Summary: Fractures (broken bones) are often thought of as emergencies. Except for hand fractures, most small fractures are not true emergencies. Therefore, if you only THINK that there might be a broken bone, this is probably because your child's pain is mild and the injury doesn't look so bad, which means that this is not likely to be an emergency (unless it is a hand injury). If the injury looks really bad, then probably there is a fracture and emergency care is needed. Not all fractures can be diagnosed on the first visit. X-rays are sometimes misread and some fractures do not show up on an X-ray.
Parents often bring their child to an ER because they are concerned about the possibility of a broken bone. If your child's degree of pain is minor and you only THINK that the bone might be broken, this generally is not a true emergency. Most of these injuries turn out to be sprains or minor broken bones. The terms broken bone, fracture and crack, all roughly mean the same thing.
To start, lets look at what is clearly an emergency: 1) Moderate or severe pain. 2) Loss of function (can't move it well). 3) Loss of sensation (can't feel normally) or a tingling sensation. 4) Obvious deformity (It looks very crooked). 5) An open wound near the broken bone. 6) Injury to the hand (near the wrist).
Pain is a legitimate emergency because there is no reason to suffer unnecessarily. ER's have the ability to use very effective pain medications to control pain. Immobilizing a fracture in a splint is also highly effective at reducing pain because most of the pain occurs when the broken bones move.
Tingling (needles sensation), loss of sensation or loss of function, are potentially serious emergencies which suggest loss of blood circulation or nerve injury. Waiting could result in an amputation so go to an ER immediately if these symptoms are present.
An obvious deformity, where the affected area looks very crooked, is a good reason to seek immediate emergency care because such an injury could get worse, it is probably very painful, and it will need prompt reduction (straightening out) or at least immobilization in a splint.
An open wound near the broken bone raises the possibility that the broken bone popped through the skin. This is called an open fracture or compound fracture (these two terms basically mean the same thing). If the bone did pop through the skin, the bone is very likely to be contaminated. Antibiotics may not be enough to prevent bone infections if the bone is heavily contaminated. The wound will need to be opened in the operating room and washed out to remove bacteria and debris.
Hand injuries near the wrist are potentially serious even if the fracture is small. The small bones of the hand near the wrist, called the carpal bones, do not heal well if a fracture occurs. Even small fractures of the carpals can heal poorly resulting in chronic pain. To best avoid this complication, all injuries of the hand near the wrist (carpals) should be evaluated immediately.
Other than these situations where immediate emergency care is required, the possibility of a broken bone is usually not a true emergency. Sprains and small, stable broken bones can be diagnosed in the office. X-rays can be ordered by your office primary care physician. If a fracture is identified, your child can be referred to a specialist such as an orthopedic surgeon at a scheduled appointment time.
For most stable fractures, immediate casting is not necessary. In most ER's, a splint (a half cast) is applied. Follow-up with an orthopedic surgeon in 1-2 days is arranged for definitive casting. While it is convenient to have a cast applied in the ER, this is usually not done for two reasons: 1) Late casting is associated with fewer complications than early casting. 2) Since immediate casting is not necessary, it is difficult to convince an orthopedic surgeon to come down to the ER.
When a fracture initially occurs, immediate swelling is noted. Swelling may continue for the first 12 hours. If a full cast is applied immediately, this places a rigid cylinder around the fracture which may continue to swell. Continued swelling may choke off the blood supply resulting in a disastrous complication (such as losing the arm). As the swelling subsides, the cast which was applied to a swollen fracture, now becomes too loose to optimally immobilize the fracture. The fracture can now jiggle about inside the cast. Thus, later casting is more optimal than early casting. A splint is highly effective at immobilization without the risk of cast complications. A splint is rigid on one side (plaster or fiberglass) with a surrounding elastic bandage holding the extremity onto the splint. This immobilizes the extremity with the elastic bandage providing the ability to accommodate the changes in the degree of swelling. The elastic permits the splint to adjust so that it is does not become too tight or too loose.
In most cities and towns, orthopedic surgeons are very busy. They often work long hours responding to emergencies. An orthopedic surgeon is needed immediately if the fracture is open (a bone is sticking out of the skin or an open wound lies over the fracture), there is evidence of nerve or blood vessel injury, or there is a deformity in need of straightening it soon. Most orthopedic surgeons are not willing to come to the ER immediately unless their presence is absolutely required. They usually recommend that a splint be applied by the emergency physician and follow-up be arranged in the orthopedic surgeon's office in 1-2 days for definitive casting.
It should also be noted that small fractures are not easy to diagnose. X-rays are sometimes misread and some fractures do not show up on an X-ray. Sprains usually get better everyday, but fractures usually have persistent pain. An injury with persistent pain should be re-evaluated even if an initial set of X-rays were normal. X-rays often need to be repeated using different views, or a more advanced imaging study (such as CT scan, MRI scan, bone scan, etc.) may be necessary to identify a hidden fracture.