An Update on Common Orthopedic Injuries and Fractures in Children: Is Cast
Immobilization Always Necessary?

Brian Tho Hang, Claire Gross, Hansel Otero, Ryan Katz

PII: S1522-8401(17)30010-1
DOI: doi: 10.1016/j.cpem.2017.02.001
Reference: YCPEM 609

To appear in: Clinical Pediatric Emergency Medicine

Please cite this article as: Hang Brian Tho, Gross Claire, Otero Hansel, Katz Ryan,
An Update on Common Orthopedic Injuries and Fractures in Children: Is Cast Im-
mobilization Always Necessary?, Clinical Pediatric Emergency Medicine (2017), doi:
10.1016/j.cpem.2017.02.001

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 ACCEPTED MANUSCRIPT

TITLE:

An Update on Common Orthopedic Injuries and Fractures in Children:

Is Cast Immobilization Always Necessary?

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AUTHORS:

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Brian Tho Hang, MD, MS

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Assistant Professor of Pediatrics
Division of Emergency Medicine &
Division of Orthopaedic Surgery and Sports Medicine

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Ann & Robert H. Lurie Children’s Hospital of Chicago
Northwestern University Feinberg School of Medicine
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Claire Gross, MD
Resident Physician
Department of Physical Medicine and Rehabilitation
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Northwestern University Feinberg School of Medicine

Chicago, IL 60611
Email: cgross02@ric.org
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Hansel Otero, MD
Pediatric Radiologist
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Department of Diagnostic Imaging and Radiology

Children’s National Health System
Assistant Professor of Radiology & Pediatrics
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George Washington School of Medicine and Health Sciences

hotero@childrensnational.org

Ryan Katz, MD
Orthopedic Hand and Reconstructive Surgeon
Curtis National Hand Center
MedStar Union Memorial Hospital
ryankatz1@gmail.com (attn: anne.mattson@medstar.net)

Corresponding Author:
Brian Tho Hang, MD, MS
Division of Emergency Medicine and Division of Orthopaedic Surgery and Sports
Medicine
Ann & Robert H. Lurie Children’s Hospital of Chicago
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Box #69
Chicago, IL 60611
Email: bhang@luriechildrens.org
Phone: 312-227-6190
Fax: 312-227-9404

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ABSTRACT

Children frequently visit emergency departments (EDs) for injuries and fractures related to

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sports and recreational activities, however the routine care of these acute minor injuries is

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shifting to the domain of urgent care centers. Physicians on the front lines may not have access

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to real-time orthopedic consultation and therefore need to be versed in the diagnosis and

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treatment of common pediatric fracture patterns recognizing potentially operative fractures as

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well as injuries that may not even require follow-up care. Unlike adults, the pediatric bone

remodels quickly and many fractures heal well without surgical intervention or even cast
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immobilization. Unnecessary immobilization of injuries can be detrimental to healing and

unnecessary orthopedic follow-up can be costly and straining on our health care system. This
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article reviews common upper and lower extremity injuries in children highlighting some of the

fractures where neither cast immobilization nor urgent/emergent orthopedic consultation is

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always necessary.
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Key Words: pediatrics, clavicle fracture, torus fracture, greenstick fracture, mallet finger, jersey

finger, skier’s thumb, scaphoid fracture, toddler’s fracture, ankle injury

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Despite advances in injury prevention and protective gear, children continue to sustain fractures

from a variety of sports and recreational activities at increasing rates. It is estimated that each

year, over 2.6 million children are evaluated in emergency departments (EDs) for injuries related

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to sports and recreational activities.[1] As routine injury care has shifted somewhat from EDs to

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urgent care centers (UCCs), physicians on the front lines may have less immediate access to

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orthopedic surgery consultation and therefore need to be versed in the diagnosis and treatment

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of common pediatric fracture patterns. Since the pediatric bone remodels quickly,

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understanding fracture patterns unique to the pediatric skeleton and how they differ from adult

bony injuries is important for injury-specific management. In recent years, there has been
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increasing evidence that early mobilization rather than immobilization of certain injuries has led

to quicker resolution of pain as well as earlier return to activity. This evolving paradigm
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questions the need for both routine cast immobilization and follow-up for certain extremity

fractures.
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In this article, we will review some of the common upper and lower extremity injuries in children

focusing on injuries where neither aggressive immobilization nor urgent orthopedic follow-up
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care is needed. This article emphasizes evolving methods to decrease unnecessary care and get

children back to school and sports.

