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Fractures, Pediatric, Emergency Medicine

Basics

Description

- Mechanism is useful in defining the potential and type of injury - Obesity and rapid growth spurts are risk factors. - NAT: - Any fracture in a child younger than 1 yr of age in whom history is not consistent with injury - Metaphyseal "corner"Ł fractures are pathognomonic. - Posterior rib fractures - Spiral femur fracture - Fractures at different stages of healing - Skull fractures crossing suture lines, especially in children younger than 1 yr - Unusual behavior in child or parent

- Decreased limb movement, unwilling to use - Swelling - Tenderness - Deformity - Ecchymosis - Crepitus - Limp - Abnormal neurovascular status of extremity - Compartment syndrome: - Severe pain, especially in forearm, calf, foot - Pain with passive stretching of fingers or toes - Sensory deficit in the distal extremity - Cool extremity - Pulseless extremity

- Thorough secondary survey looking for deformities, bruising, other injuries - Assess neurovascular status: - Motor/sensation - Distal pulses - Capillary refill

- CBC, ESR, CRP, arthrocentesis may be indicated - Transient synovitis vs. septic hip - More likely septic if: - Fever - Elevated ESR/CRP - WBC elevation - Refusal to bear weight

  • 20% of pediatric patients with acute traumatic injuries will have a fracture
  • Boys have fractures more commonly than girls
  • Anatomy:Diaphysis: Physis to physis; bone shaftEpiphysis: Cartilaginous center at or near end of bone that is site of bone growthEpiphyseal (growth) plate: Radiolucent line between epiphysis and metaphysis; cartilaginousMetaphysis: Region of rapidly growing trabecular bone underlying base of cartilaginous growth plate; between diaphysis and epiphysisMost long bones are ossified by the end of puberty
  • Bones are highly resilient, elastic, and springy
  • Allow for fractures not seen in adults:Greenstick fracture:Incomplete fracture through cortex on opposite side of impactTorus (buckle) fracture:Usually at junction of metaphysis and diaphysisCompression of bone of 1 cortexPlastic deformity:Bowing without disruption of cortexFractures involving the physis
  • Cartilaginous growth plates are potential areas of injury.
  • Ligaments more resistant to injury than growth plates
  • Salter-Harris classification:Risk of growth disturbance increases from type I to type V.Type I:Separation of epiphysis from metaphysis without displacement or injury to the growth plateTenderness and pain at point of growth plateRadiograph typically normalGrowth disturbance is rare.Type II:Metaphyseal fracture extending to physisMost commonGrowth disturbance is rare.Type III:Intra-articular fracture extending through the epiphysis into the physisMost common site is distal tibial epiphysis.Growth disturbance possibleType IV:Epiphyseal, physeal, and metaphyseal fractureLateral condyle of humerus is the most common site.Growth disturbance highly likelyType V:Crush injury to epiphyseal plate, producing growth arrestUsually occurs in joints that move in only 1 plane such as knee
  • Fractures often accompany dislocations.
  • Nonaccidental trauma (NAT) if history inconsistent with findings

Etiology

  • Mechanism is useful in defining the potential and type of injury
  • Obesity and rapid growth spurts are risk factors.
  • NAT:Any fracture in a child younger than 1 yr of age in whom history is not consistent with injuryMetaphyseal "corner"Ł fractures are pathognomonic.Posterior rib fracturesSpiral femur fractureFractures at different stages of healingSkull fractures crossing suture lines, especially in children younger than 1 yrUnusual behavior in child or parent

Diagnosis

Signs and Symptoms

  • Decreased limb movement, unwilling to use
  • Swelling
  • Tenderness
  • Deformity
  • Ecchymosis
  • Crepitus
  • Limp
  • Abnormal neurovascular status of extremity
  • Compartment syndrome:Severe pain, especially in forearm, calf, footPain with passive stretching of fingers or toesSensory deficit in the distal extremityCool extremityPulseless extremity
  • Open fracture may be obvious or subtle (collection of blood with fat globules under skin)

History

  • Mechanism of injury:Velocity of car, bike, etc.Height of fall
  • Neurologic compromise
  • Events surrounding injury
  • Other injuries

