Chapter 2 Index

A. Evaluation by system

B. Other categories of illnesses:

1. Metabolic and Endocrine

2. Collagen-Vascular Illnesses

3. Chromosomal Abnormalities

4. Generalized

5. Sexual Abuse

6. Hematology

7. Trauma and Surgery
--Surgery in Pediatrics: Timing and Indications for Procedures

Fractures in Children

Introduction: Concern is that children can have a fracture through the epiphysis, which makes obtaining x-rays of affected extremities more necessary than in adults, but sometimes fractures are not always apparent on the first x-ray e.g. elbow.

1. Skull Fracture: Physical findings may occur up to 5-7 days after the accident.  PE will show a hematoma that is ballotable.  If x-ray does not show a depressed fracture, no need to refer.  Some suggest re-x-ray in several months to rule out a leptomeningeal cyst.

2. Clavicle Fracture: Sling an important ancillary treatment.  Question of whether an x-rayis usually necessary since this is a clinical diagnosis.

3. Elbow Injury: Difficult x-rays to interpret.  Remember, if blood in the elbow joint - refer because of possible supracondylar fractures.

4. Forearm and Leg Fractures: Forearm fractures result from falling with hand outstretched.

Different categories of fractures for which treatment can vary.  In general, upper extremity fractures are immobilized for 3-6 weeks, lower extremity fractures for 6-8 weeks.

• Greenstick Fractures: failure of tension results in this type of fracture.
• Torus or Buckle Fractures: fractures can be just a bowed bone, but come from twisting
• Transverse Fracture
• Spiral Fracture: from twisting the involved extremity e.g. toddler’s fracture of tibia.
• More Severe Types Such as Overriding, Fragmented Fractures

5. Finger and Toe: Salter and Harris system of six categories of injury classification:

• Type I and II: low risk of growth arrest and easily treated
• Type III and IV: involve the joint surface in addition to the growth plate and require open reduction and fixation.  High risk of growth arrest.
• Type V and VI: more severe.

Finger: Indications for x-ray: some say with each injury; others when involves or could involve the joint.

Treatment: Splints must be applied carefully if used.  Finger needs to be in position of function.  Orthopedists here put cotton between fingers and tape.

Toe: Not many indications for aggressive evaluation since only treatment is to tape together.

6. Ankle:

• Type I: equivalent to sprain; some orthopedists recommend immobilization - depends on the symptoms of the patient.
• Type II: greenstick fracture of the fibula.  Treat closed: separation of the distal physis
• Type III: epiphyseal injury to later aspect of the distal tibia.  May need open reduction.

How to examine an ankle:

• First determine if you think a fracture; if so - refer.
• Next if no fx, check ligaments around ankle - if severe pain may need referral; if increased mobility - refer

When to x-ray: If can’t tell whether fracture present, or if symptoms severe.

7. Metatarsal Fracture: Involved foot will be swollen and painful - sometimes days later.

8. Unusual Fractures: bones of hand, patella, talus, and calcaneus.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004