UPPER EXTREMITY

Clavicle Fracture

Etiology/Mechanism: Clavicle fractures are one of the most common injuries to the pediatric

skeleton occurring from birth through adolescence. They can occur from either direct or indirect
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trauma but are most commonly associated with falls, such as a fall on an out-stretched hand

(FOOSH) or a fall directly onto the shoulder. The majority of clavicle fractures occur in the

middle third of the clavicle.

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Physical Exam/Radiographs: Young patients typically present with refusal to use or raise the

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injured arm. Adolescent patients may hold that shoulder in a splinted position placing the arm

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against their body for support. Physical exam may reveal swelling, gross deformity, tenderness

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over the clavicle, crepitus, and/or a mobile fracture fragment. A fracture can generally be

identified on an AP shoulder radiograph (Figure 1). A view with a 30 degree cephalad tilt can
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allow for more clear visualization.[2]
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Management: Non-operative management of clavicle fractures is the mainstay of treatment.

Management typically is aimed at symptom relief and limiting range of motion during the initial
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painful period. Either a simple sling +/- swathe or figure-of-eight splint is recommended to take
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weight off the shoulder girdle and improve comfort. Both methods have demonstrated similar

outcomes,[3] although in this authors’ opinion, a sling is more comfortable, less cumbersome to
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put on, and causes fewer skin problems. These slings are not used for true immobilization but

rather to reduce the need for the patient to self-splint the arm which can cause shoulder

fatigue/cramping discomfort. In addition, slings can also serve as a reminder to the patient (and

others) of the injury and encourages limitation of activity. The use of a sling otherwise has little

general effect on healing, as clavicle fractures have low complication rates. Follow-up

radiographs are generally not necessary to monitor the healing process as either a fibrous or

bony union can result in an excellent functional outcome.[3] Simple minimally displaced

fractures can be followed up by a primary care physician in 1-2 weeks, mostly for assessment to
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return to sports. Completely displaced clavicle fractures in older children should be followed by

an orthopedist to evaluate shoulder function with healing.

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Relative indications for orthopedic consultation and possible surgical intervention in an

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otherwise stable patient include skin tenting, open fracture, neurovascular compromise, sterno-

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clavicular dislocation, and re-fracture. Generally, long-term patient-reported outcomes are

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favorable following non-operative treatment,[4] and nonunion is rare in children.[5] There is

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evidence that non-operative management and open reduction internal fixation (ORIF) are

equivalent with regard to time to return to activity, full range of motion, and radiographic
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healing.[6] Even pediatric patients with established malunion after non-operative management

have not been shown to have clinically meaningful functional impairments.[7] More recently in
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the adult population, ORIF for displaced midshaft clavicle fractures has demonstrated a reduced

rate of nonunion and better cosmesis compared to non-operative treatment.[8] The extent to
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which these outcomes can be extrapolated to the pediatric population is unknown. However,
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there was a significant increase in operative management of adolescent clavicle fractures from

2007 to 2011,[9,10] and there is postulation that older adolescents and overhead athletes (i.e.
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pitching, throwing) may be more likely to benefit from surgical treatment. At this time, it is

unclear what risk factors exist in the pediatric population for long-term functional impairment,

pain, or unsatisfactory cosmesis after non-operative management of clavicle fractures. Overall,

there is not yet consensus for surgical versus non-surgical treatment of adolescent overhead

athletes and this specific patient population should be referred to orthopedics for outpatient

care.

