It is easier to go back to school walking in a below knee cast than trying to maintain partial weight bearing with crutches and ankle strapping.įigure 34: Removable splint for buckle injuryįigure 35: Collar and cuff for humeral fractures.Ĭlosed reduction and cast immobilisation is the treatment of choice for the majority of displaced fractures in children of all ages. Some soft tissue injuries in the lower limb, such as ankle sprains are more effectively managed in casts than with strapping because children can then weight bear with comfort and without the need for crutches. This includes most clavicle fractures and some proximal humeral fractures. Some upper limb fractures are best managed in a collar and cuff (Figure 35) or triangular sling. The simple formula, believed by many parents (and some doctors), that "bony injury = a plaster cast" and "soft tissue injury = a bandage" is not always true. Most complete plaster casts need to be removed in the ED or fracture clinic. A plaster backslab, held in place with a crepe bandage can be removed by parents or at the time of review by the child's GP. Splints for these injuries should be simple and safe and easy to put on and take off. A plaster backslab does not make a buckle injury heal more quickly but it does provide excellent pain relief. Removable forearm splints are ideal as primary management for undisplaced fractures of the distal radius (Figure 34). However, the majority of fractures and epiphyseal injuries are painful and immobilisation is often the best analgesic. When a fracture is undisplaced or minimally displaced, reduction may not be necessary. Some minor buckle injuries may not require casting or immobilisation. Sometimes specific treatment is not required. No matter how trivial the injury, parents deserve an adequate explanation, appropriate advice and answers to their questions. Local anaesthetic blocks can also be useful, especially femoral nerve blocks for fractures of the femoral shaft. Entonox is also useful for simple fracture manipulations and reductions. Bier's block is very useful for many forearm and wrist fractures. Most units have clinical practice guidelines to ensure safe and effective practice. All forms of analgesia and sedation have specific risks and benefits. Procedural analgesia is very important in the ED and can be provided by many different means according to the child's needs and the clinical setting. Rectal administration may be helpful in the fasting child. Non-steroidal anti-inflammatory agents are especially useful for musculoskeletal pain. Pain relief can be provided by paracetamol (20 mg/kg per dose) or diclofenac (up to 1 mg/kg per dose). Early immobilisation by temporary splinting, combined with reassurance can be very effective analgesia.
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