Orthopaedics

Virtual Fracture Assessment Clinics (vFAC), is a pathway of fracture care, that takes place following an attendance at the Emergency Department. This is a virtual clinic and you do not need to attend with your child.

The Orthopaedic Consultant at the clinic will review your child’s X-Ray and medical notes and determine if any further care or treatment is needed. It is a safe and fast process for assessing your child’s injury and need for an Orthopaedic Fracture Clinic review. It has greatly improved the efficiency and standard of care provided to Trauma patients.

Previously, a child who attended the Emergency Department with a suspected fracture would have been treated and sent home with an appointment to attend an Orthopaedic Outpatient Trauma clinic for follow-up.

Following a Virtual Fracture Assessment Clinic, your child will be discharged from the hospital with a plan of care, or will be booked in for a follow-up review in a Fracture Clinic, or if necessary, your child will receive an admission date for surgery.

Referral

Your child will be referred to a Virtual Fracture Assessment Clinic following an attendance at our Emergency Department with a musculoskeletal injury.

Developmental dysplasia of the hip (DDH) is a condition requiring early diagnosis and management to optimise long-term outcomes.

The DDH Clinical Nurse Specialist will review the x-ray with the Orthopaedic Consultant.

Following this, the family will be contacted by telephone by the Clinical Nurse Specialist to advise on any treatment plan if required. This can range from referral to an appropriate Nurse led or Consultant Clinic, Virtual Hip Clinic surveillance or discharge.

The referring doctor and parents will receive a letter following a review to inform a plan.

Benefits include earlier x-ray review leading to timely diagnosis and treatment if required, fewer work days missed by the parents, fewer miles travelled to attend the clinic, and less money spent on fees such as parking and dining it also saves resources in the outpatient department.

Referrals

Children can be referred by their GP or Community Health Doctors.

What to expect

When you come to CHI at Temple Street, you will meet many different people. Each member of the Scoliosis and Spinal Team has a different role to make sure your child is ready for their operation.

A few weeks before your child’s surgery, you will be asked to bring them into hospital for the day for a pre-operation assessment in the Day Ward. This is to check that your child is fit for their surgery and to make sure you know what will happen and why.

Some investigations will be carried out, and you will have the opportunity to speak to different professionals about all aspects of your child’s surgery.

Where to go and what to bring

When you and your child come to the hospital, make your way to the Day Ward and check in at the office just inside the entrance on your left. Bring along some of your child’s favourite toys/things and any specialised food or equipment they may need.

Investigations or tests your child may have

Your child may need to have x-rays of their spine and chest and some blood tests. An ECG (tracing of their heart rhythm), breathing tests and measurements of their height and weight will also be carried out. Your child may also need to see a cardiologist.

Who you may meet

• The Anaesthesiologist, who will discuss your child’s anaesthetic in detail.
• The Spinal Clinical Nurse Specialist, who will coordinate your care, answer your questions and link in between the different professionals on your behalf.
• A Respiratory Scientist, who will check your child’s breathing and lung function.
• A Radiologist, who will take x-rays of your child’s chest and spine.
• A Physicians Assistant (PA) who is a member of the Orthopaedic Surgical Team.

You may also see:

• A Cardiologist who will check your child’s heart.
• An Occupational Therapist (OT) who will check their wheelchair, if they use one, or if they need any alterations to their equipment.

Risks of having spinal surgery?

Any surgery carries risks and it is important that you are aware of these before you agree to your child’s surgery. You should be fully aware to allow you to make an informed decision.

Your child’s consultant will have balanced all these risks with the benefits of surgery to decide if surgery is appropriate.

The main risks are:

• Spinal Cord Damage. This can range from slight weakness, altered sensation to paralysis. Spinal cord monitoring may be used to reduce this risk.
• Wound or bone infection.
• Bleeding during the operation.
• Metalwork failure.
• Failure of your child spine to fuse.

Author: Michelle Edge

Version: 2

Approval Date: August 2024

Review Date: August 2027

Copyright © Children’s Health Ireland

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Spinal Surgery Pre-operative Assessment For CHI at Temple Street Oct 2024

Scoliosis information hub

Proximal humerus fracture: Non-operative management

Your child has sustained a fracture to the arm (humerus) just below the shoulder. This fracture usually heals well in a simple sling, called a collar and cuff. The sling will help keep your child comfortable while the bone heals.