Proximal Humerus Fractures

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Etiology/Mechanism: Proximal humerus fractures can occur after a FOOSH injury or direct

trauma to the shoulder though pathologic fractures as a result of tumors should also be

considered in this area. Fractures can occur in the metaphysis, diaphysis or physis. Fractures of

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the proximal physis of the humerus account for approximately 3 to 7% of all physeal injuries in

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the preadolescent population.[11]

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Physical Exam/Radiographs: The patient will present with pain localized to the anterior shoulder

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with difficulty raising the affected arm. In the setting of a presumed humerus injury, it is

important to obtain both anteroposterior (AP) and lateral radiographs of the entire humerus.
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Only the proximal one-third of the humerus is well visualized on standard shoulder radiographs

[AP in internal and external rotation and a scapular “Y” (lateral) view]. Therefore, mid-shaft or
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distal humeral injuries may be missed with a shoulder series or a single AP humerus view. Mid-

shaft fractures can be associated with radial nerve injury which would present with a wrist or
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finger drop.
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Management: The general management of proximal humerus fractures is comparable to clavicle

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fractures as bone union and remodeling typically occur without complication (Figure 2).

Treatment includes a sling +/- swathe usually worn until the pain subsides in a few weeks. Early

range-of-motion (ROM) rehabilitation beginning with pendulum exercises followed by shoulder

strengthening exercises are initiated 2 to 4 weeks post-injury and are guided by the patient’s

reduction in pain. Rarely do proximal humeral fractures require a closed reduction. Operative

versus non-operative management of proximal humerus physeal fractures have not shown

significant difference in complication rate, return to activity, or cosmesis.[12] However, the

more severely displaced fractures may benefit from immobilization with a hanging (weighted)
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cast or a coaptation splint. Most proximal humeral fractures can be easily diagnosed and initially

managed without orthopedic consultation in the ED or urgent care setting. However, follow-up

is usually recommended with an orthopedist or sports medicine specialist within 2 weeks for

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pain reassessment, neurovascular evaluation, and follow up radiographs.[13]

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Incomplete Forearm Fractures (Buckle/Greenstick)

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Etiology/Mechanism: Distal forearm fractures are common in school age children after a FOOSH

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injury. These injuries are uncommon until children can brace a fall with their wrist, leading to

the fracture. If the force of the fall bends but does not “break” the malleable bone, a buckle
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(torus) fracture results (Figure 3a). Buckle fractures are unique to the pediatric skeleton because

of the increased flexibility of pediatric bone. A greenstick fracture occurs when only one cortex
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breaks leaving the other side intact, analogous to what occurs when one tries to snap an

immature “green” stick as opposed to snapping a mature twig cleanly into two pieces (Figure
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3b).
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Physical Exam/Radiographs: On examination, patients with forearm fractures demonstrate

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swelling and tenderness. The clinician should also examine the clavicle, supracondylar humerus,

proximal forearm, and scaphoid as these bones can also be injured from the same FOOSH injury.

Standard two-view radiographs of the forearm should suffice unless there is tenderness along

other bones. A dedicated three-view series of the wrist is generally not indicated unless there is

a concern for carpal bone involvement in the older child or adolescent. If a fracture is identified,

dedicated or inclusive radiographs of the elbow should be considered to evaluate for associated

injury patterns, such as the Monteggia fracture (proximal ulna fracture with radial head

dislocation) or Galeazzi fracture (distal radius fracture and dislocation of the distal ulna).
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Management: Since non- or minimally-angulated buckle fractures of the forearm have excellent

healing potential, traditional casting may not be required. Management using a removable

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prefabricated volar wrist splint is sufficient for low-risk buckle fractures with minimal to no

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angulation.[14] A recent systematic review supports the use of volar removable splints as

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superior to casting for routine forearm buckle fractures in terms of function, cost, satisfaction,

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and convenience without any increased pain or rate of fracture complication.[15] These

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fractures can be followed by a primary care physician in 1-2 weeks to look for signs of deformity

or persistent pain. When patients are pain-free, removal of the splint and ROM exercises are
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encouraged as are simple regular activities such as washing the dishes. Traditional splinting and

orthopedics follow-up should be considered for more significant forearm fractures at risk for
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subsequent angulation, including mildly angulated fractures, unstable fractures, post-reduction,

and fractures of both the radius and ulna.[16]

