With fractures making up 25% of injuries in children, senior physician associate Jessica Treiber, PA-C, MPAS, MPH, wants to ensure pediatricians don’t miss the most common bone breaks; can readily determine whether surgical evaluation is warranted, including by ordering the right X-ray views; and can match treatments, such as braces and boots, to a child's needs and temperament. From the collarbone to the ankle, her tips cover how to scrutinize images, pick up on urgent or complicated fractures, and make sensible treatment plans by age group.
Perfect. All right. Today we're gonna be talking about pediatric fractures and when you have surgical indications and what you can potentially treat in a primary care outpatient setting. Um, like they mentioned, my name is JT. It may show up as Jessica Driver, but here in office, I go by JT. Um, so my objectives today, first disclosures, I have none, there's no financial relationships. Feel free to leave cash and candy on my desk. I always appreciate it. Um, objectives today, we're really gonna be focusing on a couple of things. The 1st 4 are things where I feel like you can really treat in an outpatient setting. The Clavicle fracture, something called a buckle or tourrus fracture, which happens in the distal radius, the distal fibula fracture or avulsion fractures in the ankle, and something called the toddler's fracture, which is actually a fracture of a weight-bearing bone, the tibia, but in that age range, you can treat an outpatient very comfortably. If we have some time, we're gonna go over supracondylar humerus fractures, because I think that's the most common thing that I see here in our clinic. We treat about 350 of them a year. Fractures in pediatrics are not the same as adults. So if you're practicing for both full adult care and, and family medicine, things to think about are that kid fractures are very different. Why are they different? It's because their bones are rubbery, elastic. They have this thick periosteum when they have these open growth plates. They're much, their bones are much more stronger than their ligaments. And the nice thing, or the good thing that's really going in their favor is they have time. Their ability to remodel their bone allows them to accept a lot more angulation in their fracture or separation of their fracture than in an adult fracture that would require surgery. What does this look like on X-rays? So on X-ray, when we x-ray through, you'll see this and maybe you can see my cursor line where it says ices in the center of the screen. You can X-ray through the fiss because That growth plate is made of slightly different bone kind of makeup and structure than the rest of the bone. So I, so I have seen in some, um, urgent cares, they will send a patient over saying, oh, they have fractures all over the place. They're growth points. So we have to be careful when we're kind of looking at the read of a radiology report and the images, kind of what we're seeing because pediatrics are their own special breed. Things to think about in pediatric fractures are we do have a greater increase of them in the summer months compared to the winter months. It is because they're outside and they're playing a lot more. You do see boys getting it more than girls. It really comes down to kind of this risk-taking ability. So if I see it a lot of girls too. So you got the snowboarder and the mountain biker that are girls, they're Going to have just as many fractures as the boys. Things that we worry about is things with low social and economic status and then being able to seek care for the injuries that they have. So sometimes they'll come in and they already have a healed fracture in an alignment that we're kind of questioning. Those are the kind of cases where you might want to call us to kind of review some things. And then if you do see A family history or multiple fractures, I'm thinking more than 3 in a kid under the age of 10. Even if they're a high risk taker, I start thinking about vitamin D and if their bones are nice and strong. And if those X-rays show any differences in how the bone kind of doesn't look homogeneous across the entire long bone, that looks kind of different, are we thinking about like a metabolic workup? Other things, when they fall, infants and children do not have the type of stability that adolescents and adults have in their proprioception, so the way that they fall and the way that they catch themselves can actually change the way that their fracture patterns appear. So as we grow older, we tend to have better proprioception up until a certain extent, but definitely in the pediatric era, everything in their preteens and teens are gonna have a not so much the head and the shoulders, they're gonna have much more the distal wrist and the ankles. Sports, it can definitely increase those pediatric fractures. Um, I always joke that trampolines really keep me employed. There's nothing wrong with them. They are quite safe for kids to play on, but anything. That increases the risk of the height of someone that is moving in the air or the velocity and speed that they're moving is going to cause an increase in your chance or risk of injuries. I tell all my patients, though, we