This application has been designed to provide recommendations for the outpatient, non-surgical treatment of common pediatric fractures, dislocations, and distortions. It specifies acceptable fracture displacement for each bone that does not require surgical intervention. This guide is intended for use by healthcare professionals as an aid for quick reference and is not a substitute for a doctor’s professional judgment. The content is derived from two primary references:
Reference 1: Astrid Lindgren’s Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden.
This reference is based on the Kompendium i Barnfrakturer (Compendium of Pediatric Fractures). It has been widely used for many years across Swedish hospitals as the primary guideline for outpatient management of pediatric fractures not requiring surgery. It is continuously updated based on accumulated clinical experience, with recommendations extending to common joint dislocations and sprains.
Reference 2: Rockwood and Wilkins’ Fractures in Children, 10th Edition.
This is an internationally recognized, comprehensive textbook covering both surgical and conservative management of pediatric trauma. For this application, only conservative treatment methods have been included to align with the focus of Reference 1.
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Structure of References
Both references are presented in two structured sections with aligned categories. The framework primarily follows the structure of Reference 1 for consistency.
Some fractures appear only in Reference 2 when they are not detailed in Reference 1 due to rarity. Conversely, some fractures are divided into subcategories only in Reference 1 for improved clarity and usability.
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Scope of the Application
The primary goal of this application is to define the acceptable limits of fracture displacement that permit conservative (non-surgical) management. These limits apply after the final reduction, whether open or closed. If the fracture position after CRIF (Closed Reduction and Internal Fixation) or ORIF (Open Reduction and Internal Fixation) does not fall within acceptable limits, it is considered unsuitable for the management.
Important Exclusions: This guide does not cover cases where surgical treatment is absolutely indicated regardless of displacement, including unstable or irreducible fractures, open fractures, high risk of infection, nail deformity, joint instability, growth plate arrest, malrotation, excessive shortening, intra-articular entrapment of fragments, vascular injury, neurological deterioration such as nerve entrapment, segmental fractures, polytrauma, severe swelling with risk of compartment syndrome, and patients with body habitus unsuitable for long-leg casting.
These situations represent contraindications for conservative treatment and should always prompt surgical consideration.
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Intended Use and Target Audience
This application is designed for healthcare professionals only. It provides medical knowledge to assist clinicians in decision-making but does not replace clinical judgment or specialist consultation. Each case must be individualized. Non-medical personnel must not use this application, as improper use poses significant risks.
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Adaptation to Local Guidelines
The original care program was written in Swedish and adapted for Swedish hospital practice. For this application, the recommendations have been modified and generalized for international applicability. Users are encouraged to adapt these guidelines to their local, geographic, economic, and cultural contexts.
When uncertain, clinicians should always contact their local pediatric orthopedic emergency department.
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Safety Margins and Biological Considerations
The recommendations intentionally include a safety margin regarding cast duration and acceptable displacement. Pediatric fractures remodel over time. Remodeling capacity is greatest in younger children, near growth plates, and when displacement aligns with the primary plane of joint motion. Younger children generally require shorter immobilization times due to faster healing.
Key Principle: Always X-ray and document both the proximal and distal joints in two planes, frontal and lateral, to fully assess the injury.
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Additional Clinical Instructions
This application does not cover all aspects of fracture care. Clinicians must also provide elevation and mobilization instructions, follow local protocols for pain management, issue written cast-care guidelines and exercise programs when available, provide crutches or wheelchairs as needed, and inform families that limping may persist for several months following cast removal of lower-limb fractures.
If a cast is replaced during treatment of an unstable fracture, a new X-ray must be taken. All immobilization times are calculated from the day of injury.
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Definitions of Key Terms
Limit for Acceptable Displacement: Describes the maximum displacement or angulation acceptable for conservative treatment, based on the references mentioned above. This applies after the final reduction.
Treatment: Refers to the recommended type of immobilization. Sometimes multiple options are provided, depending on patient compliance and fracture characteristics.
Follow-up and Immobilization Time: Suggests a timeline for cast duration, weight-bearing progression, and X-ray monitoring.
Avoiding Risky Activities: Patients should refrain from high-risk activities such as sports, cycling, trampolining, climbing, and similar activities until full rehabilitation. Return to competitive sports requires restored range of motion, muscle strength, and absence of significant swelling.
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Methods of Immobilization
Long arm splint: This is a type of plaster splint that begins on the outer side of the upper arm at the armpit level, extends down the back of the elbow, and then curves forward to cover the entire back of the forearm and wrist up to the knuckles. It necessitates additional splints on both the inner and outer sides of the elbow.
Forearm dorsal splint: This method consists of a plaster splint that extends along the full length of the back of the forearm up to the knuckles and is sufficiently wide to encompass the entire dorsal side of the forearm.
Twin bandage: This method involves attaching the injured finger to an adjacent finger by wrapping tape around the phalanges while ensuring that the joints remain mobile. It is crucial to insert compresses between the fingers. This bandage is especially appropriate for older children with stable fractures, although prefabricated finger fixation bandages may also be utilized.
Fix-over-roll: This technique is applicable to a range of hand and finger fractures, particularly in smaller hands or among younger children. To begin, an elastic bandage roll is placed in the hand, allowing the fingers to encircle it, achieving 60 degrees of flexion at the MCP and IP joints, along with 45 degrees of dorsal extension at the wrist. A compress or gauze is inserted between the fingers. Next, the entire hand, or a part of it excluding the thumb, is wrapped with the elastic bandage. Finally, tape is used to secure the bandage in place. This bandage can be modified for two, three, or four fingers.
Long leg cast: This is a circular cast that starts at the mid-thigh area and extends down to the toes. It is essential to ensure that the ankle is maintained at a 90-degree angle to support walking and weight-bearing on the cast.
Short leg cast or cast boot: This is a circular cast that begins just below the knee joint (without restricting knee movement) and ends at the toes. It is vital to ensure that the ankle is positioned at a 90-degree angle to aid in walking and weight-bearing on the cast.
Leg cylinder: This is a circular cast that starts at the proximal thigh and extends about 15 to 20 cm above the malleolus, ensuring it does not touch the malleolus in case of slippage.
Collar and cuff: This consists of a removable sling made from foam plastic tape, covered in a fabric stocking that supports the neck and wrist while keeping the elbow at an angle of 70 to 90 degrees of flexion.
Sling: This option may be more appropriate for younger children.
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Weight-Bearing Instructions
Step marking (“touch-down weight bearing”, “toe-touch”)
The patient is permitted to rest the foot on the ground solely for the purpose of maintaining balance. The weight applied is minimal – often described as “sufficient to support a raw egg beneath the foot without causing it to break.”
There is no actual weight bearing involved; it serves merely as a step marker to enhance gait, balance, and proprioception.
Weight bearing as tolerated (WBAT, “up to pain limit”)
The patient is allowed to apply as much weight as they can comfortably manage without inducing significant pain. The threshold is determined by the patient’s pain levels. This can vary from partial to nearly full weight bearing.
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Conclusion
This application is intended as a comprehensive, structured, and safe guide for conservative management of pediatric fractures and dislocations in outpatient care. It is a decision-support tool for clinicians, not a substitute for expert consultation or clinical judgmen