used. 

Complete and moderately displaced fractures are better managed in a hanging U-slab. This uses gravity to decrease the deformity by relaxing the muscles and also improves the child’s comfort. Provided there is no radial nerve injury, the fracture can be reduced under procedural sedation to improve clinical alignment. After reduction, the child is placed in a U-slab or coaptation splint for 2 weeks. In the fracture clinic, they will then be reassessed and braced in a functional clamshell brace until approximately 4 weeks.

Hanging U-slab

Refer for orthopaedic assessment in ED if there are any of the following features present:

  • Compound fracture with neurovascular compromise
  • Open fracture
  • 100% displacement
  • Fracture with clinical deformity 
  • Angulation more than 20° in children and 10° in adolescents
  • Compartment syndrome (rare in midshaft humeral fractures)

Operative management involves open reduction and internal fixation. It is indicated in many of the above but also the multiply injured patient to aid in early ambulation including concomitant forearm fractures resulting in a “floating elbow”.  

‘Floating elbow’ in a child with concomitant humeral and forearm fractures. Image from Orthobullets.com

Outcomes

  • Malunion is common, but there’s usually little functional loss. These remodel well.
  • Initial fracture shortening may be compensated for by later overgrowth
  • Nonunion is uncommon
  • Radial nerve palsy is less common, and when occurs, is usually a temporary neuropraxia

Rosie was brought to theatre for an open reduction of her left midshaft humerus fracture. The radial nerve was trapped in the fracture line but not severed. After a few weeks of physio Rosie has regained full movement of her wrist and hand and she loves the fact that she has a scar on her arm. Skateboards have been banned from the house…

References

  1. JC. Cheng, JY. Shen. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15
  2. S. Carson, DP. Woolridge, J. Colletti, K. Kilgore, Pediatric upper extremity injuries. Pediatr Clin North Am. 2006 Feb;53(1):41-67, v.
  3. Figure 3 – Case courtesy of Dr Hani Salam, <ahref=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <ahref=”https://radiopaedia.org/cases/13537″>rID: 13537</a>
  4. https://emedicine.medscape.com/article/1231103-overview
  5. https://www.rch.org.au/clinicalguide/guideline_index/fractures/Humeral_shaft_fractures_Emergency_Department/

Midshaft radius and ulna fractures

Cite this article as:
Rie Yoshida. Midshaft radius and ulna fractures, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.21902

Alvaro is a 12-year-old boy who presents to the ED with a painful and swollen right arm. He was trying out his new skateboard and fell whilst trying to master the kickflip. (He tells you it’s not cool to say he’s been skateboarding: “It’s skating, but not the on-ice kind, that’s not cool either.”)

On examination, he is tender in the middle third of his right forearm with swelling and some mild deformity.  There are no open wounds. There is pain on forearm rotation with limited pronation and supination but a good range of movement at the wrist and elbow.  There are no signs of neurovascular compromise or compartment syndrome. 

You top him up with some intranasal fentanyl and send him for an x-ray. His AP film shows a greenstick in the middle third of the ulna. 

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 66836

But when you look at his lateral you do a double-take. There’s pretty significant angulation with radial bowing. You always make sure you look at both x-ray views but this really shows why that’s so important.

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 66836

You know that ulna fractures can be associated with radial head dislocations as part of the Monteggia fracture-dislocation pattern so send Alvaro back for an elbow x-ray.  Radio-capitellar alignment is maintained so you’re happy this isn’t a Monteggia injury but given the significant ulna angulation, you give your orthopaedic on-call colleague a ring.

 

Epidemiology

Forearm fractures are the most common fractures in children, representing 40% of all childhood fractures. Although the majority of these occur at the distal end of the forearm, 20% are located at the midshaft and often involve both bones.  Peak incidence occurs between ages 10-14.

 

Anatomy

The radius and ulna are connected by an interosseous membrane and meet at the distal and proximal radioulnar joints at the wrist and elbow.  Due to these connections, a break in one bone is often accompanied by a break in the other.  It is also important to look at the proximal and distal radioulnar joints to identify Monteggia and Galeazzi fracture-dislocations.

Mechanism

Midshaft radius and ulna fractures usually occur due to a fall from a height onto the forearm or an outstretched hand or direct blow to the forearm.

 

Examination findings

Examine the forearm, wrist and elbow joint.  You may find swelling and possible deformity with tenderness of the forearm. Check for any open wounds and check the tetanus status of the child.

The range of movement will be reduced, particularly with forearm pronation and supination. Check for signs of neurovascular compromise or compartment syndrome.