live in California, we live on an earthquake fault line on planet Earth, and you breathe oxygen. You have to take risks. All of these things are risks. Just daily living is a risk, but you got to let them be kids and let them play. You just want to do it as safely as possible. When we're thinking about the different types of fractures that we see, and we've kind of categorized them, I pulled out some of the bigger ones. The main ones that I think you guys are going to be seeing are clavicles, that distal radius and buckle, and ankle injuries. Ankle injuries primarily in the. fibula, which doesn't hold a lot of your weight when you're standing. The last one that I kinda added in here was that supracondylar just because we see so many of them that, and they do require surgery in some types. I wanted to us to be able to kind of put that on here in case we have time to talk. So, fracture classifications, you can have bowing of the bones. Why do kids get the bowing? It's because their bones are a lot more elastic, so they kind of bend like a plastic spoon instead of break straight in half. You can get those torus or buckle fractures, and we'll go over this more a little later, where you have a little crunch on the side of the bone without it truly moving the bone into two different places. Green sticks where it breaks. But it doesn't quite move out of place. It just kind of bends. You can get complete going all the way across fractures, which you have to be very careful to identify this compared to a buckle or kind of that little torus fracture. You can also have oppothesis or like those spices kind of injuries, so you can have some point point of the growth plate actually fracturing off and displacing itself. And then the last thing that we think about, which everyone probably remembers vaguely from school, is the Solter-H Harris classification. The things that we think about are types 1 and 2 are not intra-articular, they're extra-articular. So those are really easy to treat in an outpatient setting. The 3s, the 4s, the 5s, when we're getting into these high impacts and we're, we're changing the articular surface, then you really want to call us. Specialists in. And sometimes we use this kind of thought process where you can turn it to the side and you can say, well, I can't remember if it's a 34 or 5, but you can draw this visual in your head. Also, radiology is most likely gonna read it for you, but if you have questions, you can always refer back to this. And here's kind of some of those examples and the red lines or how it would look into, into that tibia ankle fracture. All right, imaging. The main thing to think about is when you are seeing a case and you're seeing a pediatric patient, you want to make sure that you get a minimum of 2 views. I have so many patients that come and see us for referrals with one view. The bone is a 3 dimensional image. I really need a minimum of 2 to kind of differentiate whether or not we need to do a procedure or whether or not it can wait to be seen in the outpatient setting. If you have any questions on, does this look normal? Is this just a growth plate, I can't decide. I haven't. Seen enough of this, you have two limbs, so you can always compare it to the other side so that you can kinda see is this different than than the other side that's uninjured. And then sometimes we think about here in inpatient, if we're gonna do a procedure, we always get the X-rays before and after. The main thing that you guys should review when you're in there is the, the, the nerve functions of the fingers. You kinda wanna make sure that they can always do that radial nerve that brings it all the way up, the median nerve, which kind of pinches your first finger and your thumb, and you wanna make sure that they're not. Flattening it, so it's not like a duck, it's a round circle and the ulnar nerve to be able to cross those two fingers. This is one of the easiest things that you can do with your patients is the real quick thumbs up, OK, cross. And if they can do that, all three of those nerves are working really well. We're gonna do this in the form of case presentation. So the first thing I'm gonna bring you up is this is a patient that's scheduled to see you in the outpatient setting. It's an 18 month old. They got some collarbone swelling and they're refusing to use their right upper extremity after they fell. And it's kind of, it's kind of hard. OK. Little kid, they can't really talk to you. What are we thinking? Is this a nursemaid's elbow, which I know some of you have seen and heard of, and do I need to reduce the elbow or if they got that swelling. And they're really tender over the clavicle, always check the clavicle because everything else distally, they may not want to move just because of the pain of trying to move that shoulder. All right? And how do we treat it? Well, we treat it with an ace wrap across the torso. What we used to do with kids is take their long sleeve and pin it across their body, but we don't use safety pins on kids anymore because we've had some injuries with that. Instead, what you can do, cause it's really just the upper. Extremity, that upper humerus, you can put an ace wrap around the body so that they