A fracture should be suspected when a child presents with deformity, swelling or localised bony tenderness of a limb after a fall. In very young children, not moving a limb or refusing to bear weight on a limb may indicate the presence of a fracture.

Examine the limb carefully for:

• deformity or swelling;

• point tenderness;

• any skin wound around the injury site, suggesting the possibility of an open fracture;

• neurological impairment distal to the injury;

• peripheral pulses and perfusion distal to the site of injury; and

• signs of compartment syndrome — excessive pain, tense compartment, and pain on movement, especially extension of fingers or toes.

Examine the child for any associated injuries and consider whether the fracture may constitute a non-accidental injury.

An x-ray should be obtained of the suspected fracture site, including the joints on either side. Both anteroposterior and lateral views are necessary for diagnosis. Comparison views of the contralateral side should not be done routinely, but may be helpful in specific circumstances if there is any doubt in interpreting the initial films (eg, around the elbow).

It is important to be able to describe fractures accurately for documentation or discussion with a colleague, especially by telephone. Include in the description:

• Anatomical site of the fracture — “which bone?”, “which side?”, and “is the fracture in the proximal, middle or distal third of the bone?”;

• Appearance of the fracture line — transverse, oblique, spiral, or comminuted (more than one fragment);

• Whether the fracture is open or closed;

• Angulation and displacement of the fracture:

• to determine angulation, draw a line along the edge of both major fragments and measure the angle of intersection of the distal fragment.

• to determine the displacement, compare it with the width of the bone at that point (eg, half a diameter displaced or completely displaced).

In metaphyseal fractures (ie, fractures in the expanded ends of long bones), it is important to note the proximity of the fracture to the growth plate, as this determines the remodelling potential of the bone and cartilage around the joint. Injuries to the growth plate are described according to the Salter–Harris classification (Box 1).2

Fractures are extremely painful. Splinting the limb effectively using whatever means is readily available, and providing early, adequate analgesia can ameliorate the pain. Displaced fractures usually require parenteral analgesia such as intravenous morphine. If this is not available or practicable give a generous dose of paracetamol/codeine mixture.

Fractures that are likely to need specialist referral include those that require reduction, open fractures, fractures with neurovascular compromise and fractures involving a joint surface (ie, Salter–Harris type III or IV). Fractures around the elbow joint often require surgical intervention.

The amount of angulation that is acceptable varies with the type of fracture and the age of the child. If the angle between the shaft of the bone and the fractured fragment is greater than 20°, manipulation of the fracture is likely to be needed. As a rule of thumb, if the limb looks deformed at clinical examination then the fracture is likely to require reduction.

A simple undisplaced buckle fracture with only one cortex involved can be treated with an easily removable plaster or fibreglass slab.3 However, if the fracture involves both cortices of the bone, an encircling plaster or a plaster/fibreglass slab extending across the joint above and below should be used.

If treating a child with an encircling plaster as an outpatient:

• Try to get the child to elevate the limb above chest level for 24–48 hours after fitting the plaster. This may not be possible in small children.

• A sling should only be worn after this period, and the hand should not be below the elbow while in the sling.

• For leg plasters, crutches should only be used by children over 6–7 years of age who have good coordination.

• A review of the plaster should be organised for the day after fitting the plaster to check whether it is too tight. Look for pain on passive extension of the fingers or toes, swelling and colour of the digits, and assess distal circulation. Pain at the fracture site alone is rarely a reason to split a plaster.

• Go through written instructions explaining the care of a child with a plaster to the parents, and give them a copy. For an example, see <www.rch.org.au/kidsinfo/factsheets.cfm?doc_id=4083>.

• What was the mechanism of injury? (inversion/eversion/crush)

• Was the patient able to bear weight immediately after the injury? (NB: a small child with a minor fracture of the tibia or fibula may continue weight-bearing.)

• Where is the swelling most prominent?

• Where is the point of maximal tenderness?

• Is the ankle stable? (Does the dome of the talus move forward with anterior stress?)

X-rays are required if any of the following are present:

• Pain over the posterior edge of the distal tibia or fibula.

• Pain over the navicular or head of the fifth metatarsal.

• The child is unable to bear weight for four steps both immediately after the injury and later in the surgery.5

These indications for an x-ray examination are commonly referred to as the Ottawa ankle rules.6 Although they are a useful guide, the Ottawa ankle rules may not be as sensitive at predicting a fracture in children as they have proven to be in adults.7

If a child has tenderness over the growth plate of the distal tibia or fibula, and x-rays show no abnormality, treat as a Salter–Harris I epiphyseal injury. If swelling is not marked, apply a below-knee plaster cast for 4–6 weeks. If there is marked swelling, treat in a backslab for 2 weeks, then re-examine. If the area over the growth plate is now no longer tender, mobilise with the assistance of physiotherapy; otherwise, continue the immoblisation. If a fracture is present, an x-ray at this time should show new bone formation.

• Treat in a similar way to a fracture: use a below-knee plaster cast (or, if the swelling is severe, a backslab followed by a full plaster cast) for a maximum of 1–2 weeks. No weight-bearing is allowed for the first few days.

• Gradual rehabilitation should occur after this.

Physiotherapy is useful in all grades of ankle ligament injury. Functional treatment — brace or tapes, with active physiotherapy — has been shown in older adolescents to produce a better outcome than immobilisation, with greater joint stability and an earlier return to sport.8

The arm is held pronated and extended (ie, limp by the child’s side, as if he or she is ignoring it!). The child is not distressed unless the limb is moved by someone else. Palpation from the clavicle to the wrist does not show any swelling or tenderness (be careful not to pronate or supinate the wrist while palpating it, as this will cause pain and falsely localise the injury). Supination of the arm causes pain and resistance to movement is felt.

If the symptoms and signs are typical of a pulled elbow, no investigations are necessary. If the history is not typical, there is swelling or your attempts at reduction fail, an x-ray of the elbow should be obtained to exclude a supracondylar or radial head fracture.

• Hold the child’s hand as if to shake it and with your other hand encircle the elbow with the thumb over the radial head.

• Apply traction and supinate the hand with moderate force.

• Flex the forearm at the elbow all the way to the shoulder. You should feel a pop as the radial head is relocated.

The child should be moving the arm normally within 10–15 minutes.