Pediatric Orthopedic Injuries: Diagnosis and Treatment
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Pediatric Orthopedic Injuries: Evidence-Based Management in the Emergency Department

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Table of Contents
 
About This Issue

Orthopedic injuries in children can be challenging to diagnose and treat due to the physiologic and skeletal differences between infants, children, adolescents, and adults. This issue reviews:

Upper and lower extremity fractures and injuries that are common in children

Optimal physical examination techniques for children of different ages with extremity injuries

Recommended splints and casts

Guidance on choosing urgent/emergent orthopedic consultation versus ED management

Identification and management of the child with injuries from suspected abuse

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Epidemiology, Etiology, and Pathophysiology
    1. Child-Specific Fractures
      1. Plastic Deformation (Bowing Fracture)
      2. Greenstick Fracture
      3. Torus Fracture
      4. Physeal Fracture
      5. Apophyseal Injuries
    2. Upper Extremity Injuries
      1. Clavicle Fractures
      2. Proximal Humerus Fractures
      3. Humerus Shaft Fractures
      4. Elbow Fractures
      5. Forearm Fractures
      6. Wrist Fractures
      7. Hand Fractures
    3. Lower Extremity Injuries
      1. Hip Fractures
      2. Slipped Capital Femoral Epiphysis
      3. Femur Fractures
      4. Knee Fractures
      5. Lower-Leg Fractures
      6. Ankle Fractures
      7. Foot Fractures
    4. Nonaccidental Injuries
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Upper Extremity Examination
      2. Lower Extremity Examination
  9. Diagnostic Studies
    1. Imaging of Injuries to Upper Extremities
    2. Imaging of Injuries to Lower Extremities
      1. Clinical Decision Rules
    3. Imaging in Suspected Nonaccidental Injury
  10. Treatment
    1. Splints and Casts
    2. Reduction
    3. Pain Control
    4. Other Treatments/Techniques
    5. Management of Nonaccidental Injury
  11. Special Circumstances
    1. Pre-existing Conditions
    2. Legg-Calvé-Perthes Disease
    3. Open Fractures
    4. Compartment Syndrome
  12. Controversies and Cutting Edge
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in the Management of Pediatric Patients With Orthopedic Emergencies
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway for the Evaluation of the Pediatric Patient With Traumatic Limb Pain
  19. Tables and Figures
    1. Table 1. Phases of the Fracture Healing Process
    2. Table 2. Common Sites of Apophysitis
    3. Table 3. Ossification Centers of the Elbow - CRITOE Mnemonic
    4. Table 4. Differential Diagnosis of Limb Pain in a Child
    5. Table 5. Splints Used for Upper Extremity Injuries
    6. Table 6. Splints Used for Lower Extremity Injuries
    7. Figure 1. Pediatric Long-Bone Anatomy
    8. Figure 2. Greenstick Fracture and Plastic Deformity
    9. Figure 3. Torus Fractures of the Distal Radius and Ulna
    10. Figure 4. Salter-Harris Classification of Physeal Injuries
    11. Figure 5. Avulsion Fracture of the Right Ischial Tuberosity
    12. Figure 6. Triplane Fracture of the Distal Right Tibia in a 13-Year-Old Boy
    13. Figure 7. Multiple Fractures in Various Stages of Healing, Indicative of Physical Abuse
    14. Figure 8. Elbow Radiographs Depicting Anterohumeral and Radiocapitellar Lines
    15. Figure 9. Radiographs of an 11-Year-Old Girl With a Left-Sided Slipped Capital Femoral Epiphysis
  20. References

Abstract

Upper and lower extremity injuries are common in children, with an overall risk of fracture estimated at just under 1 in 5 children. Pediatric bone anatomy and physiology produce age-specific injury patterns and conditions that are unique to children, which can make accurate diagnosis difficult for emergency clinicians. This issue reviews the etiology and pathophysiology of child-specific fractures, as well as common injuries of the upper and lower extremities. Evidence-based recommendations for management of pediatric fractures, including appropriate diagnostic studies and treatment, are also discussed.

Case Presentations

A 12-year-old obese boy presents with 1 week of progressively worsening right hip pain. He has no fever or history of trauma. He went to his primary care physician earlier in the week and was diagnosed with a hip strain, but his pain has continued to worsen. He is now unable to bear weight on the right leg. Physical examination reveals a well-appearing boy with no tenderness to palpation about the hip joint, femur, or knee, but markedly decreased internal rotation of the right hip. Neurovascular examination of the right lower extremity is normal. You wonder: What is the most likely cause of this child’s pain? What laboratory or imaging studies will be most useful for diagnosis and management? Should this child be allowed to continue bearing weight? Does he need an urgent orthopedic consultation?

A 3-year-old girl presents after a fall onto her outstretched left hand. She is using the left arm much less than usual. Physical examination reveals minimal swelling at the elbow. She flinches with palpation over any part of the elbow, but has no tenderness over the distal forearm or shoulder. She can move her thumb and fingers spontaneously. Radiographs of the left elbow show no fracture. You wonder if this girl could possibly have a nursemaid’s elbow. Should you be looking for something else on these radiographs? Do you need to get additional radiographs?

A 3-month-old boy is brought to the ED by his mother, who states that he seems to be moving his right arm less than usual today. Physical examination reveals a happy, interactive child with slightly decreased spontaneous movement of the right arm, but no apparent point tenderness to palpation along the extremity or shoulder. Grip strength in the right hand is normal. No bruises are noted. You try to obtain further history regarding a possible mechanism of injury, but the mother states she does not know of any traumatic incidents. What other questions should you ask? How concerned should you be about a possible fracture? You begin to think about nonaccidental injury. If you find a fracture in this child, what additional workup would be appropriate?