The first 24-48 hours after injury

Your child will have pain in the shoulder initially. Medication such as Ibuprofen and/or Paracetamol as needed (as long as not allergic) following the directions on the package will help decrease the pain.

Although nerve and artery injuries are very rare with this injury, you should return to the Emergency Department if your child develops numbness or tingling in the hand.

Follow-up appointment

You will be notified by the Trauma Assessment Clinic Physiotherapist with regard to review in the Fracture Clinic with the Consultant Orthopaedic Surgeon, usually about 7-10 days after the injury. A new x-ray may be ordered at that appointment. You will be asked to take off the sling (collar and cuff) 4 weeks after the injury and allow your child to begin moving the shoulder. No further follow-up is usually required.

After 3 weeks

Remove the sling (collar and cuff) 3 weeks after your child broke the arm. With the sling (collar and cuff) off, your child can begin moving the shoulder. At first, the shoulder may be stiff. The movement will get better with time but this may take up to 6 months. Physiotherapy is not usually necessary.

To decrease the risk of re-breaking the arm, your child should not participate in high-risk activities such as playing on monkey-bars, trampolines or contact sports for 6 weeks after the injury. However, your child can return to low-risk activities such as swimming, as soon as the shoulder is comfortable.

If your child continues to have pain in the shoulder 6 weeks after the injury contact your GP.

Key Points

• Your child needs a sling (collar and cuff) to help heal the broken arm.
• You will take off the sling (collar and cuff) at home after 3 weeks.
• Your child will need to avoid high-risk activities for a total of 6 weeks after the injury.
• Your child's shoulder may need 6 months to fully recover strength and movement.
• If your child continues to have pain in the shoulder 6 weeks after the injury contact your GP.

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Proximal humerus fracture: Non-operative management

Stable fracture of the hand

Your child has sustained a fracture to the hand. This fracture usually heals well in a splint or buddy strapping. This immobilisation will help keep your child comfortable while the bone heals.

The first 24-48 hours after injury

Your child’s hand and fingers may swell in the first 24-48 hours after the injury. To decrease this swelling, your child should rest the hand up on a pillow when sitting or lying down.

You should check the temperature, colour of the fingers about every 4 hours during waking hours.

Your child will have pain in the hand initially. Medication such as Ibuprofen and/or Paracetamol as needed, (as long as not allergic), following the directions on the package will help decrease the pain. Elevation is key in providing pain relief.

Signs of a problem

• Severe pain in the hand or the fingers.
• Fingers that are blue or white.
• Fingers that are cold (you can compare them to the fingers on the other hand).
• Numbness or pins and needles in the hand.

If your child has any of these signs, rest your child’s arm on a pillow while lying down for 30 minutes.

If the problem does not get better, contact your GP, or go to the Emergency Department.

Follow-up appointment

Children with a stable hand fracture do not require follow-up with the Consultant Orthopaedic Surgeon, or need to get another x-ray.

After 3 weeks

Remove the splint or the buddy strapping 3 weeks after your child’s injury. With the splint or buddy strapping off, your child can begin using the hand. At first, the hand may be stiff. The movement will get better with time but this may take up to 2 months. Physiotherapy is not usually necessary.

To decrease the risk of re-breaking the hand, your child should not participate in high-risk activities such as playing on monkey-bars, trampolines, or contact sports for 2 weeks after the injury. However, your child can return to low risk sports such as swimming as soon as the hand is comfortable.

Contact your GP if your child has not regained normal hand movement 2 months after injury.

Key Points

• Your child needs a splint or buddy strapping to help heal the broken hand.
• You will take off the splint or buddy strapping at home after 3 weeks after the injury.
• Your child will need to avoid high-risk activities for a total of 2 weeks after the injury.
• If your child has not regained normal hand movement 2 months after the injury, contact your GP.

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Stable fracture of the hand

Toddler’s Fracture (Radiological Evidence)

Your child has broken (fractured) the leg (tibia). This fracture usually heals well in a simple splint. The splint will help keep your child comfortable while the bone heals. While in the splint, your child should avoid walking on the injured limb.