can move from their elbow very comfortably. You can also use a sling in older kids. So let's talk about that clavicle and why we can do that. First of all, you can always get the bilateral view so that you can see the difference from one side to the other. Most clavicle fractures are not gonna be severely displaced unless we're talking about teenagers that are getting hit in American football. But these fractures do tend to, to happen when they say fall off a chair, little kid on the trampoline, all these fun things. You wanna make sure that they're sitting upright and you get at least one view. You really want those two views to kind of determine where it's situated in space. And we Wanna make sure that it's just one break in the clavicle and not 2, so you don't have this kind of Z looking fragment. The displacement of it. Both of these I would consider non-displaced because there's not a finger's width between the two bones, which means they are fine to be treated in the outpatient setting. Clavicle fractures mainly happen in the middle third of the bone, and they typically happen on that side that you fall on, but you can also see it in birth trauma. So these real little infants when they come in and they already got some healing over it. Those infant trauma kind of Birth issues. Those heal really quickly within the first couple of weeks. We're always happy to see them in clinic and make sure that they're fully healed though. Here on the bottom of the slide, you can see kind of what that new reaction or that new bone growth looks like. It looks like a nice ball over the center. Most kids, once they're over about the age of 2, I treat them for about 4 to 6 weeks, a little less if they're super young, a little longer if they're a little older. They don't necessarily have to be in the sling and the ace wrap the whole time, but it is something nice to remind teachers, parents, and other kids around them that they're injured. And then sometimes when we get into the older kids, I kind of hold them out of sports, and I hold them out of uh activities until they can really do that itsy bitsy up the wall and they can stretch that arm all the way over their head and they have their normal range of motion back. Things to tell the parents, when that bone heals over that mid midclavicular, you are going to have what's called a bony prominence. It's gonna look like your knuckle, it's gonna feel like your knuckle. It's not gonna be painful once it's healed. It's not gonna change the way that they use their arm. But it is a little bit of a bony prominence. It's cosmetic. We don't do any surgery on it cause you'd be, you'd be kind of exchanging that kinda hard little ball of bone which isn't causing any problems for a big scar and a lot of hardware, so we just don't do it. All right. The mid clavicle fractures really are the main thing looking at, and that bony remodeling happens over time. So as the older the patient is with the clavicle fracture, the more chance there is that they're gonna still have a little bump later in life. But like I said, only cosmetic. Now, things to help you sleep at night when you go, OK, I can do this, but wait. As long as these things are not occurring. You're not having a Z fragment, so you're not having that little kick stand, or you can see in the upper corner that extra little piece kind of rotated. You're not having the skin poked through, as you can see in kind of this in an adult. Patient where it's really poking through, and you're not having the rest of the scapular, the rest of the shoulder kind of fractured. All of those things are very, very rare. They do tend to happen, but they happen more in like ATV, high energy impacts, those sorts of things. Most of your kids who fall off of a high, high, high chair or fall off of the couch are not gonna have this. One thing I would say when you're checking their exam, even in a kid that doesn't want you to touch them, check over the sternal clavicular joint. You should not feel it wiggle or move. It should be right where it needs to be. I have seen sternal clavicular joint dislocations. I've only seen them in a firecracker to the chest. So in the summer when kids are playing with those firecrackers, that's a high impact and it can dislocate the clavicle inward towards the lungs, and that needs to go directly to our ED. All of this aside, if you just have that simple break in the middle of the bone, a simple fall, you can treat it in the outpatient setting. Case presentation number 2, you have a 6 year old male with wrist pain who fell off of the monkey bars. Those things keep me employed. When we're looking at these X-rays and when we're looking at the exam, the main thing that you're going to look at is you're gonna see a little swelling, maybe a little bruising over the wrist. You're not gonna see any bleeding. You're not gonna see a bone poking out. They're gonna be able to wiggle their fingers distally even though they don't want to, but they can. And then on the X-rays, you may see that only one side, maybe you can't even tell, has a little crunch. The crunch of the bone in these kids because their fis is open, kind of looks like you're stepping on a soda can. Crunch, not a crack all