Pediatric emergency medicine trisk 3419 3419

Avulsion Fractures
The frequency of avulsion fractures in pediatrics is a consequence of the strong
muscular attachments to relatively weak secondary centers of ossification in the
developing skeleton known as apophyses. During intense muscular contraction,
fractures can occur through the apophyseal plate. Common sites include the
pelvis, tibial tubercle, and the phalanges. Avulsion fractures infrequently require
open or closed reduction. Conservative care is the mainstay of treatment.

GENERAL PRINCIPLES OF ACUTE ORTHOPEDIC CARE
CLINICAL PEARLS AND PITFALLS
Any child with obvious extremity deformity should be made nil per os
(NPO) at triage given the potential need for procedural sedation or
operative management for fracture reduction and casting.
Based on the history and mechanism of injury, the possibility of other
injuries (e.g., head, chest, intra-abdominal organs) should be
considered.
Physical examination must include inspection, palpation, range of
motion (passive and active), and neurovascular examination with
careful examination of the joints proximal and distal to the point of
maximal tenderness.
Always carefully remove all splints, bandages, and clothing in order to
perform an accurate examination with documentation of breaks in the
skin, which may represent an open fracture.
Splinting the injured extremity immediately after evaluation and before
radiographs are taken can decrease the child’s discomfort and prevent
further injury.
Neurovascular status should be assessed before and after any splinting
is performed.
If an orthopedist is not readily available, gentle longitudinal traction and
gross realignment may be performed by the emergency clinician for
fractures that are grossly displaced, unstable, or if there is vascular

compromise.

Current Evidence