Q4 Urgent Caring- Pediatric Orthopedic Injuries: Evidence-Based Management in the Urgent Care

EB Medicine


Splints and Casts

Most stable fractures can be splinted, with urgent (within 1 week) pediatric orthopedic follow-up for eventual reduction (if needed) and cast placement. Splinting and casting preserve proper bone alignment and alleviate discomfort while preventing further injury and promoting healing; splinting may be preferable in the first few days after injury, as progressive soft tissue swelling can lead to neurovascular compromise within a circumferential cast.117 Table 5 details the appropriate type of splint for specific injuries. Commercial preformed splints provide convenience of application and are appropriate for sprains and low-risk fractures. Custom-molded splints provide a higher degree of immobilization and may be associated with higher patient compliance, as they are more difficult to remove. Walking boots, which allow for periodic removal for skin visualization, may be considered in place of a lower extremity splint, which have been associated with skin breakdown. Neurovascular status should be checked again after splinting or cast immobilization is achieved. 

Splinting should be performed for injuries with focal tenderness and decreased range of motion even in the absence of definitive radiographic evidence of fracture in the initial period after injury. Salter-Harris I fractures, Type I supracondylar humerus fractures, toddler fractures, and scaphoid fractures, among others, may become radiographically distinguishable only after callus formation. The presence of a radiolucent fat pad posterior to the distal humerus on lateral elbow radiographs is an indication for splinting and referral for orthopedic follow-up. In a review of 59 patients diagnosed with toddler fracture in an ED setting, 41% of children with initial normal radiographs demonstrated radiographic evidence of new bone growth at follow-up, supporting the diagnosis of fracture.118 In the case of toddler’s fractures, a child may self-limit their weight bearing. Risks associated with splinting, including skin breakdown and pressure sores, may outweigh the benefit of immobilization as outcomes are unchanged when these fractures are treated conservatively without immobilization; consultation with a specialist may be indicated to determine the appropriate course of action on case-by-case basis.

Scaphoid fractures carry a high risk of nonunion because the proximal portion of the scaphoid receives its blood supply only via retrograde flow through the distal portion. In patients with scaphoid tenderness, the wrist should be immobilized in a thumb spica splint even if no fracture is visualized initially, and confirmatory radiographs should be obtained in 2 weeks to exclude occult fracture before discontinuing immobilization.119 A systematic review of 75 studies pertaining to the diagnosis of scaphoid fracture found that 25% of patients with occult fracture had negative plain radiographs.120 In a review of 351 scaphoid fractures, 90% healed with nonoperative treatment, with some requiring prolonged cast immobilization.121 


The need for reduction depends on the age of the patient and the involved area of bone, as well as the degree of angulation, displacement, and malrotation. Fractures with significant angulation (>20°), displacement, or neurovascular compromise require immediate orthopedic consultation for emergent reduction. Skeletal immaturity conveys higher potential for bone remodeling; in general, greater degrees of displacement and angulation can be tolerated in younger children. For example, in children aged <5 years, proximal humerus fractures with up to 70° of angulation and 100% displacement may be managed conservatively with sling immobilization, whereas in children aged >12 years, up to 40° of angulation and 50% displacement are acceptable.122 In children with distal forearm fractures with <15° of angulation, immobilization without reduction leads to complete remodeling and no clinical or functional sequelae.123,124 Patients with fractures that require reduction should be provided analgesia, placed in a fasting state (NPO) in anticipation of procedural sedation, and have the extremity placed in an appropriate splint. 

For radial head subluxation, manual reduction can be achieved by various maneuvers. Five small prospective, randomized studies generally support the hyper-pronation technique compared with supination-flexion, citing more effectiveness and no measurable difference in pain.19,36,125-127 Parents should be educated in avoiding a pulling mechanism on the arm to decrease risk of recurrence. 

Pain Control

Pain is typically most severe in the first 72 hours after injury. A 2014 survey of 683 North American pediatric emergency physicians and orthopedic surgeons regarding pain management in children with musculoskeletal injury indicated overall poor management of pain, particularly in younger children, and at home after discharge.128 

Adequate analgesia should be maintained with ibuprofen and acetaminophen as first-line medications, with opioids (oral, intranasal, or parenteral) if further pain control is required; opioids should be reserved for moderate or severe pain. Clinicians should avoid the use of codeine-containing products, per the recommendations of the US Food and Drug Administration and the AAP,130,131 due to the risk of overdose or under analgesia associated with CYP2D6 polymorphism causing variable rates of metabolism to the active metabolite (morphine). Children receiving codeine may experience either inadequate analgesia or opioid overdose effects, including respiratory depression.132 

Other Treatments/Techniques

Nondisplaced and minimally displaced fractures of the middle third of the clavicle may be immobilized using either a sling or figure-of-eight bandage, with similar outcomes.133,134 Emergent orthopedic referral is indicated for open fracture, neurovascular compromise, and tenting of the skin. Complete fracture displacement, comminution, shortening, distal third fractures involving the acromioclavicular joint, and proximal third fractures with posterior displacement should also prompt referral.