the way across. So these are what's called buckles or tourus fractures. I have a buckle, I have a Taurus. It's not a true fracture. It's all a true fracture. It's like saying I have a shoe on my foot, but what kind of shoe? Are you wearing a sandal? Are you wearing a high heel? These particular fractures only really, really cause one side of the cortex, maybe two sides to kind of crunch. Through. And when you look at it, there's no displacement. So if you cover over that fracture with one or two fingers, you see the bone looks perfectly straight above and below, and you can't trace a line going all the way across and you don't see anything shifted. You can treat these outpatient and you can treat these in a brace. Bracces are gonna be great because kids can remove them to shower and sleep. Brace braces are not gonna be great for your kid that doesn't comply, takes it off and doesn't behave. If that's the case, call me. Cause the thing that you want to make sure is when you see something like this, you see both sides, this kind of 11 cortex is, is in the AP kind of involved, but then you see two sides in, in one view, and you also see a little bit of the ulna. You can treat these outpatient if you have a kid that is very in a family that's very reliable and is gonna wear the brace. If you have any questions about it, then you want to sleep well, call me. Because the things that we're thinking about are these complete breaks, and if they're going to shift when they're out there. In a brace. I am always OK putting a kid in a cast, and these ones right here specifically because they're more than a buckle. They're either complete, they're all the way through. They're a little crunch in the back that's going up towards the growth plate. If I want to sleep well, I'll put them in a cast. Open fractures. If you see any blood on them, make sure that it is just a superficial abrasion and it is not something where the bone tried to poke through and come back. If you have any questions, send them to an ER or an urgent care to have a. Double check and make sure that we're not missing anything. But for instance, this picture, that's just a superficial abrasion and I would be fine treating them in an outpatient setting in a brace if it's just a buckle, if it's a complete or going all the way across, then I'm putting them in a cast. Next case. So we got a six year old boy with some ankle swelling after he inverted his ankle or he rolled his ankle. The most common ankle injury in kids is when they roll that ankle, you don't see anything on X-ray, and you're like, but I swear they're walking and they're talking like they have a fracture. It'll be on the lateral ankle right over the fis, right over that lateral malleolus where they're Tender. If that's the case, the thing that I think about in kids is they're going to crack open that growth plate when they roll their ankle, and then the growth plate goes right back to where it needs to be on that fibula side. Those can be treated in splints or cams, controlled ankle motion boots. If you don't have those in clinic, you can always get them on Amazon. I do that with a lot of my patients who can't afford the clinic. Ones. So that distal fibula, that's that Salter Harris 1 or 2 or even a distal abulsion, a little fleck off the very end. So here I'm trying to give you a couple more X-rays to kind of think about where these fractures are. I got a Salter Harris. Uh, one, really, you, you're not gonna see an X-ray, but a 2 is your biggest one in the center of the screen here. And let's see if you can see my cursor. Other. Otherwise, you get these little avulsions off the tip, avulsion off the tip, but that salter Harris 2 comes through the growth plate and goes up the bone instead of down into that, that joint space. When we're thinking about this, what you can do is treat all of this the same way. So as long as we feel like it's just the lateral side, it's just near that growth plate or below on that fibula. Boot it. It's great. Those boots can come off when they shower and sleep. That's totally fine, but boot during the day is gonna function just as well as a cast. So these are very common ankle injury in kids with that skeletal immatureness. So someone under the age of about 12 to 14, and it happens cause that ficus is weak. Those ligaments are so strong that they actually pull the ankle, that fibula distal fis open when you roll that ankle and go right back to where they need to be. If it is tender over that distal fibula, even if you see nothing on X-ray. Boot it, splint it, give it a week or two because you wanna make sure you're not having them continue to walk out there on something that could be a Solter Harris one that you can't even see on X-ray, but if they're really irritated, you don't want them to re-injure it. These cam boots kind of look like this. You want to make sure that they're tall enough to cover the whole ankle and they're a good size that's well fitted for them. They can remove, like I said, to shower and sleep. And after somewhere between 4 to 6 weeks, we start transitioning to normal. Shoes and we see, see some healing on the X-ray, and their exam is no longer tender. I tend to transition these kids to walking