Fractures, Pediatric, Emergency Medicine

Basics

Description

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 shaft
- Epiphysis: Cartilaginous center at or near end of bone that is site of bone growth
- Epiphyseal (growth) plate: Radiolucent line between epiphysis and metaphysis; cartilaginous
- Metaphysis: Region of rapidly growing trabecular bone underlying base of cartilaginous growth plate; between diaphysis and epiphysis
- Most 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 impact
- Torus (buckle) fracture:
  - Usually at junction of metaphysis and diaphysis
  - Compression of bone of 1 cortex
- Plastic deformity:
  - Bowing without disruption of cortex
- Fractures 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 plate
  - Tenderness and pain at point of growth plate
  - Radiograph typically normal
  - Growth disturbance is rare.
- Type II:
  - Metaphyseal fracture extending to physis
  - Most common
  - Growth disturbance is rare.
- Type III:
  - Intra-articular fracture extending through the epiphysis into the physis
  - Most common site is distal tibial epiphysis.
  - Growth disturbance possible
- Type IV:
  - Epiphyseal, physeal, and metaphyseal fracture
  - Lateral condyle of humerus is the most common site.
  - Growth disturbance highly likely
- Type V:
  - Crush injury to epiphyseal plate, producing growth arrest
  - Usually 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 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

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, foot
- Pain with passive stretching of fingers or toes
- Sensory deficit in the distal extremity
- Cool extremity
- Pulseless 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/sensation
- Distal pulses
- Capillary 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 supracondylar
- 10-15% 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 fracture
- May need tangential view radiograph or bone scan to diagnose
- Splint 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 bracing
- Activity 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 malignancy
- Pediatric patients with leukemia may present with limp as their initial complaint
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

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 fracture
- Femoral 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.

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)

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