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Steve:
 
Depends on which avulsion fracture you are talking about? An avulsion
fracture of the base of the 5th MT needs only a hard soled shoe and gradual
ambulation. Avulsions of the talar dome, seen occasionallly, get a short
leg walking cast from our orthopods.
 
However, an avulsion fracture of the ankle ring, as in a distal tibial or
fibular avulsion fracture, in an immature skeleton, can be a whole
different entity. These are usually an intra-articular fracture or if the
fracture line extends more proximally, a SH IV Fx. The latter could also be
part of a "triplane fx".
 
My experience with the peds orthopods is similar to yours. For the above
reasons, they tend not to tolerate any degree of displacement. I usually
splint, non weight bear & refer for casting within 2-3 days if the swelling
is significant. More often, they get casted right off the bat.Because the
physes is a weak link the isolated avulsions of the distal tibia or fibula
are not common.
 
Not sure if this was your question. BTW, enjoyed reading your IM ketamine
article in Annals. Reinforces my faith in this PCP analogue!!
 
Jay
Jay Pershad
"We care for wee folks"
 
> From: Steve Green <[log in to unmask]
>
> The Ottawa Ankle Rules are based on the premise that avulsion fractures
<3
> mm in size are not clinically significant in adults and do not require
> casting.  A small study* (n=71) suggests that these rules might be
> sensitive in children as well (95% confidence interval 77%-100%).
>
> Is the same 3 mm casting threshold appropriate for children?  Is it the
> current standard of care to cast or not cast, say a 2.5 mm ankle avulsion
> fracture in a three year-old?  At my hospital all children with
> radiographically visible fracture fragments are casted, but apparently
this
> is not the case everywhere.
>
> I'd like to hear both thoughts on this subject and what is done at other
> centers.
 
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