Suspected extremity fracture (< 18 years)

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Suspected extremity fracture (< 18 years)

Morphine injection


Injuries inconsistant with underlying story, injuries concerning for abuse pattern or social history concering for abuse (including neglect)

Are any of the following present?

  • Humeral shaft fractures, nondisplaced.
  • Proximal humeral fractures nondisplaced or displaced < 50%.
  • Non-displaced hand fractures (such as scaphoid, metacarpal)
  • Type I supracondylar humerus fractures
  • Nondisplaced midshaft tibial fractures (Toddlers fracture)

Off pathway

Ottawa knee rules

Fracture specificity for abuse


  • Classic metaphyseal lesions
  • Rib fractures, especially posterior
  • Scapular fractures
  • Spinous process fractures
  • Sternal fractures
  • Unexplained fracture in an infant


  • Multiple fractures, especially bilateral
  • Fractures of different ages
  • Epiphyseal separations
  • Vertebral body fractures and subluxations
  • Digital fractures
  • Complex skull fractures


  • Subperiosteal new bone formation
  • Clavicular fractures
  • Long bone shaft fractures, unless child pre-ambulatory
  • Linear skull fractures

Ottawa ankle rules

Are any of the following present?

  • Closed clavicle fractures - place in sling only
  • Non-displaced fibula fractures with normal mortise (including proximal fibular head fractures) - provide only crutches
  • Digit fractures (except those with significant displacement, rotational deformity, or articular disruption) - splint/buddy-tape
  • Buckle or non-displaced distal radius and/or ulnar fractures (metaphyseal or physeal) with less than 5 degrees angulation - splint (may be velcro wrist splint)
  • Non-displaced ankle fractures with a normal mortise - splint
  • Non-displaced proximal radial head fractures - place in sling only
  • Non-displaced forefoot fractures - provide cast shoe and crutches
  • Non-displaced fractures of mid-shaft forearm bones - sugar-tong splint and sling

Are any of the following present:

  • Open fracture
  • Fracture that is significantly displaced or angulated (except digit or clavicle fractures)
  • Facture-dislocation
  • Pelvic, hip, or femur fracture. (except avulsion fractures of pelvis)
  • Pathologic fracture

  • Social work consult
  • Non-accidental trauma workup

Signs of neurovascular compromise?

Inclusion Criteria
  • Injury or other clinical factor placing the patient at risk for fracture
Exclusion Criteria
  • Active cancer or immunosuppressed
  • History of complex orthopedic surgery at the site of injury
  • Genetic or metabolic bone disease

Signs of compartment syndrome?

Is this patient in severe pain?

Urgent orthopedic consultation

Emergent orthopedic consultation, remove any restrictive dressing, splint, cast or other covering, place the limb level with the heart, avoid causes of hypotension

Injury type

Phone consultation with orthopedic surgeon

Obtain x-rays of suspected injury

Discharge with follow up with orthopedics in one week

Consider other source of symptoms including dislocations, soft tissue injury, child abuse, etc.

Emergent orthopedic consultation, immediate reduction if signs of poorly perfused extremity