The first 24-48 hours after injury

Your child’s leg, foot and toes may swell in the first 24 - 48 hours after injury. To decrease this swelling, your child should rest the leg up on a pillow when sitting or lying down.

You should encourage your child to bend and straighten the toes every hour during waking hours. You should check the temperature, colour and movement of the toes about every 4 hours during waking hours.

Your child will have pain in the leg initially. Medication such as Ibuprofen and/or Paracetamol as needed (as long as not allergic) following the directions on the package will help decrease the pain.

Signs of a problem

• Persistent pain in the foot or ankle may indicate a splint that is too tight.
• Severe pain when moving the toes.
• Toes that are blue or white.
• Toes that are cold (you can compare them to the toes on the other foot).
• Toes that cannot curl up or straighten out.
• Numbness or pins and needles in the foot.

If your child has any of these signs, rest your child’s leg on a pillow while lying down for 30 minutes.

If the problem does not get better, call your GP, or go to the Emergency Department.

Follow-up appointment

Children with a toddler’s fracture do not require follow-up with the Consultant Orthopaedic Surgeon, or need to get another x-ray.

After 3 weeks

Remove the splint 3 weeks after your child’s injury. With the splint off, your child can begin using the leg. At first, leg may be stiff. Your child will limp, this is normal. The movement will get better with time but this may take up to 3 months.

Physiotherapy is not usually necessary.

Occasionally, children who are very comfortable will remove the splint and resist wearing it prior to 3 weeks. In this instance, a simple bandage or no support may suffice with close observation of comfort levels.

To decrease the risk of re-breaking the leg, your child should not participate in high-risk activities such as playing on monkey-bars, trampolines or contact sports for about 6 weeks after the injury. However, your child can return to low-risk sports such as swimming as soon as the leg is comfortable.

Your child will limp for up to 3 months after sustaining a toddler’s fracture.

If your child continues to limp after that time, contact your GP.

Key Points

• Your child uses the splint to keep comfortable as the broken bone heals.
• Your child may begin to walk on the splint, this indicates fracture healing.
• You will take off the splint at home after 3 weeks after injury.
• Your child will need to avoid high-risk activities for a total of about 6 weeks after the injury.
• Your child will limp for up to 3 months after sustaining a toddler’s fracture.
• If your child limps 3 months after sustaining the injury, contact your GP.

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Toddler’s Fracture (Radiological Evidence)

Stable foot fracture: Non-operative management

Your child has sustained a fracture to the foot. This fracture usually heals well in a walking boot. The boot will help keep your child comfortable while the bone heals. While your child is in bed, or in the bath, or in the shower they do not need to wear the boot.

The first 24-48 hours after injury

Your child’s foot and toes may swell in the first 24-48 hours after the injury. To decrease this swelling, your child should rest the foot up on a pillow when sitting or lying down.

You should encourage your child to bend and straighten the toes every hour during waking hours. You should check the temperature, colour and movement of the toes about every 4 hours during waking hours.

Your child will have pain in the foot initially. Medication such as Ibuprofen and/or Paracetamol as needed, (as long as not allergic), following the directions on the package will help decrease the pain. Elevation is key in providing pain relief.

Signs of a problem

• Severe pain when moving the toes.
• Toes that are blue or white.
• Toes that are cold (you can compare them to the toes of the other foot).
• Toes that cannot curl up or straighten out.
• Numbness or pins and needles in the foot.

If your child has any of these signs, rest your child’s foot on a pillow while lying down for 30 minutes.

If the problem does not get better, call your GP, or go to the Emergency Department.

Follow-up appointment

You will be notified by the Trauma Assessment Clinic Physiotherapist with regard to review in the Fracture Clinic with the Consultant Orthopaedic Surgeon, usually about 1 week after the injury. Your child can begin to walk on the injured foot as soon as comfortable. The boot can be removed 6 weeks after the injury.

After 6 weeks

Remove the boot when comfortable (approximately 6 weeks after your child’s injury). At first, the ankle may be stiff. The movement will get better with time but this may take up to 3 months. Your child will limp for 3 months after the injury, this is normal. Physiotherapy is not usually necessary.