activities only for a few weeks because I want to make sure they get that ankle range of motion and that calf strength back. They do it all on their own and they don't really need physical therapy. They're ready to get excited and run back out with their friends. So we're really slowing them down a little bit until they feel strong enough. And then they go back to full sports, so those big contact sports in about 2 weeks from their initial injury. Wrote the rest in the distal fibula is very rare. I have not seen it in my practice. Other ankle injuries that can occur, so things to help you sleep well. As long as the X-ray doesn't look like this, the medial side is totally fine. The shifting of that distal fibula is not shifted. It's nice and nice and aligned and straight up and down, then you're good to go. But if you're ever concerned, if you feel like they can't put any weight on it, you might be missing something. You just doesn't feel right. Send them on and we're always here. Has presentation #4 is a 2 year old boy that refuses to bear weight after going down a slide with his dad. It is very subtle. A distal tibia fracture right here. And let's see if the next one has a good kind of, I think I got one over here. See that little spiral right there. A spiral fracture is called a toddler's fracture. We call it a toddler's fracture because the periosteum around that bone is so strong that they can't really shift their tibia out of place. Instead, they cause it kind of looks like that glue line on a paper towel roll, that spiral line kind of coming down. There you need, you definitely need to get two views, so both the AP and the lateral of the tibia to make sure that you're not missing it, cause these are so small, tiny little hairlines that are very delicate to see, and you may not even see it. But if they don't want to put weight on that leg, they tripped, they fell, they planted their foot, and they twisted any of those things, you wanna put them in a cam boot so that they're protected while they're walking around. In about 3 to 4 weeks after their initial injury, you will see what's called the periostear reaction on X-ray, which means the whole bone looks re-encased, and that'll be when you know it's safe for them to come out of the boot and start walking around. Most of the time, Well over half of these fractures that I see are in the distal half of the bone. If you start seeing a fracture up towards the knee, those are different. That, that uh cam boot is not gonna fully cover over the fracture site. But in these distal ones, especially what you see here on X-ray, even though they're kind of hard to see and sometimes you don't see them. Treat in the cam boot for about 4 weeks. Repeat the X-ray to make sure that it's healed. I do keep them off of heights, those bouncy houses and trampolines for 8 weeks total, because I want them to get back to their normal toddler date and running around and not feel unsteady when they're going on those heights. All right. Things to think about. The peak incidence of this is somewhere between 9 or 9 months and 4 years. If a child has this fracture and they're not walking yet, that's a different story. You want to make sure that they're a walking child that typically happens in toddler ages, and it's a low energy. They're on the ground. They're not a big energy where they're jumping and falling off of someone. It's much more of a little bit of a twist of that bone. Big things to keep in mind, and I see this a lot in the community, is we put splints on these cute little babies that like to wiggle their ankles. When they're wiggling their ankles, they can get a bad pressure sore. So if you were at all concerned about trying to put something on or a splint and leaving it in place. An extended period of time, and it is a fracture that is in the distal half of the tibia or the ankle and foot. Put it in a cam boot. Get the boot over the counter instead of putting them into the splint because that way you don't, you don't worry about this pressure sore on the back of the ankle. Other things to think about is if the, if the fracture you're concerned with is in the top or the proximal portion of the tibia closer to the knee, we're gonna start thinking about casting in our clinic and putting a hard cast on. And if it's both injuries to the tibia and fibula, even near the distal ankle, in any case, you kind of start to think maybe that might not be as stable as if it was only in one bone, and then we're also starting to think about casting. And if anything about this scares you, call me, send it to the ED. We're here. Case presentation number 5. All right, we got there. We got through the good stuff. When we start thinking about elbow pain and swelling, and you fall from something, especially something motorized like a little scooter, we are starting to think about that lovely supracondylar humerus fracture. These X-rays that I put up here are very common for people to see out in the, out in the community. You see kind of that swelling, if you look on the lateral view of like an anterior and a posterior, what we call sail sign or fat pad sign where it looks like you got a little sailboat coming off of that humerus. Maybe on