Introduction

Orthopedic complaints account for approximately 15% of the 5.3 million annual pediatric visits to United States emergency departments (EDs).1 The anatomic and physiologic differences between the adult and pediatric skeletal system result in injury and disease patterns that are specific to children, and this can present diagnostic challenges. In addition to specific fracture and injury patterns in children, emergency clinicians should understand potentially nontraumatic conditions, such as slipped capital femoral epiphysis (SCFE). The possibility of nonaccidental injuries in children should always be on the differential, guided by an understanding of particular historical elements and physical examination findings that may heighten concern. This issue of Pediatric Emergency Medicine Practice provides an overview of various pediatric fractures and injuries, as well as practical recommendations for appropriate management.

Critical Appraisal of the Literature

A literature review was performed in PubMed for articles on pediatric orthopedic emergencies published from 1966 to 2017. Keywords included: pediatric + fracture + ankle, clavicle, elbow, femur, foot, forearm, hand, hip, humerus, knee, and wrist; buckle fracture, child abuse, compartment syndrome, emergency pediatric orthopedics, Legg-Calvé-Perthes disease, Lisfranc injury, nonaccidental trauma, patellar avulsion, patellar sleeve fracture, radial head subluxation, slipped capital femoral epiphysis, supracondylar humerus fracture, tibial spine fracture, toddler fracture, and torus fracture. Additional articles were identified and reviewed based on references from the initial search results. Over 800 total articles were reviewed, 157 of which were determined to be relevant to this topic. A search for relevant policy statements on pediatric orthopedic conditions by the American College of Emergency Physicians (ACEP), the American Academy of Orthopedic Surgeons (AAOS), the American Academy of Pediatrics (AAP), the American College of Radiology (ACR), and the National Guideline Clearinghouse (www.guideline.gov) yielded 4 results: 3 regarding suspected child physical abuse, and 1 on management of pediatric supracondylar humerus fractures.

The current literature on diagnosis and management of acute pediatric orthopedic conditions is based primarily on case reports and retrospective reviews. Some prospective studies have been performed that address decision rules for ankle and knee radiography, management of subluxation of the radial head, management of torus fractures, and point-of-care ultrasound for fracture diagnosis. A few smaller prospective studies have addressed knee effusions in children and the significance of the posterior fat pad in elbow trauma.

Risk Management Pitfalls in the Management of Pediatric Patients With Orthopedic Emergencies

1.“The patient complained only of wrist pain, so I just ordered x-rays of the wrist.”

Fractures of the forearm may be accompanied by other injuries in the same extremity, such as a supracondylar fracture. Physical examination should extend to the joint above and the joint below the area of interest, thereby guiding appropriate imaging. While radiographs of the joints above and below do not need to be ordered as reflex, a thorough examination of adjacent joints and working knowledge of fracture patterns that involve other joints are important.

2. “The patient was complaining of worsening pain, and the pain medication doesn’t seem to be helping. I told him to elevate his arm further.”

Severe, worsening pain may be an indication of compartment syndrome, which can progress rapidly to significant morbidity. Appropriate actions in the setting of possible compartment syndrome include frequent serial re-evaluation, removal of external compression, avoidance of limb elevation, appropriate analgesia, measurement of compartment pressures, and emergent orthopedic consultation if suspicion for compartment syndrome persists.

3. “The patient has pain over the lateral elbow, but the ossification centers look normal on xray.”

Pediatric elbow radiographs can be difficult to interpret due to the numerous ossification centers that appear at different ages. Contralateral images can help differentiate fractures from normal development. Lateral condyle fractures are often operative and must not be missed.

4. “The child was tender over the lateral malleolus, but the x-ray looked normal, so I treated it like a sprain.”

The presence of open growth plates in children makes interpretation of radiographs more challenging. A Salter-Harris type I fracture, which traverses through the growth plate, may not be visible radiographically due to the cartilaginous nature of the physis. Point tenderness over a physis should be managed as a physeal fracture in most bones.

5. “She has wrist pain, but no fracture was seen on wrist x-rays, so her wrist can't be broken.”

Scaphoid fractures may not be visible on standard wrist radiographs, and can be associated with poor healing if not properly managed. Examination of a child with wrist pain should include palpation of the anatomic snuffbox, and tenderness in that area should prompt specific imaging of the wrist in ulnar deviation to better visualize the scaphoid. If the area over the scaphoid is tender, regardless of whether a fracture is noted on imaging, immobilization and orthopedic follow-up are needed, given the high rate of nonunion.

6. “The patient was complaining that he was experiencing pain in his knee, but the knee x-ray was normal and the knee exam was benign.”

Children with SCFE can present with only knee pain. Any patient with a complaint of knee pain should undergo thorough examination of the hip as well.

7. “The AP view of his wrist was normal, so I didn’t want to order additional x-rays.”

Extremity radiographs should always include at least 2 views. Torus fractures of the distal radius can be quite subtle, and may be visible only on 1 view.

8. “I didn’t want to make the child uncomfortable, so I didn't remove the splint for the examination.”

Evaluation of any patient with a suspected or known fracture should include visualization of the skin all around the extremity as well as inspection for swelling, ecchymosis, and neurovascular status.

9. “The wound on her forearm was tiny, so I just cleaned it and put a bandage on it.”

Open fractures may be accompanied by small wounds. Thorough visual examination of the affected extremity is necessary for diagnosis.

10. “The parents aren’t sure how this 3-month-old baby broke her arm.”

Any fracture inconsistent with the child’s developmental abilities, as well as lack of an adequate explanation for a significant injury should raise concern for nonaccidental injury.

Tables and Figures

Table 1. Phases of the Fracture Healing Process

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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