Avulsion Fractures The frequency of avulsion fractures in pediatrics is a consequence of the strong muscular attachments to relatively weak secondary centers of ossification in the developing skeleton known as apophyses During intense muscular contraction, fractures can occur through the apophyseal plate Common sites include the pelvis, tibial tubercle, and the phalanges Avulsion fractures infrequently require open or closed reduction Conservative care is the mainstay of treatment GENERAL PRINCIPLES OF ACUTE ORTHOPEDIC CARE CLINICAL PEARLS AND PITFALLS Any child with obvious extremity deformity should be made nil per os (NPO) at triage given the potential need for procedural sedation or operative management for fracture reduction and casting Based on the history and mechanism of injury, the possibility of other injuries (e.g., head, chest, intra-abdominal organs) should be considered Physical examination must include inspection, palpation, range of motion (passive and active), and neurovascular examination with careful examination of the joints proximal and distal to the point of maximal tenderness Always carefully remove all splints, bandages, and clothing in order to perform an accurate examination with documentation of breaks in the skin, which may represent an open fracture Splinting the injured extremity immediately after evaluation and before radiographs are taken can decrease the child’s discomfort and prevent further injury Neurovascular status should be assessed before and after any splinting is performed If an orthopedist is not readily available, gentle longitudinal traction and gross realignment may be performed by the emergency clinician for fractures that are grossly displaced, unstable, or if there is vascular compromise Current Evidence