The major challenge in managing trauma is avoiding complications. Children’s fractures generally heal quickly. Vascular complications are uncommon, nerve injuries usually recover with time, and joint motion recovers spontaneously. In general, outcomes are excellent, unless problems develop. Most complications are due to the injury, while a few result from mismanagement. A good strategy in managing trauma is to consider what complications are most likely to occur from that injury and to take active measures to avoid them.
It has been estimated that about 15% of children’s fractures are misdiagnosed. Being aware of occult injuries and pitfalls and performing a careful evaluation will reduce this risk.
Be aware that certain fractures carry a high rate of complications.
Supracondylar fractures The risks include forearm ischemic contracture, nerve injuries, and malunion causing cubitus varus.
Lateral condylar fractures This injury has the potential for nonunion and displacement.
Radial neck fractures For severely displaced fractures, avascular necrosis, overgrowth, and rotational stiffness are risks.
Midshaft forearm fractures in older children may be complicated by malunion that limits forearm rotation, causes refracture, and rarely cross union.
Femoral neck fracture may develop avascular necrosis and coxa vara.
Distal femoral physeal fracture often develops growth arrest.
Proximal tibial metaphyseal fracture may result in overgrowth, causing genu valgum.
Nonpreventable Complications from Injuries
Some complications are due to irreparable damage at the time of injury.
Avascular necrosis of the proximal femur or radial head can be caused by vascular injuries to the epiphysis vessels. Even with joint decompression and anatomic reduction, this complication may occur.
Physeal injuries that damage the germinal layer of the growth plate often cause shortening and angulatory deformity.
Some complications of fractures can be avoided by skillful management.
Compartment syndromes may result from vascular injury, prolonged operative procedures, cannulation of arteries, catheterization procedures, intravenous fluid infiltration, osteomyelitis, and necrotizing fascitis. Prevent or manage effectively by early recognition and treatment before muscle necrosis occurs.
Malunion due to inadequate reduction or loss of position are common in older children.
Physeal bar formation results from fractures that simply traverse rather than damage the germinal layer. Anatomic reduction reduces the risk of a physeal bar forming across the growth plate.
Deformity from small physeal bars can be prevented by identifying and resectioning bars (less than 50% of physis) before significant deformity occurs.
Most fixation complications are preventable by proper selection and application that is age appropriate. Fixation complications include placement that damages the physis, a type that is inadequate, a position that leads to stress risers, and premature removal that results in secondary fracture.
Cast complications are common and usually due to excessive pressure that causes limb ischemia or pressure sores. Poor cast technique may result in cast failure and loss of correction. Failure to mold the cast may result in loss of reduction while being immobilized.
Before treatment, consider what serious complications are possible and take steps to avoid them. These suggestions have been made earlier, but they are worth restating here for emphasis.
- Avoid tibial traction pins Femoral pins are equally effective and pose less risk.
- Avoid intravenous narcotics In the postreduction period, these may mask a compartment syndrome or other serious problem.
- Assume the child will be unreliable Make the cast extra thick, and immobilize with the knee flexed to prevent walking.
- Split casts for fractures Do this where swelling is common, such as in tibial and forearm fractures.
- Avoid high-risk treatment methods For example, avoid Bryant’s overhead traction for femur fractures in infants and external pin fixation for closed noncomminuted fractures.
- Inform families about risks Do this in advance for deformities from physeal injuries, avascular necrosis, and compartment syndromes.
- Provide follow-up See patients with fractures after 1 week for radiographs to identify any loss of reduction while rereduction is still feasible. Follow physeal injuries for 1 year to be certain that growth is proceeding normally.
- Respect the physis Avoid any injury from fixation such as reaming for IM fixation in the growing child and large devices across the physis.
- Communication problems Be concerned about the fussing infant or young child or the child with a communication problem because these children cannot identify or describe a site of pain or other problem.
- Allow stiffness to resolve spontaneously Forceful ranging of the joint may increase stiffness or fracture the adjacent bone.
- Compartment syndromes Be aware that compartment syndromes are often silent in the child.
- Avoid prolonged immobilization In osteopenic children, avoid casts in conditions such as osteogenesis imperfecta and myelodysplasia.