Clear and structured communication between the emergency and orthopaedic teams is paramount to ensuring a smooth transfer of care for children with fractures and traumatic injuries. Use this checklist to structure your referrals to ortho like a pro, and test your x-ray interpretation skills with the quiz below.
History
Injury is force meets child; child is damaged. The force causes an easy-to-remember event – shock, pain, ‘crack’, blood, fear – so there will always be a history of an injury.
When taking a history, remember the six honest men: when, how, where, what, who, and why.
In addition to a full history of the presenting complaint and past medical, vaccination and developmental history, a trauma history should include:
- Date and time of injury
- The exact mechanism of injury, when possible, preferably in the parent’s or child’s own words
- The environment in which the injury occurred
- Symptoms at the time of injury and subsequently
- Hand dominance for upper limb injury
- Analgesia administered
- Fasting status
- Relevant past medical history, such as bleeding disorders
Sadly, we must always remain vigilant for signs of non-accidental injury (NAI). The presenting injury needs to reasonably fit with the account as to the mechanism of injury.
Examination
Whilst the majority of the examination of a traumatic injury is centred on the affected site, the examination must always include:
The examination should be broken down into:
- Inspection
- Palpation
- Movements and gait
- Neurovascular status
- Special tests
Imaging
Fractures can generally be identified on an AP and lateral radiograph. Use a systematic approach and apply the rule of twos.
Apply the rule of twos:
- Two views as standard; occasionally, other views may be required
- Two joints viewed
- Two sides where comparison of normal is necessary
- Two occasions before and after procedures or in specific instances (such as when a scaphoid fracture is suspected)
A fracture may appear as a lucency (black line) where a fracture results in separation of bone fragments or as a dense (white) line where fragments overlap. If bone fragments are impacted, then increased density occurs. This may be the only radiological evidence that a fracture exists.
Sometimes, there is no direct evidence of a fracture, so we need to rely on indirect evidence. Looking for radiological soft tissue signs can provide clues to fractures. These include displacement of the elbow fat pads or the presence of a fluid level.
The AABCS approach, described by Touquet in 1995, can be used to carry out a structured interpretation of a limb x-ray.
Key points:
•   Examine the entire radiograph in detail before concentrating on the area of concern – Look at the whole x-ray and the x-ray as a whole
•   Remind yourself of the mechanism of injury – Are the radiographic findings relevant to patient history? How do the findings correlate with clinical findings? Do you need to re-examine the patient?
•   Take an x-ray before and after procedures
•   Get help – If the x-ray doesn’t look right, ask someone else, and ensure there is a backup reporting system in place
•   Document both what you see and what you don’t see on the x-ray
How to describe a fracture
Fractures are described systematically. Start with the site (name and part/portion of bone), then the extent (fracture type/line, open/closed, articular involvement), then describe the distal fragment (displacement and angulation). Describe any involvement of the skin and damage to related tendons and structures such as nerves or blood vessels.
Describing the site of the fracture
Long bones are often described based on thirds: proximal, middle (diaphyseal) and distal segment. Including nearby anatomical landmarks (head, neck, body /shaft, base, condyle, epicondyle, trochanter, tuberosity) helps describe the area of interest.
In paediatrics, fractures are described using the anatomical divisions of the bone segments: the epiphysis, the epiphyseal plate, the metaphysis and the diaphysis.
- The diaphysis is the shaft of the bone.
- The physis is the growth plate. Also known as the epiphyseal plate, the physis occurs only in skeletally immature patients and is a hyaline cartilage plate in the metaphysis at the end of a long bone.
- The metaphysis lies between the diaphysis and the physis. An easy way to remember this is to think of the word metamorphosis – a change; the metaphysis is the area of change between the physis – the growth plate – and the diaphysis – the shaft. The metaphysis is only used to describe a bone before it matures – the growing end of the long bone. Metaphyseal fractures are almost pathognomonic of NAI. They are also known as corner fractures, bucket handle fractures or metaphyseal lesions.
- The epiphysis sits above the growth plate – epi (Greek for over or upon – like the epidermis) – physis – upon the physis.
Describing the extent
See the fracture terminology glossary below for specific terms.
Key characteristics to include whether the fracture is open or closed and whether the fracture is intra-articular (inside the joint capsule) or extra-articular. Extra-articular fractures are usually less complicated.
Describing the distal fragment
There is a convention to ensure that the same injury is described in the same way: angulation, displacement, and dislocation are described by where the distal fracture fragment is in relation to the proximal fragment or in the direction of the fracture apex.
Displacement is the loss of axial alignment: dorsal (posterior), volar (anterior) or lateral displacement of the distal fragment with respect to the proximal fragment. The degree of displacement can be roughly estimated from the percentage of the fracture surfaces in contact. Where none of the fracture surfaces are in contact, the fracture is described as having ‘no bony opposition’ or being ‘completely off-ended’, and are potentially unstable. Displacement is usually accompanied by some degree of angulation, rotation or change in bone length.
