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Sunday, 7 February 2016

Long Bone Fractures - in Children

Femoral fractures are uncommon, as considerable force is often required. There is often a history of a fall with the leg twisted awkwardly. In children fractures are more common at the physis, and we need to know about the "SALTER" classification. There is a bimodal distribution of femoral fractures - they are common in 2 - 4 year olds, and adolescents. We should always consider child abuse and non accidental injury, especially if the fracture presents in a patient before walking age.

Radiology of Note
The distal femoral epiphyses are normally present from birth to 18 -20 years
The patella ossifies between 3 - 6 years

Management
Support the leg with the hip and knee slightly flexed
Analgesia (intra-nasal very likely to be helpful)
Splintage
X-ray
Traction
Orthopaedic referral

Splinting
Most sources agree that splinting should be carried out as soon as possible, although practically this can be difficult.
< 3months:           Pavlick harness
>3 months/ 16kg:  Gallows traction
> 16kg:                Thomas splint (skin traction)

I have written a presentation that says all this with pretty pictures.

References
http://www.emdocs.net/pediatric-trauma-pearls-pitfalls/ 
http://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures--pediatric
http://www.tamingthesru.com/blog/acmc/traction-splints-applying-the-ktd-traction-splint 
http://www.ncbi.nlm.nih.gov/pubmed/23922601 
http://www.youtube.com/watch?v=DNyyYdtOX5Q 
http://www.sciencedirect.com/science/article/pii/S002013831500577X 
http://www.bestbets.org/bets/bet.php?id=1533 
http://www.sort.nhs.uk/Media/Guidelines/Wessexchildrensmajortraumaguidelines.pdf 
http://www2.rcn.org.uk/__data/assets/pdf_file/0004/608971/RCNguidance_traction_WEB_2.pdf
Emergency Care of Minor Trauma in Children. Ffion Davies et al. 
ABC of Emergency Radiology

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