Author Question: Pediatric Fall From Skateboard

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!


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.

Author Question: Complex Traumatic Injury

Rachel Asks:

I love your blog, and I have a fictional medical question for you.

motorcycle-654429_1280I have a young teen character in the near future (about 2075) who is a motocross racer. She has a horrible crash near the end of her freshman year of college and suffers a large injury – she has to stop school.

I want her to recover in 3-6 months, well enough to go to school, and show up full of plates and wires. I was thinking a severe shoulder fracture would do it, and assuming she got good enough PT, she could eventually race again (and even move onto a more demanding kind of racing.)

Is this a likely enough scenario? What would be a typical range of wires and plates to put in? I want a specific number for her to obsess about as she overcomes her fear of biking. Other injuries you could suggest? What about the recovery timeline? I need her off the bike for about 6-9 months, but some of that could be psychological, not physical recovery.

In this novel, there is some integrated AI technology. Obviously, the answer can incorporate speculative medical advances, but I’d like to know what is typical today so I can make them sound convincing.

Jordyn Says:

My first impression is that the shoulder may not be the best option if you want lots of plates and screws. You have to consider the bones that make up the shoulder and how those injuries would be treated. The scapula is very hard to fracture and likely wouldn’t be repaired that way. I’ve only actually seen one scapula fracture in my entire ICU/ER career in the span of almost 25 years. Collar bones we basically let heal on their own without surgical intervention. Even the upper arm— at least in kids— is not even splinted if you can believe that (most often)! Ligament repairs, labral tear, rotater cuff repairs, etc, could potentially take your time frame (with some complications) but would not involve a lot of plates and screws.

If you wanted to stick with an upper body injury— you could do amputation and then have your character learning to use a prosthetic which might tie in nicely with your integrated AI technology.

If you want to stick with a ton of plates and screws, alternative injuries could be a pelvic fracture or a complex upper or lower (or both) leg fracture. For instance, you could probably Google– x-rays of pelvic fractures repaired using plates and screws or x-rays of lower leg fractures repaired using plates and screws as references to come of with a specific number for her obsessive counting, etc.

Hope this helps and good luck with your story!

Fractures: General Guidelines

Fiction, particularly the thriller genres, generally require a character to sustain an injury. These can run the gamut from minor to life-threatening.

Today, I’m going to focus on a couple of general guidelines if you injure a character with some type of fracture.

Though it may be hard to break a bone, sometimes it seems the most minor accidents can cause a fracture. My mother once slipped off a small rock onto the side of her foot. Her foot was bruised and mildly swollen and in my nursing wisdom (I was only in nursing school at the time), I said, “There’s no way you broke it slipping sideways off a rock.” Needless to say I was wrong. Yes, broken foot.

Guideline #1
: The amount of swelling is not indicative of fracture. Ankle injuries are classic for this. Patients come in with a horribly swollen ankle, convinced they broke it. My guess in the pediatric realm (up to age 21), the ankle is 95% of the time sprained and not broken. Arms that have an obvious deformity and you can see the limb is broken before you get an x-ray, have little swelling in comparison.

Guideline #2: If something is broken, generally the joint above and below will need to be immobilized (or very close to the next joint). Someone asked me once if a person broke one bone in their lower leg, could they drive? There are two bones in the lower leg: the tibula and the fibula. Depending on how close the fracture is to the knee, the ankle and knee will have to be immobilized. I don’t know how many people can drive with a straight leg.

Guideline #3: Splints are placed first. It is rare to put a cast on in the emergency department. The reason splints are placed first is to allow for swelling to come and go. A splint is generally fiberglass sheets secured in place with an ace wrap. This allows for expansion during swelling. Then in 7-10 days, the patient is referred to an orthopedic doctor for cast placement.

Guideline #4: A good rule is that a cast will be in place for 6-8 weeks. Now, this is highly variable and if an author said the cast needed to stay in place for nine weeks, it probably wouldn’t drive me nuts enough to go check it out. However, a cast on for two weeks is unlikely. You should consider this guideline because it will effect your character for that length of time and inhibit their mobility. Maybe, this is something you want as the author.

Guideline #5: My observation: these bones/joints have a higher incidence of requiring surgery: ankle, elbow, and femur. Now, you can make any fracture bad enough to require surgery but these ones can be more common to require the OR.

What other guidelines would you like to see?