Management of orthopedic injuries in the ED starts with pain control for patient comfort and optimal evaluation. Once pain control is established and the clinical evaluation is complete, management decisions center around whether operative or nonoperative care is necessary to stabilize the fracture (Fig. 29-3). Traditionally, most pediatric fractures have been managed by conservative, nonoperative means due to their tremendous ability to remodel and heal. Most are managed by closed reduction, if necessary, and then sent home with appropriate immobilization. Operative repair is necessary in some situations, and consultation with an orthopedist is always recommended for Salter–Harris III and IV fractures, most tibia fractures, all femur fractures, supracondylar fractures, and any fracture with significant displacement. Emergent orthopedic consultation is required if there are any signs of neurovascular compromise, compartment syndrome, or the possibility of an open fracture. When present, compartment syndrome is limb-threatening and most often occurs in the forearm and lower leg. Early symptoms include pain out of proportion to the injury or extreme pain with passive range of motion. Do not wait for late signs such as pallor, pulselessness, and paresthesias before consulting orthopedics. Open fractures need irrigation, antibiotics, and appropriate tetanus prophylaxis in the ED while awaiting orthopedic consultation.
Algorithm for the management of physis injuries in children.
The hallmarks of nonsurgical fracture care are closed reduction and immobilization. Closed reduction is necessary for significantly displaced or angulated fractures. Reduction is often performed by orthopedists, but can also be performed by appropriately trained emergency physicians in many hospitals. The use of procedural sedation is strongly recommended for any attempts at fracture reduction.
Once a fracture has been reduced, or if it was initially nondisplaced, the fracture is immobilized. Immobilization offers protection, decreases the risk for any further displacement, and improves patient comfort. The most common types of immobilization involve plaster, fiberglass or commercial splints. Casts are avoided by many in the ED because of the risks associated with progressive swelling in acute injuries. The types of splints differ in the degree of molding allowed, the ease of application, and the ability to properly immobilize the injury. A sling and swathe provide immobilization for injuries of the clavicle, shoulder, and humerus. For supracondylar, elbow, forearm, and wrist injuries, a posterior long-arm splint with the elbow at 90 degrees and the hand in neutral works well. An ulnar gutter splint best immobilizes fractures of the fourth and fifth metacarpals. The scaphoid and thumb are immobilized with a thumb spica splint. Fractures to the distal femur, knee, and majority of the tibia require a long-leg posterior splint. Ankle and foot injuries can usually be immobilized in a posterior short-leg splint. When in doubt, always immobilize the joint proximal and distal to the injury.
The final step in caring for orthopedic injuries is to remember proper discharge instructions, and their importance cannot be overemphasized. Discharge instructions need to include information on splint/cast care, indications for returning to the ED, specific follow-up plans, and outpatient pain management. Elevation and ice are important to control pain and decrease swelling. Returning to the ED is emphasized for specific findings such as changes in extremity color, severe swelling, or a marked increase in pain. Follow-up plans should be clear and within 1 week due to the rapid rate of healing in children. Outpatient pain control is also very important and should not be overlooked in children. Fractures and significant injuries need pain control to last until their orthopedic follow-up. Proper discharge instructions result in optimal patient care and fewer unnecessary returns to the ED.6
Nonaccidental trauma is a major concern in pediatrics, and one that often presents with an orthopedic injury. About 25% to 50% of abused children will have some type of fracture. Before 1 year of age, one out of every three fractures is nonaccidental, and before 18 months of age, it is one out of every nine fractures.7 The younger the patient with a fracture, the higher the suspicion should be for possible abuse (Table 29-3). Recent evidence shows the most common fracture with abuse is the routine transverse fracture (Fig. 29-4).10 The biggest clue is not the fracture type, but the inconsistent history. Any history that appears inconsistent with the type or degree of injury or the child's developmental stage should raise concerns about possible abuse. The law in all 50 states requires physicians to report any concerns about nonaccidental trauma to the proper authorities for further investigation. Any suspicion of nonaccidental trauma in young children requires a skeletal survey and hospital admission for further evaluation. The skeletal survey should include the long bones of the skeleton along with the hands, feet, spine, and pelvis. Significant numbers of occult fractures can be missed if all views are not included.8
TABLE 29-3Radiographic Findings Suggestive of Nonaccidental Trauma ||Download (.pdf) TABLE 29-3 Radiographic Findings Suggestive of Nonaccidental Trauma
Very High Index of Suspicion
Any fracture with an inconsistent history or evasive explanation
Metaphysis fractures (i.e., the “corner” or “bucket-handle” fracture)
Rib or spinous process fractures
Transphyseal distal humerus fractures
Fractures at various stages of healing
High Index of Suspicion
Less Suspicion with Plausible History
These are rare fractures which are often referred to as classics in nonaccidental trauma. A. Illustrates a “bucket-handle” fracture of the distal tibia. B. Illustrates a “corner” fracture of the distal femur. C. Illustrates a lumbar fracture of L-2.
Fractures from Birth Trauma
Fractures seen within the first few weeks of life may be due to birth trauma. Many of these fractures are found accidentally on chest x-rays, in evaluations for not moving an extremity, or due to parental concerns about a “bump.” The most common fracture from birth trauma involves the clavicle, but fractures of the femur and humerus are not uncommon. Healing from birth injuries is rapid, and callus should be seen within 2 weeks of delivery. A lack of callus formation within this time line or an absent history of traumatic delivery requires closer investigation for possible nonaccidental trauma.
Pediatric Sports Injuries
Over half of all children and adolescents participate in organized sports and many more participate in less-organized individual sports such as skateboarding, bicycling, and “extreme sports.” Previous data indicate more than 20% of all pediatric injury–related visits are sports-related. These injuries include fractures, dislocations, contusions, sprains, strains, lacerations, and other injuries quite familiar to the ED physician.11–13 A number of sports-related musculoskeletal injuries are discussed below, but also remember many sports-related injuries may involve multi-system injuries (abdominal trauma, concussion, dental injury, etc.) and are discussed elsewhere in this textbook.
Fractures are extremely common in youth sports. A recent study shows 10% of high school sports injuries involve a fracture and is even greater in the younger athlete.14As the growth plate begins to close during adolescence, both fractures and sprains may occur depending upon the forces involved. Adolescents are more prone to unique fracture patterns like the SH III and IV which often involve a partially closed physis. Keep in mind the stage of the growing skeleton when evaluating sports injuries, and remember “the younger the athlete, the more likely it's a fracture!”15
Avulsion fractures are fairly unique to adolescents and most commonly occur in sporting activities. These injuries occur when a stronger tendon from a large muscle group adheres to a weaker area of bone called a secondary ossification centers or apophysis. When a strong muscular contraction occurs, this tendon actually “pulls” the apophysis off from the larger piece of bone. The most common site for avulsion fractures is the pelvis at either the iliac crest, anterior inferior iliac spine (AIIS), anterior superior iliac spine (ASIS), or the ischium (Fig. 29-5). Avulsions are occasionally seen at the tibial tubercle, greater and lesser trochanters, and phalanges. A unique avulsion of the knee is the tibial spine (eminence) avulsion which occurs following hyperextension. Management of avulsion fractures is usually nonoperative, but surgical repair may be necessary if there is a significant avulsion or intra-articular displacement. Most pelvic avulsion fractures are managed with crutches and non–weight-bearing for 4 to 6 weeks.16
A 13-year-old girl who presented to the ED because of inability to bear weight after feeling a “pop” while doing the splits during gymnastics. Radiographs revealed an avulsion of her ischium.