To decrease the risk of re-breaking the foot, your child should not participate in high-risk activities such as playing on monkey-bars, trampoline, rugby, or other contact sports for 8 weeks after the injury. However, your child can return to low risk sports such as swimming as soon as the foot is comfortable.

Contact your GP if your child has not regained normal foot movement 3 months after the injury.

Key Points

• Your child needs a boot to help heal the broken foot.
• Your child does not need to wear the boot in bed, or in the bath, or in the shower.
• You will take off the boot permanently 6 weeks after the injury.
• Your child will need to avoid high-risk activities for a total of 8 weeks after the injury.
• Your child will limp for up to 3 months after the injury, this is normal.
• If your child limps 3 months after sustaining the injury, contact your GP.

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Stable foot fracture Non operative management

Supracondylar humerus fracture without displacement

Your child has sustained a fracture to the arm, just above the elbow. A backslab (half cast) and a sling are required to allow the bone to heal properly.

It is often easiest to place the backslab and the sling under loose clothing instead of through a shirt sleeve.

The first 24-48 hours after injury

Your child’s arm, hand and fingers may swell in the first 24 -48 hours after injury. To decrease the swelling, your child should rest the arm up on a pillow when sitting or lying down.

You should encourage your child to bend and straighten the fingers every hour during waking hours. You should check the temperature, colour and movement of the fingers about every 4 hours during waking hours.

Your child will have pain in the elbow initially. Medication such as Ibuprofen and/or Paracetamol as needed (as long as not allergic) following the directions on the package will help decrease the pain

Signs of a problem

• Severe pain when moving the fingers.
• Fingers that are blue or white.
• Fingers that are cold (you can compare them to the fingers on the other hand).
• Fingers that cannot curl up or straighten out.
• Numbness or pins and needles in the fingers.

If your child has any of these signs, rest your child’s arm on a pillow while lying down for 30 minutes.

If the problem does not get better, call your GP, or go to the Emergency Department.

Follow-up appointment

You will be notified by the Trauma Assessment Clinic Physiotherapist with regard to review in the Fracture Clinic with the Consultant Orthopaedic Surgeon, usually about 7-10 days after the injury. The Consultant Orthopaedic Surgeon will show you how to take off the cast at home, 3 weeks after the date of the injury. No further follow-up is usually required.

After 3 weeks

Remove the backslab 3 weeks after your child’s fracture. Removing the backslab is not difficult. When taking off the backslab, carefully cut up front soft part of the half cast with scissors.

After removing the backslab, your child's arm may be dry and itchy and look dirty. Use warm water and soap to gently wash the arm and cream to moisturise the skin.

When the backslab is off, your child can begin moving the elbow. At first, the elbow and the wrist may be stiff. The movement will get better with time but this may take up to 6 months. Physiotherapy is not recommended.

To decrease the risk of re-breaking the arm, your child should not participate in high-risk activities such as playing on monkey-bars, trampolines or contact sports for 6 weeks after the injury.

Key Points

• Your child needs a backslab (half cast) to help heal the broken arm.
• You will take off the backslab at home after 3 weeks.
• Your child will need to avoid high-risk activities for a total of 6 weeks after the injury.
• Your child's elbow may need 6 months to fully recover strength and movement.

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Supracondylar humerus fracture without displacement

Volar Plate Injury of the Finger

Your child has sustained a volar plate injury of their finger. This is an injury to the mechanism that allows your child’s finger to flex. This injury usually heals well but will require hand therapy to minimise stiffness and swelling. Preserving movement is important so no immobilisation is required. It is normal for children with this injury to have a stiff finger for up to 4 months and a small degree of swelling may persist for up to 12 months.

The first 24-48 hours after injury

Your child’s hand and fingers may swell in the first 24-48 hours after the injury. To decrease this swelling, your child should rest the hand up on a pillow when sitting or lying down.

You should check the temperature, colour of the fingers about every 4 hours during waking hours.

Your child will have pain in the hand initially. Medication such as Ibuprofen and/or Paracetamol as needed, (as long as not allergic), following the directions on the package will help decrease the pain. Elevation is key in providing pain relief.