 

Investigations

For all midshaft forearm injuries, order true AP and lateral x-rays of the forearm including the wrist and elbow (including distal humerus). Note: 5% of forearm fractures are associated with supracondylar fractures.

In a true AP x-ray, the distal radius (R) and ulna (U) should be visualized with minimal overlap. The trochlea (T) and capitellum (C) should be seen in profile, as long as the child is old enough for them to have both to have ossified.

In a true lateral, the distal radius (R) and ulna (U) will be superimposed at the wrist.  If there is no plastic deformity the posterior border of the ulna is straight, sitting on an imaginary horizontal line, and the radius is bowed. The trochlea and capitellum will be superimposed at the elbow (denoted by *).

True AP: Case courtesy of Dr. Aditya Shetty, Radiopedia.org, rID:31106 True lateral: Case courtesy of Dr. James Hayes and Dr. Aditya Shetty, Radiopedia.org, rID:31107

 

Classification

The Rule of Fours can be used to describe the fracture and identify the correct fracture pattern.

There are 4 types of fracture patterns:

  • Plastic deformation: there is bowing of the bone with no cortex disruption. It’s most commonly seen in the ulna and is easily missed on x-ray. A top tip for spotting on x-ray: on the lateral view, a normal ulna has a straight posterior border.  But if the posterior border does not sit nicely on a horizontal line there is plastic deformation.

  • Greenstick fractures: there is a break on one side of one bone that does not extend all the way through the bone.
  • Complete fractures: there is a fracture through both cortices of the radius and/or ulna, often with displacement.
  • Comminuted fractures: these are fractures with multiple bony fragments. They are uncommon in midshaft fractures in children.

 

Treatment

The vast majority of paediatric forearm fractures can be managed non-operatively, with closed reduction and casting.

Firstly, check whether the fracture needs to be referred to the orthopaedic team. Any fracture with complications, either a plastic, comminuted or open fracture or one with neurovascular compromise, compartment syndrome or associated Monteggia or Galeazzi dislocation, must be referred to the on-call orthopaedic clinician.

Next, assess the degree of angulation. If the child is under 5 years of age, up to 20 degrees angulation is acceptable; aged 5 – 9 up to 15 degrees is allowable; and in children 10 years and older fractures with angulation of up to 10 degrees will remodel without manipulation. Fractures that are more angulated than this will need to be reduced.

Closed reduction should be performed by an experienced ED practitioner or clinician or by the orthopaedic team.  It may be done either under procedural sedation in the ED or in theatre with image intensification if this fails (or if the fracture is complicated).  Always, always, reassess neurovascular status and repeat an x-ray after manipulation to reassess the degree of angulation and ensure no further complication has arisen. And finally, an above-elbow (long arm) cast should be applied with follow-up in fracture clinic within a week.

 

Indications for orthopaedic referral

  • Open fracture
  • Neurovascular compromise
  • Compartment syndrome
  • Comminuted fracture
  • Monteggia or Galeazzi fracture
  • Failed reduction or unable to perform in the ED

 

Top tips

  • Always check both lateral and AP films. Alignment can look deceptively good in one plain and very angulated in another.
  • If a break in one forearm bone is identified, remember to look at the other bone and the radioulnar joints. Don’t forget forearm fractures are associated with supracondylar fractures and can be complicated by Monteggia or Galeazzi fracture-dislocations.

 

Alvaro’s ulna greenstick fracture had over 10 degrees of angulation and you and your orthopaedic colleague agree a closed reduction in ED is called for.  You manage Alvaro’s procedural sedation while the orthopaedic doctor re-moulds the fracture and places Alvaro in an above elbow backslab.  Post-reduction films show good alignment.  A few months later you’re walking past the local skate park and you smile to yourself as you see Alvaro with his skateboard (correction, on his board). He gives you a grin as he spins into a kickflip.

 

Selected References

Vopat, Matthew L et al. “Treatment of diaphyseal forearm fractures in children.” Orthopedic reviews vol. 6,2 5325. 24 Jun. 2014, doi:10.4081/or.2014.5325

Orthobullets Both Bone Forearm Fracture – Pediatric https://www.orthobullets.com/pediatrics/4126/both-bone-forearm-fracture–pediatric

Schweich P. Midshaft forearm fractures in children. Post TW (Ed). UpToDate, Waltham, MA. 2019.

Price CT. Acceptable alignment of forearm fractures in children: Open reduction indications. J Pediat Ortho 2010; 30: S82-4.