Angulation is the angle created between the distal fragment and the proximal fragment as a result of the fracture. The anatomical reference point is the long axis. Angulation is described using words like: dorsal/palmar; varus/valgus; radial/ulnar. It may be described by reference to the direction in which the apex of the fracture points (apex volar or apex dorsal) or by indicating the direction of the tilt of the distal fragment. Medial angulation can be termed ‘varus’, and lateral angulation can be termed ‘valgus’. To measure angulation, one line is drawn through the midline of the shaft. A second line is then drawn through the midline of the fragment and the angle can now be measured.
Rotation is present when a fracture fragment has rotated on its long axis relative to the other. It may be with or without accompanying displacement or angulation. It is more readily diagnosed on clinical examination.
Perfecting your referral
Referrals to the orthopaedic team, using a framework like the ISBAR tool, should start with the child’s name, hospital number and who is with the patient. Then, proceed to take a history, including a full history of the presentation, hand dominance, fasting status and any relevant clinical risk factors such as bleeding disorders. Describe your clinical findings, including neurovascular examination, and then the radiological findings in the order of:
- the bone(s) involved
- part of bone
- type of fracture
- fracture line
- extent of deformity and angulation
- and any associated clinical findings
Describe any other investigations, management to date and ongoing treatment. Summarise events that have occurred before referral – analgesia, backslab casts, splints, antibiotics, tetanus boosters, wound cleansing, dressings etc.
As with any good referral, be clear about why the child is being referred. It may be reasonable to transfer full care of a child. Or, the referral may simply be to gain a second opinion on the diagnosis followed by management. Be clear about the type of care expected. And finally, discuss whether you feel the referral is urgent or not. It should be stated how quickly you expect the patient to be seen. Do you feel they need to be seen urgently, soon or routinely?
At this stage, a management plan and expected outcome can be discussed and agreed. This information can then be reiterated to the child and family. Make sure everything is clearly and concisely documented.
Done!
Fracture terminology
Non-displaced fracture: A fracture where the pieces of the bone line-up.
Displaced fracture: The pieces of the bone are out of line.
Closed fracture: Either the skin is intact or, if there are wounds, these are superficial or unrelated to the fracture.
Open/compound fracture: A wound is in continuity with the fracture site.
Unstable fracture: A fracture with a tendency to displace after reduction.
Complete fracture: The fracture line extends across the bone from one cortex to the other separating the bone into two complete and separate fragments.
Greenstick fracture: Only one cortex is fractured.
Torus/buckle: Buckling of the cortex with no break.
Comminuted: There are more than two fragments.
Transverse fracture: A fracture across the bone.
Oblique fracture: A fracture at an angle to the length of the bone.
Spiral fracture: A fracture that curves around the bone diameter.
Depressed: A portion of bone is forced below the level of the surrounding bone.
Avulsion fracture: The muscle have torn off the portion of bone to which is attached.
Stress fracture: Tiny cracks in the bone caused by repetitive injuries. A cortical break is not always seen but there is greying of the cortex due to callus formation.
Pathological fracture: A fracture arising within abnormal bone weakened by benign or malignant cysts or tumours.
Impacted fractures: One fracture fragment is driven into the other.
Plastic deformation: Deformation of bone without fracture of the cortex.
Epiphyseal fractures: A fracture to the growing end of a juvenile bone that involves the growth plate. Use the Salter-Harris classification if the fracture involves the epiphyseal plate.
Fractures don’t always occur in isolation – a joint may be involved.
Fracture-dislocation: A dislocation is complicated by a fracture of one of the bony components of the joint, such as a Galeazzi or Monteggia fracture-dislocation.
Subluxation: The articulating surfaces of a joint are no longer congruous, but loss of contact is not complete.
Dislocation: Complete loss of contact between the articulating surface of a joint. Displacement of one or more bones at a joint.
References
Bickley S. & Szilagyi P. (2003) Bates’ Guide to Physical Examination and History Taking (8th edn.) Philadelphia. J.B. Lippincott, Philadelphia.
Davis, F.C.W., 2003. Minor Trauma in Children. A pocket guide. London: Arnold.
Duderstadt, K. 2006. Pediatric Physical Examination. Mosby. Elsevier.
Purcell, D. 2003. Minor Injuries. A Clinical Guide. Edinburgh: Churchill Livingstone.
Larsen, D. & Morris, P. 2006. Limb X-ray Interpretation. Whurr Publishers Limited.
McRae, R. 2003. Pocketbook of Orthopaedics and Fractures. 3rd ed. Edinburgh: Churchill Livingstone.
Raby, N., Berman, L. & De Lacey, G., 2001. Accident & Emergency Radiology. A Survival Guide. Edinburgh: W.B. Saunders.
Touquet et al, 1995. The 10 Commandments of Accident and Emergency Radiology. BMJ 1995; 311: 571.
Image source for final quiz case: https://radiopaedia.org/cases/2c1840c5145638e56f599031f23dd0c8?lang=us