Supracondylar humerus fractures are managed according to their Gartland classification and the American Academy of Orthopedic Surgeons’ 2014 Appropriate Use Criteria for the Management of Pediatric Supracondylar Humerus Fractures,135 which is available at http://doi.org/10.5435/JAAOS-D-15-00406 Type I fractures are managed with immobilization with a cast or posterior long-arm splint without reduction, whereas Type II and III fractures are typically managed operatively, with emergent orthopedic consultation, given the increased risk of compartment syndrome. The affected elbow should be maintained at 90° of flexion, as flexion beyond 90° can produce elevation of compartment pressures.136

A child with suspected SCFE should be made non–weight bearing immediately to prevent further slippage of the femoral head and should be evaluated by a pediatric orthopedist for operative reduction and internal fixation as soon as possible to decrease the risk of avascular necrosis.137

Knee immobilization is appropriate for children with knee fractures. Most other knee injuries require only conservative management, including adequate analgesia and weight-bearing as tolerated. Range-of-motion exercises are critical to preventing loss of mobility and contracture.138 Patients with tibial spine fractures and patellar sleeve fractures should have urgent orthopedic consultation, with possible operative repair.58,61

Toddler fractures have been noted to heal reliably within four weeks, despite immobilization type and duration, and may not ultimately need any immobilization.139,140 A walking boot may be utilized provide comfort for during ambulation and may be worn as tolerated by the child.

Calcaneal fractures, severe foot injuries and confirmed or suspected Lisfranc injuries may be immobilized in a bulky dressing and warrant same day referral to orthopedics. Patients should be non–weight-bearing on these injuries.

Management of Nonaccidental Injury

Once medically stabilized, a child with concern for nonaccidental injury should be evaluated by a child protection specialist. Mandatory reporting laws require that concerns for abuse be reported to Child Protective Services. Transfer to the ED with possible subsequent hospital admission may be warranted to facilitate further evaluation and/or protection from the home environment.86

Table 5. Splints Used for Orthopedic Injuries129


Type of Splint


Upper Extremity Injuries

Ulnar side of hand

Ulnar gutter splint

· Fracture of fourth and fifth metacarpals and proximal/middle phalanges

Radial side of hand

Radial gutter splint

· Fracture of second and third metacarpals and proximal/middle phalanges

Thumb, first metacarpal, and carpal bones

Thumb spica splint

· Fracture of scaphoid/trapezium

· First metacarpal fracture

· Thumb fracture

Finger injuries

Buddy taping

· Proximal/middle phalangeal shaft fracture

· Finger sprain

Aluminum U-shaped splint

· Distal phalangeal fracture

Dorsal extension-block splint

· Middle phalangeal volar plate avulsion

· Reduced proximal interphalangeal joint dislocation

Mallet finger splint

· Extensor tendon avulsion from base of distal phalanx


Volar/dorsal forearm splint (may use a prefabricated cock-up wrist splint)

· Soft-tissue injury to hand/wrist

· Acute carpal bone fracture (excluding scaphoid/trapezium)

· Nondisplaced, minimally displaced, or torus fracture of distal radius

Bulky hand compression dressing

· Severe hand fracture


Simple sugar-tong splint

· Fracture of distal radius and ulna

Elbow, proximal forearm, and skeletally immature wrist injuries

Long-arm posterior splint

· Fracture of distal humeral and proximal/midshaft forearm fracture

· Non–torus wrist fracture

Double sugar-tong splint

· Elbow fracture

· Forearm fracture

· Nondisplaced, extra-articular Colles fracture

Shoulder and proximal/midshaft humerus

Sling and swathe splint or Velpeau bandage or prefabricated shoulder immobilizer

· Clavicle fracture

· Proximal/midshaft humerus fracture

· Reduced shoulder dislocation

· Acromioclavicular joint separation

Sling, shoulder immobilizer or figure-of-eight bandage

· Clavicle fracture (middle third)

Lower Extremity Injuries


Buddy taping

· Phalangeal fracture


Walking boot or hard-soled show

· Distal metatarsal and phalangeal fracture

Bulky foot compression dressing

· Calcaneal fracture

· Severe foot injury

· Lisfranc

Lower leg, ankle, and foot

Walking boot

· Severe ankle sprain

· Fracture of distal leg, ankle, or foot

Stirrup splint

· Ankle sprain

· Isolated, nondisplaced fibular malleolar fracture

Knee and lower leg

Posterior knee splint or knee immobilizer

· Significant knee soft tissue injury 

· Bony injury of lower extremity (distal femur, patellar, proximal tibia fractures)

