Authors: 
Moira Davenport, MD
Chad Nesbit, MD, PhD

Peer Reviewers: 
Craig A. McElderry, MD  
Paula J. Whiteman, MD, FACEP, FAAP

 Publication Date: 
May 2009; Volume 6, Number 5

Excerpt from the issue… 

You are working the Friday night shift when the triage nurse tells you that a 4-year-old-boy has been brought in by his parents because he is refusing to walk. The nurse tells you that the boy looks “pale and sweaty” in his dad’s arms. On your examination you find an ill-appearing child who is very irri­table, febrile, and complaining that his right hip hurts. You order acetamino­phen, fluids, a CBC and a hip x-ray. Half an hour later, the child is resting more comfortably but still complaining of hip pain and refusing to move his leg. Although he looks better, you ask yourself, “Do I need to do anything more here?” 

Your next patient is a 5-year-old girl who is holding her right forearm and refusing to use her hand. Her mother tells you that the patient and her 8-year-old brother were playing on the swings and jumped off, landing on outstretched hands. The 8-year-old notes pain to his left elbow. He is also hesitant to use the extremity. Neither has any other obvious trauma. Are x-rays needed? What common injury should be suspected for each sibling? What is the best treatment modality?

Your third patient is a 14-year-old football player who has significant left knee pain after falling on his flexed knee during a tackle. He is not able to walk due to the pain. What condition should you consider in addition to patellar fracture or dislocation? How is this diagnosed?

The fourth patient to present is a 15-year-old male noting increasing left knee pain over the last 1 to 2 months. His pain is increasing to the point that he has difficulty ambulating. What conditions should be considered in this case? What imaging should be performed? What is the prognosis for this condition?

Orthopedic injuries are a common presenting condition to emergency departments (EDs), with both pediatric and adult patients affected. Neu­rovascular status is of paramount concern in these injuries. However, structural differences between growing and mature bone (as well as tendons and ligaments) mandate that particular attention be paid to the pediatric patient to ensure that subtle age related injuries are not missed.

This issue of Pediatric Emergency Medicine Practice focuses on the challenge of evaluating and manag­ing the pediatric orthopedic patient and highlights conditions with which the ED clinician may not have significant experience. Many of these injuries are of the simple “bumps and bruises” variety and require little more than ice, pain control, and education about the injury. However, there are some diagnoses that require truly emergent care in order to salvage a limb or prevent future loss of function. Differentia­tion between the urgent and emergent patient may not be overtly obvious. This article will focus on the available literature with the caveat that much of the information available is based on small case studies and retrospective reviews. By raising clinician aware­ness of these conditions and applying the available evidence, the ED clinician can work to ensure the best possible outcome for pediatric orthopedic patients.