Fig. 1
Salter-Harris classification of fractures (Source: Christopher Coppola)
(c)
As a general rule, higher Salter-Harris grade results in increased incidence of growth disturbance.
4.
History:
(a)
Age, mechanism of injury, time of injury, witnesses to event, prior injuries.
(b)
Birth, developmental, family and social history.
(i)
Underlying metabolic bone disorders.
(ii)
Osteogenesis imperfecta.
(iii)
Risk factors for non-accidental trauma.
5.
Physical examination:
(a)
Skin:
(i)
Any communication of fracture through skin is an open fracture.
(ii)
Overlying lacerations and wounds may not be at exact level of open fracture.
(iii)
“Impending open” fractures present with skin tenting from underlying bone.
1.
Can erode skin and convert closed fracture to open fracture.
2.
Requires reduction.
(iv)
Open fractures have higher infection risk. They require immediate IV antibiotics and urgent debridement in operating room.
(b)
Soft tissues: assess myofascial compartments for soft tissue swelling.
(i)
Compartment syndrome:
1.
Can occur even without fracture.
(a)
Crush injuries, burns, bleeding.
2.
Assess for 5 P’s.
(a)
Pain with passive stretch.
(b)
Parasthesias.
(c)
Pulselessness (late finding).
(d)
Paralysis.
(e)
Poikilothermia.
3.
Exam can be unreliable in children.
(a)
Agitation, anxiety and increasing narcotic analgesia requirement should be monitored in pediatric patients.
4.
Concern for compartment syndrome requires emergent orthopaedic consult.
(a)
Treatment is fasciotomy in the operating room.
(b)
Missed compartment syndrome has devastating neurovascular consequences.
(c)
Neurovascular examination:
(i)
Document complete neurologic examination.
1.
Can be limited by age and patient compliance.
2.
Motor and sensory exam.
(ii)
Vascular exam:
1.
Palpate peripheral pulses.
2.
Duplex ultrasound examination of pulses.
3.
Assess perfusion of extremity.
(a)
Capillary refill.
(b)
Temperature.
(c)
Color.
6.
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Imaging:
(a)
X-rays:
(i)
Orthogonal views of the fracture.
(ii)
Obtain radiographs of the joint above and below the fracture.
(iii)
Comparative radiographs of contralateral extremity are helpful to distinguish fractures from normal anatomic variants.
(iv)
Descriptive terms:
1.
Location.
(a)
Physeal.
(b)
Metaphyseal.
(c)
Diaphyseal.
2.
Angulation.
3.
Displacement.
4.
Comminution.
5.
Shortening.
(b)
CT:
(i)
Consider for intra-articular fractures, physeal injuries.
(ii)
Increased exposure to radiation compared to plan radiographs.
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