Fractures: Broken Bones in Children

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Guest: Dr. William Basco. – Pediatrics

Host: Dr. Linda Austin – Psychiatry

Announcer: Welcome to an MUSC Health Podcast.

Dr. Linda Austin: I am Dr. Linda Austin and I am talking today with Dr. William Basco - Associate professor of pediatrics at MUSC. Dr. Basco, all kids have accidents and injuries in the course of growing up and sometimes the parent may wonder if a bone is broken and if the child needs to go to the emergency room. What are some of the ways that a parent can evaluate if indeed there might have been fracture?

Dr. William Basco: Dr. Austin, you are right that almost any parent at some point in their lives will have to deal with this question of does my child likely have a broken bone or not based on what’s happen to the child? There are few guidelines to think about; one is that broken bones in general are very painful. So, the longer the child cries, if it’s a young child, or expresses pain after an event, the more likely it is to be broken and easy thing to focus on would be, is there any visible deformity. So, in a long bone of leg and arm, if something is poking out the way it is not supposed to that needs to be evaluated right away.And another thing we put a lot of emphasis on when we are evaluating child in clinic or emergency department is the tenderness the child has over a bony prominence or is it just, in general, soft tissue tenderness. So, an ankle injury for example, ankle injuries are almost always sprains or strains from twisting or something like that, but if the child has tenderness over those bony prominences on the inside or the outside of the ankle or even on the long bones of the toes, that’s really worrisome for a fracture. If it is muscular tenderness and this can be hard to sort out even for providers, but if it seems to be tenderness mostly in the muscles around a joint or in a leg or an arm, that’s generally less worrisome for a fracture. It is the case that we see children in clinic often who have sustained some sort of injury and we don’t x-ray them all. We don’t image them all. One of the best ways, we have to sort that out to see what happens after the first day or two after the injury. In general, I tell parents that if by 48 to 72 hours, you can tell that the pain is improving then you are less likely to have a fracture. If the child is having the same degree of pain, that may mean limp or the pain, we can elicit when we examine them after 48 to 72 hours then often times we will gets some x-rays on that child if we have not already done it. Obviously, there are some children that have a degree of pain or concerning enough examination that we will image them on first visit.

Dr. Linda Austin: How about small bones like fingers and toes, do they always need to be set if there are fractured?

Dr. William Basco: Not every fracture needs to cast, some need to be splinted if nothing else to protect the finger or toe in this case from further injury, but that’s best decision left up to the health care provider and not something parents should try to decide on their own.

Dr. Linda Austin :What about pain relief? What do you suggest to parents, let’s a child has had a broken bone and it has been casted or splinted but they are having trouble sleeping let’s say because of pain, what would you recommend?

Dr. William Basco: In general, parents should be able to provide pain relief for the child with a fracture with an anti-inflammatory drug such as ibuprofen or acetaminophen. It is actually a study published in the past six months or so looking at whom who presented to the ER with extremity injury, and it was the study of trying to determine whether acetaminophen or ibuprofen did as well as narcotics in pain control within first hour after the injury. It turns out that ibuprofen actually did the best of the drug tested, but again that’s just looking at the first hour or so, but the point is that most children even with fractures don’t require narcotics for pain control, if they do you can often limit there use to the first few days after the injury. For long term, you generally want to try to provide pain control with either acetaminophen or ibuprofen and both of those drugs have some potential issues to that parent seem to be where aware of. So, in general if a child has any sort of bleeding problem, you are going to avoid ibuprofen and children with liver problems should avoid acetaminophen, but if you have any questions about safety of those drugs for longer term use that is something you should view with the health care provider.

Dr. Linda Austin: Dr. Basco, thank you so much.

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