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Any fracture with significant angulation requires closed reduction or early orthopedic follow-up

depending on the degree of angulation and level of discomfort.[17] For the patient with an
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angulated forearm fracture presenting to an UCC, it may be preferred and more cost effective to

coordinate outpatient closed reduction by an orthopedist, either in a surgery center or office,

especially for a younger patient where a hematoma or Bier block may not be possible. Patients

with significant discomfort or comorbidities may be better served by referral to an ED for closed

reduction under procedural sedation. For mid- and distal-shaft fractures, closed reduction

should be considered if the distal fragment is dorsally angulated greater than 20 degrees (< 5

years), greater than 15 degrees (5-10 years), or greater than 10 degrees (> 10 years). Less

angulation is accepted with ulnar or radial angulation on the AP view. In proximal forearm shaft
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fractures, closed reduction is necessary for lesser degrees of angulation and generally should be

considered for all ages with greater than 10 degrees angulation.

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Hand and Finger Injuries

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Etiology/Mechanism: Finger trauma due to crush injuries (often due to closing doors) or falls is

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common in toddlers and school age children. Among adolescents, finger trauma is often the

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result of ball handling sports such as basketball, volleyball, and football. As jam, crush, twist,

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hyperextension or hyperflexion mechanisms will each result in different injury patterns, an

attempt to identify the exact mechanism of injury can assist in making the correct diagnosis.
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Metacarpal fractures typically require direct axial force such as when the hand hits an immobile

object such as a wall, floor, or helmet.

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Physical Exam/Radiographs: Physical examination should include careful inspection and

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palpation of each metacarpal, phalanx, and joint with a focus on areas with ecchymosis or pain.
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Evaluating for angulation or rotational deformities is important as these deformities, if not

recognized and corrected, can cause significant functional disturbances (eg., digital scissoring).
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One way to assess digital angulation or rotation is to inspect the hand with the fingers loosely

flexed in a “fist” position. (Figure 4) When in flexion, each finger should point towards or just

past the scaphoid. Any deviation from this can indicate malrotation of the metacarpal bone or

phalanx. One can also compare the digital cascade of the injured hand with the uninjured hand.

Metacarpal Fractures

Closed metacarpal fractures require splint immobilization and careful attention to angulation

and rotational deformities that may require closed reduction or surgical stabilization. The index
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finger and middle finger metacarpals have almost no carpometacarpal (CMC) motion to

otherwise compensate for fracture displacement and therefore tolerate the least angulation

before function may be affected (Figure 5). Therefore, fractures to the index and middle finger

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metacarpals require prompt care and expedited orthopedic follow-up as treatment is often

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surgical if angulation is greater than 10 degrees.[18] Common fractures of the thumb

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metacarpal include the Bennett and Rolando fractures, both of which involve the metacarpal

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base and CMC joint. The Rolando fracture is comminuted whereas the Bennet fracture is not.

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Fractures to the 5th finger metacarpal bone are common from punching injuries, hence the term

“boxer’s fracture” which is a fracture of the metacarpal neck (Figure 6). Most “boxer’s
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fractures” do not require reduction and can be managed non-operatively because unlike

fractures to the index and middle finger metacrapals, the 5th finger CMC joint has significant
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motion allowing for proximal compensation of distal displacement. 5th finger metacarpal neck

fractures can accept up to 60 degrees of angulation before functional deficits warrant surgical
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referral. A thumb spica splint should be placed for the majority of fractures to the thumb and
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ulna gutter-type splints are indicated for fractures of the 4th and 5th fingers. Indications for

orthopedic referral include intraarticular fractures, comminuted or unstable fractures, displaced

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fractures of the metacarpal diaphysis (shaft), CMC dislocations, significant angulation, and post-

reduction injuries.