Signs of a problem

• Severe pain in the hand or the fingers.
• Fingers that are blue or white.
• Fingers that are cold (you can compare them to the fingers on the other hand).
• Numbness or pins and needles in the hand.

If your child has any of these signs, rest your child’s arm on a pillow while lying down for 30 minutes.

If the problem does not get better, contact your GP, or go to the Emergency Department.

Follow-up appointment

Children with a volar plate injury do not require follow-up with the Consultant Orthopaedic Surgeon, or need to get another x-ray. However a close follow up with a Hand Therapist is required.

After Injury

Your child will be referred to a Hand Therapist for supervised rehabilitation. If the Hand Therapist is unhappy with your child’s progress they will refer your child to a Specialist Hand Surgeon who will direct the appropriate treatment. While awaiting review you should encourage your child to perform the exercises shown below in the pictures for 5 minutes at a time 5 times per day.

Key Points

• Your child does not need a splint or buddy strapping to help heal the broken hand.
• Your child will be referred to a Hand Therapist to help them to recover from this injury.
• Your will need to help your child with the exercises given on this sheet while they are waiting for a review by a Hand Therapist. (5 minutes each 5 times per day).
• It is normal to expect stiffness for 4 months and some swelling for up to 12 months after this injury.
• Should your child not make adequate progress with the Hand Therapist your child will then be referred to a Hand Surgeon who will direct further treatment.

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Volar Plate Injury of the Finger

Collar bone (clavicle) fracture in children less than 10 years of age

Your child has sustained a fracture to the collar bone (clavicle). This fracture usually heals well in a simple sling. The sling will help keep your child comfortable while the bone heals.

It is often easiest to place the sling under loose clothing.

The first 24-48 hours after injury

Your child will have pain in the shoulder initially. Medication such as Ibuprofen and/or Paracetamol as needed (as long as not allergic) following the directions on the package will help decrease the pain.

Although nerve and artery injuries are very rare with this injury, you should return to the Emergency Department if your child develops numbness or tingling in the hand.

Follow-up appointment

Most children under 10 years of age with collar bone (clavicle) fractures do not require follow-up with the Consultant Orthopaedic Surgeon.

After 3-4 weeks

Remove the sling 3-4 weeks after your child broke the collar bone (clavicle). With the sling off, your child can begin moving the shoulder. At first, the shoulder may be stiff. The movement will get better with time but this may take up to 3 months. Physiotherapy is not usually necessary.

To decrease the risk of re-breaking the collar bone (clavicle), your child should not participate in high-risk activities such as playing on monkey-bars, trampoline, rugby or other contact sports for 8 weeks after the injury. However, your child can return to low-risk activities such as swimming as soon as the shoulder is comfortable.

Your child may feel a bump on the collar bone (clavicle). This is normal, it means that the fracture has healed. The bump will get smaller over the next few years. In some cases, a small bump may remain.

Contact your GP if your child continues to have pain in the shoulder 6 weeks after the injury.

Contact your GP if your child has not regained normal shoulder movement 6 months after the injury.

Key Points

• Your child needs a sling to help heal the broken bone.
• You will take off the sling at home after 3-4 weeks after the injury.
• Your child will need to avoid high-risk activities for a total of 8 weeks after the injury.
• Your child may have a bump on the collar bone where the fracture has healed.
• If your child continues to have pain in the shoulder 6 weeks after the injury, contact your GP.
• If your child has not regained normal shoulder movement 3 months after the injury, contact your GP.

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Collar bone (clavicle) fracture in children

Buckle Fracture

Your child has sustained a fracture to the arm (radius). This fracture heals well in a simple velcro splint. The splint will help keep your child comfortable while the bone heals.

It is often easiest to place the backslab and sling under loose clothing instead of through a shirt sleeve.

The first 24-48 hours after injury

Your child’s arm, hand and fingers may swell in the first 24 - 48 hours after the injury. To decrease the swelling, your child should rest the arm up on a pillow when sitting or lying down.

You should encourage your child to bend and straighten the fingers every hour during waking hours. You should check the temperature, colour and movement of the fingers about every 4 hours during waking hours.

