What is the initial approach to managing pediatric fracture patterns?

Initial Management of Pediatric Fracture Patterns

The initial approach to pediatric fractures prioritizes conservative management with immobilization, immediate assessment for non-accidental trauma in children <24 months, and thorough neurovascular evaluation, with most fractures successfully treated non-surgically due to children's superior healing and remodeling capacity. 1, 2

Immediate Assessment Priorities

Neurovascular Examination

• Perform immediate and thorough neurovascular assessment at presentation, including evaluation for absent pulses, cold/pale extremity, and nerve function, as nerve injuries occur in approximately 10% of pediatric fractures and vascular compromise can lead to catastrophic outcomes including limb loss. 3
• Document motor and sensory function in all extremities before any intervention. 3

Non-Accidental Trauma Screening

• In children <12 months old with any fracture, skeletal survey is necessary regardless of fracture type or reported history, with rare exceptions. 1
• In children 12-23 months old, skeletal survey necessity depends on fracture type and mechanism. 1
• Skeletal survey is mandatory if fracture is attributed to abuse, domestic violence, being hit by a toy, or if there is no history of trauma. 1
• The high rate of occult fractures in abuse victims (20-25% in infants <12 months) necessitates this screening to prevent ongoing morbidity and mortality. 1

Conservative Management Framework

General Principles

• Most pediatric fractures should be treated with closed reduction, immobilization, and close follow-up rather than surgical intervention. 4, 2
• Accept more initial deformity than traditionally tolerated, as children's high remodeling potential mitigates residual deformity risk. 1
• Maximize use of removable casts and splints to facilitate monitoring and reduce complications. 1

Immobilization Specifics by Location

Upper Extremity:

• For non-displaced proximal humerus fractures, use posterior splint rather than collar-and-cuff, as it provides superior pain relief within the first 2 weeks. 5, 6
• For undisplaced supracondylar fractures (Gartland Type I), posterior splint immobilization is recommended over collar-and-cuff based on moderate-strength evidence showing better pain control. 6, 3
• Most upper limb fractures can be managed conservatively with removable splints. 1

Lower Extremity:

• The majority of lower extremity fractures can and should be treated with closed reduction and immobilization. 4

Imaging Strategy

Initial Imaging

• Obtain comparison radiographs of both sides with appropriate views to assess physeal widening and fracture severity. 5
• Minimize imaging that will not change management, as immediate postoperative imaging provides only 0.22% absolute benefit in identifying complications. 1

Follow-up Imaging

• Obtain radiographic follow-up during the first 3 weeks of treatment and at cessation of immobilization to confirm fractures remain non-displaced. 5
• Keep imaging to minimum, choosing the single most useful modality to limit patient-healthcare worker contacts. 1

Surgical Indications

Clear Indications for Operative Management

• Fractures requiring anatomic realignment of physis or articular surface. 4, 2
• Open fractures (consider wash-out and windowed cast application). 1
• Displaced supracondylar fractures (Type II-III requiring closed reduction with percutaneous pinning). 3
• Fractures with coexisting vascular injuries. 2
• Multiple injuries requiring mobilization. 7, 2
• Failed initial conservative treatment. 2
• Specific fractures with poor conservative outcomes: femur neck fractures, displaced lateral condyle fractures, femur/tibia/forearm shaft fractures in older children/adolescents. 2

Vascular Emergency Protocol

• If absent wrist pulses and cold, pale hand persist after reduction and pinning, perform immediate open exploration of the antecubital fossa due to catastrophic risks including limb loss, ischemic contracture, and permanent functional deficit. 3

Special Considerations

Open Fractures

• Perform wash-out and consider windowed cast application. 1
• Minimize procedures and use PICC line at time of surgery. 1
• Consider at-home intravenous antibiotic treatment where possible. 1

Dislocations

• Reduce in emergency department wherever possible. 1
• Manage as day surgery if admission required. 1

Overuse Injuries (Little League Shoulder)

• Require complete throwing cessation for minimum 6 weeks, followed by 6 additional weeks of strengthening (total 3 months rest from throwing). 5
• Implement rotator cuff, periscapular, and core strengthening with capsular flexibility exercises. 5

Follow-up Protocol

Duration and Monitoring

• Standard immobilization is approximately 3-4 weeks, though insufficient evidence exists for definitive optimal duration. 5, 3
• Clinical judgment must guide removal of immobilization and return to activity based on radiographic healing and symptom resolution, as high-quality evidence for specific timing is lacking. 6, 3
• Minimize in-person follow-ups using teleconference where clinically appropriate to reduce exposure risks. 1

Rehabilitation

• Insufficient evidence exists to recommend for or against routine supervised physical or occupational therapy. 6, 3
• Guide rehabilitation decisions based on the child's recovery of motion and function using clinical judgment. 3

Critical Pitfalls to Avoid

• Missing non-accidental trauma in infants <12 months: Failure to perform skeletal survey can result in ongoing abuse and additional injuries with significant morbidity and mortality. 1
• Inadequate neurovascular assessment: Missing vascular compromise can lead to limb loss and permanent disability. 3
• Over-treating with surgery: Most pediatric fractures heal successfully with conservative management due to superior remodeling capacity. 1, 2
• Obtaining unnecessary imaging: Postoperative imaging rarely changes management and increases healthcare contacts. 1