the Uh, AP, you don't see anything. You might not. Sometimes you see a little medial lateral collapsing, sometimes you see a little hairline, sometimes you see nothing. If you're at all concerned, then I want it in a, in a posterior splint, and I want it to see us in clinic as soon as possible. These are those supracondylar humerus fractures that you can see out in the community and you could even potentially treat, but they're tricky, so I want you to be able to sleep well. These little arrows kind of show you where that fracture is. And then we start thinking about, is this something that needs surgery and needs to call JT right away. On the lateral side, what I'm looking for when I'm reviewing these films is the anterior line of the humerus comes straight down and crosses into the capitellum, typically in the anterior third of the capitellum, but I need it to at least touch the capitellum. Then I need the radius that's coming across the forearm to cross into that capitellum. If I get that true alignment, I consider that X-ray blast and I can leave it. The other thing I think about is the swelling and kind of what's going on on the side, on those AP bones, and if I got any collapse in those areas. In this case, this one is completely non-displaced, a supracondylar type one. I'm good treating it in a cast. It can be in the outpatient setting. It can wait to see me in clinic for a week. These most commonly happen in boys that are about 4 to 7, because they like to do all the high impact things. They're falling off the monkey bars, they're jumping on the trampolines with their buddies. But that type one, place it in a splint, see me in clinic in a week, we can take care of that. Anything that looks like it might be displaced, a type 2, a type 3, we should be getting peer to peer reviews. We should be getting someone to put eyes on it, and we should be considering, does it need to come into the ER? Like I said, we see about 350 of these out in, uh, here, and so that's about 1 a day I'm reviewing. And I typically treat them with about 4 weeks of a long arm cast and about 8 weeks of total restrictions. This is What it looks like with the type 2, very different. Now, that anterior humeral line, that cappollum's nowhere near that line. That AP view, now we got a big crunch and it is very obvious. These sorts of things you're gonna call me for. This is a supracondylar type 3 where now it's displaced and you can tell this does not look right and I don't feel safe. Call me. Then we'll start talking about surgery and getting them into the ED. Surgical signs that we really look for in any case with any sort of injury, but mainly with supracondylars, is the skin puckering. So really that skin is kind of getting tinted on the bone where it broke. The other thing we think about is if that thumb cannot do a full all the way up or a halfway down, and we really think about. The PIN goes up, the AIN comes down, but either way, that's your nerve function. And if they can't wiggle that thumb up and down or you see those fingers looking a little pale, we got to bring them into the ED and make sure that they're in a good enough alignment to be out in the community. All right. That is the main portion of my talk. So I'm gonna go quickly through what I like to do when I learn things is one key point slide for each of the things we covered, and then we'll start going through questions cause maybe this will answer some of your questions. The first, the things to think about with clavicle fractures, if you remember nothing else from this, these 5 little blue slides. What you want to look at. Most of them are gonna be in the mid shaft. Most of them are gonna be one break all the way through, and that clavicle is not gonna be displaced more than one finger's width near near itself. So it's not gonna be in two different planes. There's no Z fragment. You're good. You can treat those in a sling. You can treat those in an A strap of the humerus to the body. That bone is. Going to heal in 4 to 6 weeks. They're gonna come back. They're gonna have full painless field goals, touch the back of their head, touch the back of their, their back, and they can move it completely and about 4 to 6 weeks, and then they're gonna go back to contact sports somewhere between 8 and 12, depending on how old they are, because you want to keep them out of sports longer if they're in those big contacts, and it takes longer for them to heal. Things to worry about in these clavicles. Skin is tinted, so it's not getting any blood flow and that bone kind of wants to looks like it's pushing its way through. Sternalclavicular joint dislocations, anything with the Z fragment or 3 pieces, those are coming in to see me. Dal radius tous fractures, this is your big bang for your buck cause I know you see a lot of them out there. It's really just a Buckle. There's no bleeding. It's just one little crunch on one little side. You want to brace them for at least 4 weeks. You want to remove it to shower and sleep. We have found in studies that this is an effective way to treat these, even if they don't consistently use that brace. That's OK. Some days they're gonna forget it, but overall, it's gonna work. Returning to sports somewhere about 6. 