Phalanx Fractures

Phalanx fractures are common in children ages 10-14 years and are most often from sports

injuries resulting in Salter Harris type II physeal fractures.[19] Minimally or nondisplaced

phalangeal shaft and Salter Harris type II fractures tend to heal well with conservative

management. Treatment options include buddy taping to an adjacent finger or an aluminum

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splint in slight flexion for at least 2 weeks or until pain completely resolves (Figure 7). Buddy

taping typically allows for more functional use of the digits while still providing adequate

stability for the injured phalanx. Similar to metacarpal fracture management, phalangeal

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fractures with a rotational deformity, scissoring, or significant displacement requires an attempt

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at corrective reduction. Phalangeal fracture reduction generally does not require orthopedic

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specialty care and can be reasonably accomplished in an urgent care or ED setting with a digital

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finger block, without fluoroscopy. Orthopedic follow-up is recommended for post-reduction

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care or for any phalangeal fracture with a greater risk for complications, such as Salter Harris

type III/IV fractures, rotational deformities, or those fractures with persistent deformity after
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reduction.
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Finger Sprains

The majority of finger injuries do not involve fractures and are simply “jammed” or “sprained”
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caused by forced hyperextension or hyperflexion of the metacarpophalangeal (MCP), proximal

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interphalangeal (PIP), or distal interphalangeal (DIP) joint. This results in ligament injuries that

manifest as a swollen tender joint with decreased range of motion. Malalignment or signs of
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angular deformities are not seen with sprains. Evidence of gross deformity should therefore

increase suspicion for an underlying fracture or dislocation. Athletes presenting with finger

sprains need to be assessed for associated tendon injuries such as a mallet finger, jersey finger,

or skier’s thumb, all of which may occur without fractures, can lead to functional deficits, and

require follow-up with orthopedic surgery.[20]

Any sprained finger can be treated with buddy taping or a splinting regimen similar to a non-

angulated phalanx fracture. If a splint is to be used, we recommend using an over-the-counter

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“baseball splint” in slight flexion for up to 5 to 7 days followed by buddy taping to the adjacent

finger for protection until healed. In general, patients with finger sprains without associated

fractures or tendon injuries can return to sports when full, painless range of motion is

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demonstrated (average 2-4 weeks).[21]

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Mallet Finger

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A “mallet finger” injury is usually caused by a direct blow onto an extended distal phalanx. This

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often occurs when catching a ball. In this injury, the terminal extensor tendon is disrupted and

the DIP becomes unbalanced and biased towards the intact flexor tendon. The distal phalanx
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thus assumes a flexed position resembling a piano mallet. On physical examination, the patient

will be unable to actively extend the DIP joint from the flexed “mallet” position (Figure 8).
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Associated distal phalanx avulsion fractures may be present but the tendon disruption can also

occur without fracture and with minimal pain and swelling. Treatment requires constant
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splinting of the DIP in neutral extension (a “stack splint”) for 6 weeks, 24 hours a day. If the
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patient removes the splint and allows flexion of the joint, an extensor lag will persist and the

end postural result may be less satisfactory. A sports medicine or orthopedic referral is
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recommended to ensure good functional outcome from splinting, regardless of whether a

fracture is present. [20,21] As time passes from the injury, the splint might have to be adjusted

to accommodate reductions in swelling. In the growing pediatric skeleton, it is important to

differentiate this injury from a displaced distal phalangeal fracture through the physis, also

known as a Seymour fracture. This fracture more often occurs from a crush mechanism rather

than a direct blow but clinically can appear similar to a mallet finger and recognition of physeal

widening can be missed. Seymour fractures often require operative intervention to prevent

growth arrest and nail plate deformity.

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Jersey Finger

A “jersey finger” can occur when there is an extension force placed on a flexed distal phalanx.

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This occurs frequently when an athlete’s finger is caught in an opponent’s jersey or facemask

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and the digit is then forcefully extended against active flexion. This results in an avulsion of the

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flexor digitorum profundus tendon from its insertion on the distal phalanx. On physical exam,

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there is an inability to actively flex the DIP joint in isolation (Figure 9). Occasionally, radiographs

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will demonstrate an associated bony fragment. This injury often requires surgical correction and

is therefore important to recognize promptly and refer to orthopedic outpatient follow-up, even
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in the absence of an avulsion fracture.[20] As these injuries are quite difficult to reconstruct

after 6 weeks, timely referral is essential.

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Skier’s Thumb / Gamekeeper’s Injury

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A “skier’s thumb” is an acute tear of the ulnar collateral ligament (UCL) of the thumb MCP joint.
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This injury occurs by forced hyperabduction, such as occurs when falling while holding a ski pole.