Copyright ©2023 EB Medicine




  1. Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998;102(1):e10. (Prospective; 85 patients)
  2. Green DA, Linares MY, Garcia Peña BM, et al. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg Care. 2006;22(4):235-238. (Prospective; 63 patients)
  3. Gans I, Baldwin KD, Ganley TJ. Treatment and management outcomes of tibial eminence fractures in pediatric patients: a systematic review. Am J Sports Med. 2014;42(7):1743-1750. (Systematic review; 580 fractures)
  4. Shin YW, Uppstrom TJ, Haskel JD, et al. The tibial eminence fracture in skeletally immature patients. Curr Opin Pediatr. 2015;27(1):50-57. (Review)
  5. Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-1354. (Clinical report)
  6. Fitch MT, Nicks BA, Pariyadath M, et al. Videos in clinical medicine. Basic splinting techniques. N Engl J Med. 2008;359(26):e32. (Review)
  7. Halsey MF, Finzel KC, Carrion WV, et al. Toddler’s fracture: presumptive diagnosis and treatment. J Pediatr Orthop. 2001;21(2):152-156. (Retrospective; 59 patients)
  8. Sendher R, Ladd AL. The scaphoid. Orthop Clin North Am. 2013;44(1):107-120. (Review)
  9. Carpenter CR, Pines JM, Schuur JD, et al. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-121. (Meta-analysis; 75 studies)
  10. Gholson JJ, Bae DS, Zurakowski D, et al. Scaphoid fractures in children and adolescents: contemporary injury patterns and factors influencing time to union. J Bone Joint Surg Am. 2011;93(13):1210-1219. (Retrospective; 351 patients)
  11. Beaty JH. Fractures of the proximal humerus and shaft in children. Instr Course Lect. 1992;41:369-372. (Review)
  12. Do TT, Strub WM, Foad SL, et al. Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. J Pediatr Orthop B. 2003;12(2):109-115. (Retrospective; 34 fractures)
  13. Boutis K, Willan A, Babyn P, et al. Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial. CMAJ. 2010;182(14):1507-1512. (Prospective; 96 patients)
  14. McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med. 1999;6(7):715-718. (Prospective; 135 patients)
  15. Bek D, Yildiz C, Köse O, et al. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial. Eur J Emerg Med. 2009;16(3):135-138. (Prospective; 66 patients)
  16. Guzel M, Salt O, Demir MT, et al. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Niger J Clin Pract. 2014;17(2):201-204. (Prospective; 71 patients)
  17. Kircher J, Drendel AL, Newton AS, et al. Acute pediatric musculoskeletal pain management in North America: a practice variation survey. Clin Pediatr (Phila). 2014;53(14):1326-1335. (Survey)
  18. Boyd AS, Benjamin HJ, Asplund C. Splints and casts: indications and methods. Am Fam Physician. 2009;80(5):491-499. (Review)
  19. Food and Drug Administration, Center for Drug Evaluation and Research. Summary minutes of the Joint Pulmonary-Allergy Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee Meeting. 2015. Accessed August 10, 2023. https://web.archive.org/web/20161023215728/https:/www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/Pulmonary-AllergyDrugsAdvisoryCommittee/UCM482005.pdf (FDA Meeting Minutes)
  20. Tobias JD, Green TP, Coté CJ. Codeine: time to say “no”. Pediatrics. 2016;138(4): e20162396. (Position statement) 
  21. Niesters M, Overdyk F, Smith T, et al. Opioid-induced respiratory depression in paediatrics: a review of case reports. Br J Anaesth. 2013;110(2):175-182. (Review of case reports; 27 patients)
  22. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987;58(1):71-74. (Prospective; 61 patients)
  23. Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2014(5):CD007121. (Systematic review; 416 patients)
  24. Heggeness MH, Sanders JO, Murray J, et al. Management of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2015;23(10):e49-e51. (Management criteria)
  25. Battaglia TC, Armstrong DG, Schwend RM. Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus. J Pediatr Orthop. 2002;22(4):431-439. (Retrospective; 29 patients)
  26. Peterson MD, Weiner DS, Green NE, et al. Acute slipped capital femoral epiphysis: the value and safety of urgent manipulative reduction. J Pediatr Orthop. 1997;17(5):648-654. (Retrospective; 91 patients)
  27. Sarraf KM, Sadri A, Thevendran G, et al. Approaching the ruptured anterior cruciate ligament. Emerg Med J. 2011;28(8):644-649. (Review)
  28. Bauer JM, Lovejoy SA. Toddler’s fractures: time to weight-bear with regard to immobilization type and radiographic monitoring. J Pediatr Orthop. 2019;39(6):314-317. (Retrospective; 192 patients) 
  29. Schuh AM, Whitlock KB, Klein EJ. Management of toddler’s fractures in the pediatric emergency department. Pediatr Emerg Care. 2016;32(7):452-454. (Retrospective; 75 patients)

Excerpted from: Wyly D, Montgomery E. Pediatric orthopedic injuries: evidence-based management in Urgent Care. Evidence-Based Urgent Care. 2023 September;2(9):1-33. Reprinted with permission of EB Medicine.