HOW TO TREAT 29
Figure 14 . Shaft fracture leading to subtle malunion .
How to Treat Quiz . are accidents . Consider whether the injury pattern matches the history . Is the child cheerfully talkative about how they fell off the monkey bars or shy and defensive about how it happened ? Does the parent confess to dragging a tardy preschooler by the hand across a pedestrian crossing and then bringing them into the doctor ’ s when they complained of a pulled elbow ? And after reduction ( hypersupinate the forearm in extension , no anaesthetic needed for this ), does the child perk up and relate to the parent without fear ? Or does the child cower ?
Certain patterns are suspicious . A spiral fracture results from a rotational injury , which is quite common in adults who jam their power drill or make a futile attempt at a twisting tackle . Children tend to fall over straight , with an angulatory rather than a rotational force — a twist may be from a grab . Are there fingerprint bruises on the wrist ? Are there multiple metachronous injuries with different coloured bruises , with doctor-shopping across multiple practices who have treated each separate injury ?
The author has treated many families where several siblings have had multiple significant injuries but usually with a clear explanation , like on the football field or where every member of the family plays representative hockey . Being the regular family GP and knowing the family ’ s interests provides an edge over the ED doctor . Active risk-takers have a higher probability of fractures .
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1 . Which ONE imaging modality is the mainstay of hand in juries in children ? a MRI . b Ultrasound . c X-ray . d Nuclear medicine scan .
2 . Which ONE imaging modality is the best means of finding a small radiolucent foreign body ? a MRI . b X-ray . c Ultrasound . d Nuclear medicine scan .
3 . Which THREE statements regarding examination of an injured hand are correct ? a When assessing any wound , consider the position of the hand when the wound occurred . b The skin is the strongest structure between the outside environment and the bone . c One needs to see the bottom of the wound . d The hand ( 9 % of the body surface area ) contains a disproportionate number of painful nerve endings .
4 . Which TWO statements regarding nerve function are correct ? a The cardinal sign of sensory nerve injury is pallor . b The principal nerve function in the hand is sensory . c A formal monofilament assessment by an experienced hand therapist will dispel doubt of a nerve injury . d The palmar surface of the radial two and a half digits is supplied by the median nerve and the ulnar two and a half by the ulnar nerve .
5 . Which THREE steps are indicated in the management of an amputation ? a Dress the hand with a moist dressing . b For transport , place the plastic bag in another plastic bag or a bucket of ice . c Rinse the amputated part , wrap in moist gauze and place in closed plastic bag . d Store the finger in the fridge before transport .
6 . Which TWO are appropriate tendon assessments in a hand injury ? a Flexing the PIP and DIP joints to test the superficialis . b Flexing the distal joint to test the profundus . c Askingthe patient to grip your finger . d Flexingthe PIP joints individually to test the superficialis .
7 . Which THREE are features of paediatric bones ? a Highly fibrous . b Rigid cartilage component . c Thick periosteum . d Physes .
8 . Which THREE statements regarding the Salter classification of epiphyseal fractures are correct ? a In a grade I fracture , the fracture goes through the growth plate . b Salter III and IV fractures require anatomical reduction , which generally means pinning or screwing . c Salter V is radiologically indistinguishable from the Salter IV on the first X-ray . d Be suspicious of a Salter V fracture after a high-energy injury .
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HAND INJURIES IN CHILDREN
Ask about the mechanism of injury , as mandatory reporting allows the doctor to ask while saying it is a legal requirement .
CASE STUDIES
Case study one
SUSAN , 23 , presents with ulnar-sided right wrist pain and ulnar carpal and distal radioulnar joint instability . Susan broke the arm aged nine , and since then , the wrist has always been ‘ weak ’, limiting her high school sport and subject choices . Symptoms have been mild but have recently flared after a game of social tennis .
X-rays show the right radius has a subtle malunion from a fracture when she was nine ( see figure 14 ). There is dorsal angulation at the distal shaft ; a straight line along the bone from wrist to elbow joints does not go up the axis of the entire shaft , unlike the normal left radius .
The radius is shorter . On the right , there is positive ulnar variance of 2mm — that is , the ulna is longer than the radius — compared with 4mm negative ulnar variance on the left . As little as 1mm of relative ulnar lengthening doubles the force on the ulnar head .
Radial angulatory osteotomy combined with ulnar shortening osteotomy is necessary to correct the bony deformity and then ligament reconstruction two years later at the time of plate removal .
Case study two
Cara , 20 , has a 35 ° angulated fracture that has malunited without reduction from an injury at the age of four .
9 . Which TWO statements regarding fractures in children are correct ? a Forearm / distal radial fractures in toddlers are usually undisplaced greenstick fractures . b In an acute and obviously painful forearm / distal radial fracture , a below-elbow cast protects against reinjury and provides pain relief . c Midshaft fractures unite faster than those of the distal radius . d Malunion close to a growth plate , in the same plane as the major movement of the joint , can remodel if there is enough growth remaining .
10 . Which THREE statements regarding hand injuries in children are correct ? a Major subungual haematomas respond to drainage . b A Seymour fracture will become infected unless it is carefully debrided then surgically reduced . c Glass will always show on X-ray , provided it is not obscured by the bone . d Wood splinters from a dilapidated fence may be friable when removed with forceps , and fragments commonly remain behind .
At skeletal maturity , it has remodelled to around 10 ° malunion , with wrist and distal radial ulnar joint pain requiring corrective sagittal radial shaft osteotomy in her 20s .
The initial angulation was around 35 °, and the fracture would have easily been reducible with general anaesthetic and an above-elbow cast , moulded with the wrist in full pronation for four weeks . This would have alleviated the immediate pain and improved the cosmetic deformity through her childhood and the loss of forearm rotation .
The bowing of the shaft is easily seen when the normal right forearm is compared with the left . As the bone has grown longitudinally , it has left the fracture site behind but not completely corrected the deformity . Growth of the radius is predominantly from the distal end .
Closed reduction initially would have been easy , preventing two decades of pain and disability .
CONCLUSION
GPs have a role in educating their patients about child safety , particularly as the tendency away from extended families living together means there is often little intergenerational transfer of childcare wisdom . Simple measures — like taking care around glass or porcelain crockery , limiting access to knives and sharp kitchen implements , and workshop safety — can prevent many injuries .
Some injuries may be prevented by advising parents to look at their homes from the child ’ s perspective — for example , a child pulling out the drawers in the kitchen to use as a ‘ staircase ’ to reach the kitchen bench and a heater at floor level is tempting to touch . Babies and toddlers have much stronger arms than legs , and we retain our simian instinct to climb up objects , including electrical cables , risking injury from falling televisions or other appliances .
Similarly , we need to reassure the parents of our paediatric patients that it is not their fault when a child sustains a play injury or selects a dangerous school sport ; some injuries are simply inevitable , and some children are inherent risk-takers .
Child abuse remains under-recognised and under-reported , and some injuries are a result of bullying by other children . Suspicion of injuries where there is an inconsistent history or physical examination is vital .
RESOURCES
• Rang M , et al . Rang ’ s Children ’ s Fractures . Lippincott Williams and Wilkins , 2005 .
• William Bora Jr F ( editor ). The Pediatric Upper Extremity : Diagnosis and Management . WB Saunders , 1986 .
• The Easter Seal Society . The Easter Seal Guide to Children ’ s Orthopaedics . Mercer Rang , 1982 . This free book should be read by every medical student and reread by any doctor who treats children .
• John Charnley . The Closed Treatment of Common Fractures . Cambridge University Press , 2010 .
References on request from howtotreat @ adg . com . au