The patient is usually tender over the UCL in the webspace and may have laxity when the
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ligament is stressed. If a skier’s thumb injury is suspected, radiographs should be taken to rule

out an associated fracture (Figure 10). A large fracture fragment located over the adductor

muscle should raise the suspicion of a Stener lesion. In this lesion, the tendon of the adductor

muscle is interposed between the fracture fragment (upon which the UCL attaches) and the

metacarpal base, thus prohibiting fracture healing and therefore healing of the UCL. A Stener

lesion requires operative intervention. In the absence of a fracture, patients should be

immobilized with a thumb spica splint (premade Velcro thumb spica splints are acceptable) and

re-examined in two weeks. If any persistent laxity or joint instability is present, an orthopedic
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referral is warranted.[22] A gamekeeper’s thumb is similar to a skier’s thumb in that it

represents failure of the UCL but differs in pathophysiology. Whereas the skier’s thumb is an

acute injury, the gamekeeper’s thumb is the result of chronic attenuation of the collateral

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ligament through repeated forceful abductions–such as when gamekeepers, as part of their

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occupation, kill poultry by manually snapping birds’ necks.

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Scaphoid Fracture

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Scaphoid fractures are rare in children under age 10 years. Classically, patients with scaphoid

fractures will have focal tenderness to palpation in the anatomic snuffbox where the scaphoid
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lies. In addition, an axial loading test of the thumb metacarpal can help to assess scaphoid pain

and raise suspicion for a scaphoid injury. Dedicated ulnar deviation views of the wrist are
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recommended for best view of the scaphoid bone as this takes the scaphoid out of flexion.

Because scaphoid fractures may not be radiographically evident on initial radiographs, suspicion
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of scaphoid fracture should prompt immobilization and orthopedic follow-up. Radiographic

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evidence of fracture on plain films may be seen several weeks after the initial injury even if no

fracture is visualized on the initial radiographs (Figure 11). The preferred management of a
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suspected scaphoid fracture is immobilization with a thumb spica splint or premade Velcro type

and orthopedic follow-up in one week.

LOWER EXTREMITY

Toddler’s Fractures
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Etiology/Mechanism: Toddler’s fractures occur in the newly walking young toddler between 9

months and 3 years. These fractures occur from simple mechanisms such as running, falling

down a couple of stairs, or jumping off the couch.

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Physical Examination/Radiographs: These patients typically present with either refusal to bear

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weight on the injured extremity or with a limp. On examination, there typically is no gross

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deformity. The most common finding is the refusal to bear weight after a minor injury,

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sometimes with some tenderness localized to the mid-distal tibial shaft, although it can be

difficult to localize tenderness in this age group especially in the absence of swelling.
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Radiographs of the tibia/fibula and possibly femur and/or foot, are indicated, especially if it is

difficult to localize pain on exam. Classic radiographic findings show a non-displaced spiral-type
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fracture of the mid-distal tibia (Figure 12). Radiographic findings are often very subtle and can

be occult, sometimes becoming more apparent on re-imaging in subsequent weeks following an

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injury.
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Management: Patients should be treated based on suggestive clinical presentation even

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without radiographic evidence given the potential for occult fracture.[23] Similar to common

non-angulated forearm fractures, toddler’s fractures tend to heal well without functional

deficits. Traditional management suggests short- or long-leg splinting followed by cast

immobilization. However, recent evidence indicates that immobilization may not be necessary

citing that patients who were splinted/casted (67% of total) were more likely to have longer

duration of immobilization, more orthopedic follow-up visits, and more radiographs ordered

than those who were placed in a controlled ankle motion (CAM) boot (24%) or not immobilized

at all (9%).[24] The most common complication associated with splinting and casting was skin
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breakdown (17%). Given bone remodeling at this age and this relatively stable fracture pattern,

a discussion with the family is suggested to discuss different treatment options. If

immobilization is used, close follow-up (24-72 hours) is suggested to evaluate for skin

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breakdown. CAM walker boots are effective and functional, but should be avoided for toddler’s

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fractures where fracture lines are readily apparent on radiograph.