Physical Exam

  • Thorough secondary survey looking for deformities, bruising, other injuries
  • Assess neurovascular status:Motor/sensationDistal pulsesCapillary refill
  • Range of motion of all joints involved
  • Exclude concurrent injuries
  • Ensure that history is consistent with injury

Essential Workup

  • Prompt immobilization
  • Imaging as below

Diagnosis Tests & Interpretation

Lab

  • Required only if concomitant injuries, surgery anticipated, or multiple/major bone involvement
  • CBC, ESR if infection suspected

Imaging

  • Anteroposterior (AP), lateral, and oblique radiographs as necessary, including the joint above and below the fracture
  • Comparison views may be useful if growth plates are involved.
  • Follow-up radiographs at 7-10 days may be required to exclude avascular necrosis or Salter I fractures.
  • Bone scan/CT/MRI may be useful to exclude fractures if plain radiographs are unhelpful or to evaluate for infection.

Diagnostic Procedures/Surgery

Arthrocentesis if infection is suspected á

Differential Diagnosis

  • Sprain or strain
  • Contusion
  • Infection
  • Tumor
  • Neurologic deficits
  • Subtle dislocations such as radial head subluxation (nursemaids elbow)
  • NAT

Treatment

Pre-Hospital

Immobilization á

Initial Stabilization/Therapy

  • Resuscitation for concurrent injuries
  • Immobilization

Ed Treatment/Procedures

  • Management of life-threatening concurrent injuries
  • Pain control
  • Dislocations require immediate assessment and attention to neurovascular compromise:Mechanism helps in understanding the direction of the force required to reduce.
  • Alignment is essential, particularly when fracture involves a joint surface.
  • Appropriate reporting of NAT

Salter-Harris Fractures

  • Type I and type II fractures require immobilization and orthopedic follow-up.
  • Type II distal femur fractures, type III, and type IV require urgent orthopedic consultation for anatomic reduction.
  • Type V fractures require immobilization and consultation.
  • Anatomic reduction does not eliminate possibility of growth disturbance.

Clavicle Fracture

  • Figure-of-8 splint or sling for comfort
  • Distal 3rd clavicle fractures should be referred with initial sling and swathe or shoulder immobilizer.

Elbow Fracture

  • >50% are supracondylar10-15% have neural injury
  • May present with only posterior effusion on lateral radiograph
  • Orthopedic consultation because of potential neurovascular complications
  • Brachial artery injury, median nerve injury possible
  • Volar compartment syndrome of forearm (results in Volkmann contracture)
  • Epiphyseal injury with long-term growth abnormalities

Distal Radius and Ulna Fractures

  • Most common site of pediatric fracture: Distal radius
  • Reduce angulated fractures >15 ░
  • Pronator fat pad along volar radius may indicate occult fracture
  • Colles fracture:Reduce by traction in the line of deformity to disimpact the fragments, followed by pressure on the dorsal aspect of the distal fragment and volar aspect of the proximal fragment.Correct radial deviation.Immobilize wrist and elbow (sugar-tong splint)Orthopedic consultation
  • Torus fracture (incomplete fracture; buckling or angulation on the compression side of the bone only):Most often in distal forearm
  • Greenstick fracture (incomplete fracture of diaphysis of long bone with fracture on tension side of cortex):Immobilize.Reduction if angulation >30 ░ in infants, >15 ░ in children

Tibia or Fibula Fracture

  • Isolated fibular fractures: Short-leg walking cast
  • Nondisplaced tibial fracture: Long-leg posterior splint, nonweight bearing
  • Displaced tibial fracture and complex fractures require consultation.
  • Toddlers fractures:Nondisplaced, oblique, distal tibia fractureMay need tangential view radiograph or bone scan to diagnoseSplint if suspect and repeat radiograph in 7-10 days.
  • May apply Ottawa Ankle Rules to children

Slipped Capital Femoral Epiphysis

  • Disruption though capital femoral epiphysis
  • Need AP and frog-leg x-rays
  • Overweight adolescent boys
  • May have referred pain to knee, thigh, or groin
  • Nonweight bearing with prompt orthopedic follow-up
  • Often bilateral

Femur Fracture

  • Most common long-bone fracture

Stress Fractures

  • Increasingly common
  • Insidious onset
  • Vague, achy pain
  • Usually associated with rigorous activity
  • Treatment:Selective bracingActivity modification

