Carol Asks:

A four-year-old falls off a moving skateboard onto a driveway (no helmet, or pads.) Someone was doing something he wasn’t supposed to do.

This is what I’m proposing happens to this child.

Result: Greenstick fracture in one of the bones of the forearm and possible concussion?

Treatment: Cast in ER and keep overnight for observation? Possible sedatives or stronger meds (like codeine) for pain that may make her sleepy?

Follow: Specialist?

Jordyn Says:

Thanks, Carol, for sending me your question.

I’ll answer in the same way you sent your scenario to me with my opinion.

Result: Yes, greenstick fracture is good. You can hit the link for further information. However, we don’t use this term (as least not in Colorado.) We say “buckle fracture” as in the bone buckles or squishes a little. Bones in this age group are very pliable. This is a very common fracture in kids. The fracture is not a line crack through the bone. Concussion, yes. And you’re right– this kid needs a helmet on!

Treatment:

Splint in the ER. Casting is rare in the emergency department. The difference between the two is a splint only has hardening material on one side and is secured in place by an ace wrap. This leaves space for the injury to swell and can limit the potential for developing compartment syndrome— though that would be rare for this type of fracture. Casting has circumferential hardening material— usually something like fiberglass sheeting that hardens. Also, some providers are just placing a removable type wrist splint on these fractures since they are very stable and the child will usually self limit activities until the pain goes away.

I’m going to assume your child/character has a mild concussion. No loss of consciousness. No amnesia. Maybe a headache, nausea, dizziness, etc. We would not give any sedative or narcotics to this patient— for the concussion nor for the fracture.

Ibuprofen is the preferred drug of choice for the fracture and even for the headache that might be associated with the concussion. Some providers are against ibuprofen in concussion because of a concern for increased bleeding (ibuprofen makes platelets less sticky), but that’s with multiple dosing. We give Ibuprofen often to kids with head injuries and they do fine. Acetaminophen can be given for headache and it will help with pain from the fracture, but it will do little to help the swelling of the fracture. This is why ibuprofen is preferred for broken bones because it helps with both pain and swelling.

Assuming this child has a normal neuro exam and is at their normal neurological baseline (meaning, they are acting as they normally do at home)— then they would be sent home. There is no reason to obs this kid overnight.

Follow up: With orthopedics in 7-10 days for reevaluation of the fracture with cast placement. Cast would be on for 4-6 weeks.

Hope this help and good luck with this story.