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Ankle Injuries

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Etiology/Mechanism: Ankle injuries are common in athletics, usually from a twisting mechanism
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when running or falling from a height.
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Physical examination/Radiographs: In addition to palpation, ROM, gait, and neurovascular

status, it is important to evaluate for presence of tenderness in the medial and lateral malleolus
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as well as the physes of the tibia and fibula (2-3 cm proximal to the ankle joint) to differentiate
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signs of bony versus ligamentous injury. Radiographic evaluation should include a three-view

series, including AP, oblique (mortise), and lateral views. If there are signs suggestive of a distal
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tibial fracture, the entire tibia/fibula should be imaged to evaluate for a Maissonneuve injury—a

spiral fracture of the proximal fibula associated with a medial malleolus fracture and

ligamentous tear of the tibiofibular syndesmosis.

Management: Significant fractures of the distal tibia generally require orthopedic consultation

and acute management. The tibia is a high-risk center for compartment syndrome and distal

tibial injuries often require early cast immobilization or surgical therapy. Isolated fractures to

the fibula are generally less significant as the fibula is a non-weight bearing bone. Nondisplaced
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distal fibular fractures can be treated with a short-leg splint or CAM boot along with crutches,

non-weight bearing status, and follow-up with orthopedics for possible cast immobilization.

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If a fracture is not identified, the diagnosis is likely to be a soft tissue or ligamentous injury.

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Lateral ankle sprains are the most common variety of ligamentous ankle injury. Conservative

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management often leads to ankle stirrups and use of crutches, especially if the patient is unable

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to bear weight. However, in the absence of fracture, early mobilization using ROM exercises

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promotes healing and return to sports.[25-30] In randomized trials of adults with ankle sprains,

the patients who had early mobilization reported less pain and returned to work and activity
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faster than the immobilized patients [30] while additionally showing no difference in residual

symptoms or re-injury rates at 1 year.[27]

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Salter Harris type I fractures of the distal fibula can mimic lateral ankle sprains. These injuries
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are generally radiographically occult but can show some widening of the fibular physeal growth
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plate relative to the tibia. While traditional management called for immobilization of suspected

occult fractures, evidence supports managing these injuries similar to lateral ankle sprains with a
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removable ankle brace or stirrup that extends proximal (above) to the fracture site.[25] Follow-

up with orthopedics or sports medicine is generally not necessary for routine lateral ankle

sprains or possible Salter Harris I fractures unless there is no improvement after 1-2 weeks or for

clearance to return to competitive sports.

High ankle sprains (Syndesmotic injuries) deserve special attention because management can be

more intensive often requiring further imaging, physical therapy, and sometimes surgical

correction. High ankle sprains occur at the tibiofibular joint and involve a disruption of the
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syndesmosis which is a complex of five ligaments that connect the tibia to the fibula. The classic

mechanism of injury is landing with the ankle dorsiflexed and the foot externally rotated, such

as slipping off a curb. This injury is often from eversion unlike the common lateral ankle sprains

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which are more likely inversion injuries. Patients with high ankle sprains localize tenderness

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along the distal tibia-fibula junction. The “squeeze test” can be performed to reproduce pain at

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the syndesmosis by squeezing the upper half of the calf in a lateral direction to create

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separation of the distal tibiofibular space. The dorsiflexion-external rotation test is a more

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sensitive tool to elicit a syndesmosis injury, whereby providers dorsiflex the ankle and then

externally rotate the foot to evaluate if pain is reproduced at the anterior tibiofibular ligament.
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Standard plain radiographs are recommended to rule out fractures but generally will not show

signs of a syndesmotic injury unless a complete tear of the syndemosis is present, indicating a
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grade 3 injury which can be manifested by diastasis on radiograph. Stress (weight-bearing)

radiographs can demonstrate lower grade injuries by showing asymmetry or widening of the
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ankle mortise, particularly on the oblique (mortise) view (Figure 13). Stress radiographs,
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however, are generally not recommended in the initial evaluation because the presence of a

grade I-II syndesmotic injury shouldn’t change initial management and stress-bearing films can
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be painful after an acute injury. Stress radiographs can be performed for subacute injuries but

ultrasound and magnetic resonance imaging may be superior imaging modalities and should be

delegated to outpatient specialty follow-up. Although most high ankle sprains can be treated

non-operatively with a period of non-weight bearing and a CAM boot, they often take longer to

heal than typical ankle sprains and are more likely to require physical therapy. Early orthopedic

follow-up should be arranged for syndesmotic injuries associated with significant mortise

widening on radiographs. Sports medicine or orthopedic follow-up should be arranged for

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patients with lower grade syndesmotic injuries who may require prolonged therapy or further

diagnostics.