Open Fractures

  • Irrigate and dress with moist saline gauze
  • Immobilize
  • Cefazolin if only small laceration and minimal contamination
  • Gentamicin if moderate contamination, high-energy injury, or significant soft tissue injury
  • Consider penicillin if concern for clostridia infection (farm injury, fecal or soil contamination)
  • Small wounds with minimal soft tissue injury may be treated with oral antibiotics and immobilization in consultation with orthopedist

Child with Limp

  • Careful exam and review of systems for signs of rheumatologic disease, infection, or malignancyPediatric patients with leukemia may present with limp as their initial complaint
  • CBC, ESR, CRP, arthrocentesis may be indicated
  • Transient synovitis vs. septic hipMore likely septic if:FeverElevated ESR/CRPWBC elevationRefusal to bear weight

Medication

  • Acetaminophen: 10-15 mg(kg PO(PR (per rectum) q4-6h; Do not exceed 5 doses/24 h
  • Cefazolin: 25-100 mg/kg daily IM/IV q8h
  • Gentamicin: 2.5 mg/kg IV/IM q8h or 6.5-7.5 mg/kg IV/IM q24h
  • Hematoma block: 1% lidocaine without epinephrine (max. 3-5 mg/kg)
  • Ibuprofen: 10 mg/kg PO q6-8h (first-line treatment)
  • Morphine: 0.05-0.2 mg/kg SC/IM/IV q2-4h

Follow-Up

Disposition

Admission Criteria

  • NAT (or per social services)
  • Open fracture
  • Potential neurovascular compromise/compartment syndrome:Condylar or supracondylar humerus fractureFemoral shaft

Discharge Criteria

  • Uncomplicated fracture: No concurrent injury or neurovascular/compartment compromise
  • Follow-up arranged and parents understand injury and management

Issues for Referral

All Salter-Harris fractures should have orthopedic follow-up. á

Pearls and Pitfalls

  • History is essential in evaluation of NAT
  • Undress patient fully especially if suspicion for NAT
  • Have a low threshold to splint and/or consult orthopedist
  • Pain control is essential and often underdosed.
  • Distal radius is often associated with other fractures: Ulna, elbow, carpal bones

Additional Reading

  • Boutis áK. Common pediatric fractures treated with minimal intervention. Pediatr Emerg Care. 2010;26:152-157.
  • Chasm áRM, Swencki áSA. Pediatric orthopedic emergencies. Emerg Med Clin North Am. 2010;28:907-926.
  • Laine áJC, Kaiser áSP, Diab áM. High-risk pediatric orthopedic pitfalls. Emerg Med Clin North Am. 2010;28:85-102.
  • Mathison áDJ, Agrawal áD. An update on the epidemiology of pediatric fractures. Pediatr Emerg Care. 2010;26:594-603.

See Also (Topic, Algorithm, Electronic Media Element)

  • Conscious Sedation
  • C-spine Fractures, Pediatric
  • Fractures, Open
  • Nursemaids Elbow
  • Shoulder Dislocation
  • Slipped Capital Femoral Epiphysis

Codes

ICD9

  • 803.00 Other closed skull fracture without mention of intracranial injury, unspecified state of consciousness
  • 807.00 Closed fracture of rib(s), unspecified
  • 829.0 Fracture of unspecified bone, closed
  • 821.00 Closed fracture of unspecified part of femur
  • 812.42 Closed fracture of lateral condyle of humerus
  • 824.8 Unspecified fracture of ankle, closed

ICD10

  • S02.91XA Unsp fracture of skull, init encntr for closed fracture
  • S22.39XA Fracture of one rib, unsp side, init for clos fx
  • T14.8 Other injury of unspecified body region
  • S72.90XA Unsp fracture of unsp femur, init encntr for closed fracture
  • S42.456A Nondisp fx of lateral condyle of unsp humerus, init
  • S89.109A Unsp physeal fracture of lower end of unsp tibia, init

SNOMED

  • 125605004 Fracture of bone (disorder)
  • 371162008 Closed fracture of skull (disorder)
  • 60667009 closed fracture of rib (disorder)
  • 71620000 Fracture of femur (disorder)
  • 208267005 Closed fracture distal humerus, lateral condyle (disorder)
  • 208634001 Closed fracture distal tibia (disorder)