• Remember to check and record the neurovascular status distal to any fracture.

• Choose analgesia appropriate to the injury.

• Options to consider are:

  • Oral paracetamol ± ibuprofen ± oramorph

  • Intranasal diamorphine

  • Intravenous morphine titrated to response

  • Digital nerve blocks

  • Fascia iliaca block/ femoral nerve block

• Always examine the joint above and below any injury and if necessary X – ray these joints

• Remember to consider NAI in all children with fractures, especially those less than 2 years of age. Mobility and developmental stage should be taken into account before you decide if the mechanism of injury is consistent with the fracture. If you have concerns seek senior ED/Paediatric ED advice.

• If you have any doubts about how to assess suspected fracture, diagnose or manage paediatric musculoskeletal injury speak to a senior ED doctor.

• Children under 2 years old usually require full limb POPs to avoid them coming off. If in doubt ask the ED nursing staff.

Some orthopaedic injuries must be recognised as time critical. Immediate attention to ABC and assessment of the following is required:

• Vascular compromise/lack of pulse / ischaemia of limb distal to injury (remember to document capillary refill time)

• Distal neurological deficit

• Ischaemic skin tented over displaced or angulated fracture or a dislocated joint

• Open fractures

• Massive soft tissue damage

• Dislocated joints

• Compartment syndrome

Salter-Harris classification of juxta physeal fractures

The Salter-Harris Classification is:

• Type I - fracture through the physis (growth plate)- possible widening of growth plate

• Type II - fracture partway through the physis extending up into metaphysis (M)

• Type III -fracture partway through the physis extending down into the epiphysis (E)

• Type IV -fracture through the metaphysis, physis, and epiphysis - can lead to angulation and deformities when healing (ME)

• Type V - crush injury to the physis

See network guideline on open fractures

South West London & Surrey Trauma Network

E1. Shoulder Girdle

E2. Humerus

E3. Elbow Injuries

A small piece of bone about the elbow joint may represent an avulsion fragment or an ossification centre.

A guide to remember the ages at which these ossification centres appear is given below:

E3.1 Elbow

E4. Forearm

Displaced ‘off ended’ distal radius fractures

• Requires rough alignment in the those aged under 10 years of age.

• Patient must be able to tolerate the procedure using intranasal (IN) diamorphine or fentanyl +/- Entonox

• Technique involves gentle pulling on middle and ring fingers whilst traction administered at the elbow

• Rough alignment with both fragments straightened

• Overlapping of fragments accepted – do not need to have ends opposed

• Registrar and above only

• Only one attempt allowed

E5. Wrist

E6. Hand

F1. Femur

Femoral Shaft Fractures

• Children with a likely displaced femoral fracture should not wait for imaging to be placed on skin traction.

• The child should be placed on a ‘ward bed’ within the Emergency department as soon as practical with skin traction applied to the affected limb. This will provide highly effective pain relief.

• Analgesia including intranasal opiates and oral diazepam are strongly encouraged.

• Weight based calculations for skin traction are historically calculated as 10% of body weight – typically 1-2kg should suffice

• Skin traction can lead to significant skin injuries, if applied incorrectly.

Overview of principles

• Femoral fractures in children are an infrequent but distressing presentation to the Emergency department (ED) with a 2018-19 review indicating 8-10 per year at Frimley Park.

• Reduction of a displaced femoral fracture into anatomical alignment provides highly effective pain relief and should be achieved as soon as practical. In a child with a suspected displaced femoral fracture, it is an acceptable and encouraged practice to put the affected limb into skin traction (ward bed) soon after ED arrival.

• Imaging of the affected limb can be performed on a ward bed whilst in traction and the child should not be moved to an ED trolley.

• Ward beds with traction applied can fit into the current lifts at Frimley Park hospital and are not a valid reason to delay application of skin traction.

• Skin traction should be applied by a competent and experienced Paediatric ED nurse. Incorrect application can result in significant pressure sores or degloving injuries, due to the mechanical forces involved.

• Skin traction counterweights are historically calculated as 10% of body weight. A pragmatic approach is required for calculations. Typically, 1-2kg is adequate. Down tilting head of bed may be required to counteract the traction weight.

• Orthopaedic input or review before application of skin traction is not necessary and leads to delays in care.

Analgesia

• Intranasal opiates - administer as soon as practical in ED.

  • Dose – see Trust guideline

• Diazepam (oral) - administer for muscle spasms.

  • Typically occurs after application of traction and should be administered pre-emptively.

  • Should only be prescribed on an ongoing basis if muscle spasm persists.

  • Dose – see BNFc for age based dose (postoperative skeletal muscle spasm)

• Paracetamol & ibuprofen prescribe as regular medications

  • Dose – see BNFc.

• Oromorph – prescribe for breakthrough pain

  • Dose – see BNFc.

Traction application: (Skin traction using adhesive dressing)

The Royal College of Nursing has a detailed guideline explaining principles and application of skin traction (Chapter 3, page 14 – last accessed 17/08/22)

• 2 full sets of skin traction kit should reside in Paed ED at all times (source replacement kit from Paediatric or Orthopaedic wards).

• Adhesive bandaging should be applied using a herringbone pattern with tape to the mid-thigh. The kneecap should be left exposed to allow movement.

• Regular limb observations should be performed.

F2. Knee

Tips

• Lipohaemarthrosis implies a fracture.

• Locking – suggestive of meniscal tear or loose body.