8 weeks after the initial injury doesn't necessarily need follow-up x-rays. So if they're way out in the community and they really can't get back in, it's a hardship for the family. I will see them once. I will know that everything is gonna head in the right direction. I will maybe see them for a video visit to make sure their range of motion is coming back and they're having no issues, and that's it. I don't even need to X-ray it. Things to think about when you're like, well, do I, do I feel safe treating this? If they're a non-compliant family, if they're a non-compliant patient, if they are defiant, if you are at all concerned that they're gonna take this thing off and they're gonna be right back on their motorbike, get them over to me, we'll put a cast on it. Something to know. We do not have waterproof casting, and I do not recommend it in anywhere that you go, because water really does pool around any little crease in that cast and can cause a lot of, a lot of injuries. If they're in a, in a spot to consider a waterproof cast, they're in a spot to consider a brace, so just get a normal brace that can be removed. Disal fibula fractures, OK. This is the weak point of that fiss on the lateral malleolus. If it is only the lateral ankle, just that distal fibula. And if there's a question of any Salter Harris vulsion, anything, rested in that cam boot, rest it as weight bearing is tolerated. You can walk in the boot if you feel comfortable. You don't have to. That controlled ankle boot works just as well as a cast. If they are defiant, non-compliant, something's concerning. I will put them in cast, but very rarely, only if I absolutely have to. They're gonna be ready to go back to all of their sports in about 6 to 8 weeks from their initial injury. Things where you're going, oh, I can't sleep with this. I need to call JT. Open fractures, displaced fractures, things involving the tibia, you have some form of sign of over swelling that doesn't make sense, and any of those higher classes of of Salter Harris classifications that are going into the joint space. So we're not just talking the distal fibula, we're talking the main tibia weight-bearing bone and something's changed on that side, then you're being, then you're really concerned, call us. Last thing, distal tibia fractures in those tiny little toddlers. These are not your, your bigger kids. These are kids ages 4 or less. That little spiral line in there can be treated with a cam boot. I don't want them without a cam boot. Really put them in the cam. If they can get it over the counter, great. If you have to put a splint on them, then you do want them to follow up in, in an orthopedic clinic relatively quickly cause you don't want anything on that posterior heel to get a little ulcer. Other things to think about is if you're getting kids that are getting these sorts of injuries in their long bones, especially the weight-bearing tibia bone, but they're not a walker yet, they're under a year old. They want to start talking, thinking non accidental trauma and potentially get a skeletal survey to rule out everything else. And that last thing that we went over, that supercomlar humerus fracture thing I worry about is that thumb being able to go up and down, and even if you can't remember that the PIN goes up and the AN goes down, you can always tell us over the phone, the thumb won't go up, the thumb won't go down. Um, and you're looking on those X-rays when you're concerned and you're like, I don't really quite see anything. I don't see a fractured line, but you see that posterior and anterior kind of sale sign or swelling, that really means that there could be an occult fracture in there. If we're worried about the alignment of that, of that elbow, then we don't wanna splint it straight at 90 degrees. We want to give it more of that 100 degrees to kind of relax all of the soft tissue. There, so it's not pushing over the area and pushing over any of the nerves. What type of supracondylar is it? If it's a type 1, you see nothing on X-ray, maybe you see a tiny little line that can be splinted, that can be slinged. We'll see it, we'll see it in our clinic in a bit. Give it a, give it a second for that swelling to come down before it sees me. Type 2, so we're talking about that anteri humeral line is not crossing into that cap. Tell them growth plate that radius isn't aligned. We're looking at, we're looking at the AP view. It's lateral medially collapsed. We need to start thinking about sending them to the ED for a review and to make sure it's not surgical. Same with type 3. Type 3 is gonna be big, displaced. They're not gonna want to move their hand. Maybe they'll flick it. You got too much swelling to feel comfortable sleeping at night. X-ray comes back and things are shifted. ED. For all supracondylars, even those that you splint and you think are non-displaced, they do need a follow-up in about 7 to 10 days. The reason why we say that is when that swelling goes down, that bone can shift. If it shifts, the alignment changes. We need to consider whether or not we need to do surgery on it. All right. I think I went through it really quickly, so it's a lot of information. Thoughts, questions.