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SUMMARY

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Attention to common pediatric fractures and injuries is important to guide acute care decisions

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and the need for follow-up care. Recognizing common pediatric fractures and the core

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differences from adult bony injuries is important for frontline providers. Although conservative

management with casting, prolonged immobilization and non-weight bearing are traditional
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options, stiffness and decreased use can delay recovery of motion and strength, and

unnecessary follow-up causes avoidable cost and burden on our health care system. For certain
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injuries, early rehabilitation exercises prevent stiffness and muscle atrophy, promote earlier

recovery, and should be started within 24-48 hours of the injury or as soon as the patient can
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tolerate. The need for follow-up with the primary care physician, orthopedics, or sports
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medicine depends on the characteristics of the specific injury and speed of recovery.
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References

1. Center for Disease Control and Prevention, National Center for Injury Prevention and
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Accessed December 18, 2016.

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4. Schulz J, Moor M, Roocroft J, et al. Functional and radiographic outcomes of
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outcome after fractures of the clavicle in patients aged 10 to 18 years. J Pediatr Orthop
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in children with established malunion of the clavicle. J Pediatr Orthop 2013; 33:544-550.

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non-operative treatment for displaced midshaft clavicle fractures: a multicenter,

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13. Paterson P, Waters P. Shoulder injuries in the childhood athlete. Clin Sports Med
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14. West S, Andrews J, Bebbington A, et al. Buckle fractures of the distal radius are
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Figure Legends

Figure 1. Clavicle fracture: 1a, mid-shaft left clavicle fracture in a 13 year old; 1b, mid-shaft left

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clavicle fracture in a 27 month old. Notice subtle angulation relative to right clavicle.

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Figure 2. Proximal humerus fracture: 1a, day of injury; 1b, 3 weeks after injury - notice callus

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formation; 1c, 2 months after injury, notice bridging; 1d, complete healing.

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Figure 3a. Incomplete buckle (torus) fracture of the distal radius [AP and lateral views].

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Figure 3b. Incomplete buckle (torus) fracture of the distal radius with minimal dorsal angulation;

greenstick fracture of the distal ulna with minimal radial angulation [AP and lateral views].
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Figure 4. Hand/fist scissoring: notice rotational deformity of the 2nd finger.

Figure 5. Second metacarpal fracture: non-displaced fracture of the mid-diaphysis of the right
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second metacarpal in a 15 year old female [AP and oblique radiographs].

Figure 6. Fifth metacarpal fracture: volarly angulated fracture of the distal right fifth metacarpal
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in an 8 year old male [AP and oblique radiographs].

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Figure 7. Baseball splint/buddy taping.

Figure 8. Mallet finger injury: 8a, avulsion fracture of the distal phalanx; 8b, notice inability to
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extend the DIP joint.

Figure 9. Jersey finger: notice inability to flex the DIP of the 4th finger.

Figure 10. Proximal thumb avulsion (Skier’s) fracture. Salter Harris 3 avulsion fracture at the

ulnar corner of the base of the proximal phalanx of the thumb in an 11 year old male [AP,

oblique and lateral radiographs].

Figure 11. Scaphoid fracture: 11a, day of injury; 11b, two weeks later – notice callus formation

at waist of the scaphoid.

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Figure 12. Toddler’s fracture: 12a, 19 month old child not bearing weight on day 1; 12b, 10 days

later – notice non-displaced spiral fracture of the tibia is more apparent.

Figure 13. High ankle sprain, notice widening of mortise on stress view suggesting a syndesmotic

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injury.

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