Orthopedics
For a child with a chin laceration examine for mandibular fracture, most common site is
condyles.

These are best imaged by computed tomography.

May present with pain, swelling, and trismus. Examine for point tenderness, deformities,
decreased sensation in the lower lip or gum, misalignment of the teeth either with
neighboring teeth or opposing teeth, decreased range of motion or deviation of the jaw to
one side as it opens. Look for sublingual hematoma and laxity of the mandible.

Nondisplaced mandibular fractures without malocclusion can be managed conservatively
with a soft or liquid diet for 2–3 weeks, oral analgesics, and close follow-up.
Tenderness at the physis in the injured child is suspicious for Type I fracture even in the
presence of normal radiographs.

Type II Fracture reduction if need, cast or splint, Ortho consult not mandatory.

Type III and above need urgent Ortho consult, reduction if required, cast, splint or ORIF.
Mandibular fracture
Salter and Harris Classification
Nerve blocks should not be used in patients who have injuries at high risk of developing
compartment syndrome.
Nerve Blocks
Supracondylar Fracture
Extension type S/C fracture is caused by fall onto an outstretched arm.
It can cause anterior interosseous nerve (AIN) injury. The inability to make a circle with the index
finger and thumb
(the OK sign) is suggestive of an AIN injury. AIN is all motor, no sensory and
part of median nerve.
If the posterior displacement is medial, the radial nerve can be affected. Patient will have
decreased ability to extend the wrist and thumb
(thumbs-up sign) , as well as altered sensation
in the dorsum of the hand at the web space between the thumb and index finger.

Flexion-type supracondylar fractures are much less common than are extension-type
fractures. It is caused by a fall directly onto the olecranon of a flexed elbow.The distal fragment
will be displaced anteriorly. The ulnar nerve is most likely to be injured with this type of fracture.
The ulnar nerve innervates the interosseous muscles; spreading fingers
( Hi Sign)
Skull Fracture
Non-depressed linear skull fractures without intracranial injury - hospitalization is not required
for patients who have normal neurological examination findings, are not at risk of having
experienced inflicted injury, and can tolerate liquids.

Depressed skull fractures have a higher likelihood of intracranial injury with the possibility of
dural injury. Neurosurgical consult is mandatory.

Basilar skull fractures can cause hemotympanum; bleeding around the orbit; bleeding over
the mastoid bone; cerebrospinal fluid leak from the ear, nose, or both; and cranial nerve deficits
related to the affected nerve. Neurosurgical consult is required. They require close follow-up for
hearing loss and persistent cerebrospinal fluid leakage.
Scaphoid Fracture
Any patient with pain to palpation over the navicular/scaphoid bone, also known as the
“anatomic snuff box,” needs to have a dedicated radiograph( scaphoid view) to evaluate for a
fracture.

For management thumb should be immobilized in a thumb spica splint, even if the
radiographs do not show a fracture.

Follow-up with a hand specialist is needed to evaluate for signs of avascular necrosis and
poor healing.
Hip Dislocation
Once this injury is identified, prompt reduction under procedural sedation is recommended.
Delaying reduction beyond 6 hours has been associated with a dramatically increased
incidence of long-term complications, including avascular necrosis, osteoarthritis, and
neurologic injury.

If any asymmetry remains following reduction, further imaging using computed tomography
or magnetic resonance imaging is crucial to identify bone fragments or labral tissue in the
joint space.
Anterior dislocations are the most common type.

Complications with an anterior shoulder dislocation include injury to the axillary nerve and
rotator cuff.

Complications with an anterior shoulder dislocation include the Bankart and Hill-Sacks
lesions, which can result in increased shoulder instability and recurrent dislocations.

Anterior shoulder dislocations with an associated fracture of the surgical neck of the
humerus are at higher risk of failed reduction and avascular necrosis of the humeral head.
Early orthopedic consultation is needed.
Shoulder Dislocations