Your child will have pain in the arm initially. Medication such as Ibuprofen and/or Paracetamol as needed (as long as not allergic) following the directions on the package will help decrease the pain.

Signs of a problem

• Severe pain when moving the fingers.
• Fingers that are blue or white.
• Fingers that are cold (you can compare them to the fingers on the other hand).
• Fingers that cannot curl up or straighten out.
• Numbness or pins and needles in the hand.

If your child has any of these signs, rest your child’s arm on a pillow while lying down for 30 minutes.

If the problem does not get better, contact your GP, or go to the Emergency Department.

Follow-up appointment

Children with a buckle fracture do not require follow-up with the Consultant Orthopaedic Surgeon, or need to get another x-ray.

After 3 weeks

Remove the splint 3 weeks after your child’s injury. With the splint off, your child can begin using the arm. At first, the wrist may be stiff. The movement will get better with time but this may take up to 2 months. Physiotherapy is not usually necessary.

To decrease the risk of re-breaking the arm, your child should not participate in high-risk activities such as playing on monkey-bars, trampolines, or contact sports for 2 weeks after the injury. However, your child can return to low risk sports such as swimming as soon as the arm is comfortable.

Contact your GP if your child has not regained normal arm movement 2 months after injury.

Key Points

• Your child needs a splint to help heal the broken arm.
• You will take off the splint at home after 3 weeks after the injury.
• Your child will need to avoid high-risk activities for a total of 2 weeks after the injury.
• If your child has not regained normal arm movement 2 months after the injury, contact your GP.

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Buckle Fracture

Stable fracture of the lateral malleolus

Your child has sustained a fracture to the ankle. This fracture usually heals well in a walking boot. The boot will help keep your child comfortable while the bone heals. While your child is in bed, or in the bath, or in the shower they do not need to wear the boot.

The first 24-48 hours after injury

Your child’s ankle may swell in the first 24-48 hours after the injury. To decrease this swelling, your child should rest the ankle up on a pillow when sitting or lying down.

You should encourage your child to bend and straighten the toes every hour during waking hours. You should check the temperature, colour and movement of the toes about every 4 hours during waking hours.

Your child will have pain in the ankle initially. Medication such as Ibuprofen and/or Paracetamol as needed, (as long as not allergic), following the directions on the package will help decrease the pain. Elevation is key in providing pain relief.

Signs of a problem

• Severe pain when moving the ankle.
• Toes that are blue or white.
• Toes that are cold (you can compare them to the toes of the other foot).
• Toes that cannot curl up or straighten out.
• Numbness or pins and needles in the foot.

If your child has any of these signs, rest your child’s foot on a pillow while lying down for 30 minutes.

If the problem does not get better, call your GP, or go to the Emergency Department.

Follow-up appointment

You will be notified by the Trauma Assessment Clinic Physiotherapist with regard to review in the Fracture Clinic with the Consultant Orthopaedic Surgeon, usually about 1 week after the injury. Your child can begin to walk on the injured ankle as soon as comfortable. The boot can be removed 6 weeks after the injury.

After 6 weeks

Remove the boot 6 weeks after your child’s injury. At first, the ankle may be stiff. The movement will get better with time but this may take up to 3 months. Your child may limp for up to 3 months after the injury, this is normal. Physiotherapy is not usually necessary.

To decrease the risk of re-breaking the ankle, your child should not participate in high-risk activities such as playing on monkey-bars, trampoline, rugby, or other contact sports for 4 weeks after the boot has been removed. However, your child can return to low risk sports such as swimming as soon as the ankle is comfortable.

Contact your GP if your child has not regained normal ankle movement 3 months after the injury.

Key Points

• Your child needs a boot to help heal the broken ankle.
• Your child does not need to wear the boot in bed, or in the bath, or in the shower.
• You will take off the boot permanently 6 weeks after the injury.
• Your child will need to avoid high-risk activities for a total of 3 weeks after the boot has been removed.
• Your child will limp for up to 3 months after the injury, this is normal.
• If your child limps 3 months after sustaining the injury, contact your GP.

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Stable fracture of the lateral malleolus

A number of international outsourcing initiatives have been finalised for children waiting on spinal surgeries. Read more.

Developmental Dysplasia of the Hip (DDH)