• Giving way – suggestive of ligamentous/meniscal tear or patella instability.

• Immediate swelling indicates haemarthrosis therefore ?bony/ligamentous injury.

• In a child with knee pain always assess hips.

• Poor fitting, or too large ‘Richard’s splint’ use wool and crepe.

F2. Knee

F3. Lower Leg

F4. Ankle

OTTAWA ANKLE RULES

Used Ankle Injury Radiography. In children give some thought to applicability of Ottawa ankle rules, they are not validated under 8 years old, as young children more likely to break than sprain due to relative strength of ligaments and bone cortex.

Indications for an ankle X-ray- Ottawa ankle rules

The patient complains of pain in the malleolar zone and any of the following:

• Bone tenderness at A, or

• Bone tenderness at B, or

• Inability to weight bear both immediately after the injury and in ED

Indications for a foot X-ray

The patient complains of pain in the midfoot zone and any of the following:

• Bone tenderness at C, or

• Bone tenderness at D, or

• Inability to weight bear both immediately after the injury and in ED

F4. Ankle

F5. Foot

• Injury to the cervical spine is rare in children but should always be considered following significant trauma.

• Full guideline on trauma network website

• The cervical spine should be presumed to be injured until proven otherwise, especially if there is obvious injury above the clavicle.

• In a co-operative or unconscious child immediate in-line manual immobilisation of the head and neck should be applied and sandbags and tape fitted. If the child is uncooperative or combative, maintain in-line manual immobilisation only. Collars are no-longer recommended.

Children who have experienced trauma, who are:

• Alert and conversant

• Not intoxicated

• Have no neurological abnormality

• No midline cervical tenderness

• No painful distracting injury (e.g., long bone fracture, visceral injury, burns etc.)

are at very low risk of cervical spine injury and do not require cervical spine X-rays.

• Children who have experienced trauma who cannot meet these criteria will require lateral, AP c-spine and open mouth X-rays. Remember the lateral view must include upper border of T1.

• If inadequate views are obtained, a CT should be considered rather than repeated X- rays

• The c-spine can only be cleared if a doctor is confident there is no clinical or radiological evidence of c-spine injury. If there is any doubt ask for a senior ED opinion.

• Remember SCIWORA-Spinal Cord Injury Without Radiological Abnormality. It is rare but it does occur in children, hence the need for clinical as well as radiological clearance

• Injuries to the thoracic and lumbar spine are rare in children. They are most common in the multiply injured child.

• When an injury does occur, it is not uncommon to find multiple levels of involvement because the force is dissipated over many segments in the child’s mobile spine. This increased mobility may also lead to neurological involvement without significant skeletal injury.

• The most common mechanism of injury is hyperflexion, and the most common radiographic finding is a wedge- or beak-shaped vertebra resulting from compression.

• The most important clinical sign is a sensory level. Neurological assessment is difficult in children, and such a level may only become apparent after repeated examinations.

• Log roll as soon as is practicable and remove spinal board or scoop to transfer child onto a trauma mattress.

• Imaging of children with suspected thoracic or lumbar spine injuries outside of those being scanned for polytrauma (ie already a CT CAP) should be a ED Consultant (OOH ST4+ SPR) to Radiology Consultant discussion to consider the best type of imaging, taking the low prevalence of these injuries and ALARA principle into consideration.

  • In Hours – ED to Radiology Consultant to decide upon best imaging modality

  • Out of Hours – ST4+ to discuss with on-call ED consultant for imaging decision. If CT, then discuss with Axon as per usual protocol. If XR imaging (or Axon advise XR instead of CT), then this will need to be discussed with and authorised by the on-call FPH Radiology Consultant as Axon cannot authorise plain film imaging.

• Refer all spinal fractures to orthopaedics for further assessment/opinion.

Refer to orthopaedic registrar for aspiration. Can be performed in ED

The indications in ED are:

• Diagnostic: Suspected septic/infected joint

• Therapeutic: Tense painful haemarthrosis (aspiration of fat globules indicates a possible underlying fracture).

• Obvious bent arm or leg – POP slab for initial analgesia immediately (not plastic splint).

• Undisplaced fractures of distal radius and ulna- not involving volar cortex - Futura Splint

• Minimally displaced mid/proximal radius and ulna fractures – above elbow backslab.

• Scaphoid fractures – futura splint for both suspected and confirmed scaphoid.

• Displaced metacarpal fractures bedford and high arm sling.

• Minimally displaced metacarpal fractures – Bedford.

• Thumb - all into futura with thumb extension unless orthopaedic SpR wants Bennets - and then they need to arrange with plaster room to do cast or do it themselves.

• Distal tibia and/or fibula and metatarsal fractures – below knee backslab.

• Minimally displaced mid/proximal tibia and fibula fractures – above knee backslab, or full cast.

• Knee problems – Richard splints, unless not one small enough and then wool and crepe.

• Ankle – undisplaced single malleolus (including Salter Harris injuries) – black boot, undisplaced multiple malleolar or displaced fractures - below knee back slab.

• Foot – black boot.

Consideration should be given to provide 16 and 17 year olds seen in PED and immobilised in either a lower limb POP or blackboot with appropriate TTO VTE prophylaxis if they are being discharged. Please see ED Guideline for further information, risk assessment and prescribing.

Based on the Nottingham University Hospitals NHS Trust and Nottingham Children’s Hospital guideline on skeletal trauma in children.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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