Table of Contents

 

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

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

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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71. Boutis K, Plint A, Stimec J, et al. Radiograph-negative lateral ankle injuries in children: occult growth plate fracture or sprain? JAMA Pediatr. 2016;170(1):e154114. (Prospective; 135 patients)
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75. Herrera-Soto JA, Scherb M, Duffy MF, et al. Fractures of the fifth metatarsal in children and adolescents. J Pediatr Orthop. 2007;27(4):427-431. (Retrospective; 103 fractures)
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77. Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4). 2010. Available at: http://www.acf.hhs.gov/programs/opre/resource/fourth-national-incidence-study-of-child-abuse-and-neglect-nis-4-report-to-0. Accessed August 15, 2017 (Government report)
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80. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-626. (Retrospective; 173 patients)
81. Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):60-66. (Retrospective; 58 patients)
82. Loder RT, Feinberg JR. Orthopaedic injuries in children with nonaccidental trauma: demographics and incidence from the 2000 kids’ inpatient database. J Pediatr Orthop. 2007;27(4):421-426. (Retrospective; 1794 patients)
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87. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010;30(3):253-263. (Meta-analysis; 5154 fractures)
88. Skaggs D, Pershad J. Pediatric elbow trauma. Pediatr Emerg Care. 1997;13(6):425-434. (Review)
89. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008;90(5):1121-1132. (Review)
90. Garg S, Weller A, Larson AN, et al. Clinical characteristics of severe supracondylar humerus fractures in children. J Pediatr Orthop. 2014;34(1):34-39. (Retrospective; 1296 patients)
91. Baratz M, Micucci C, Sangimino M. Pediatric supracondylar humerus fractures. Hand Clin. 2006;22(1):69-75. (Review)
92. Ross G, Cronin R, Hauzenblas J, et al. Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma. 1996;10(2):119-122. (Case report)
93. Joshi N, Lira A, Mehta N, et al. Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a systematic review. Acad Emerg Med. 2013;20(1):1-15. (Review)
94. Barata I, Spencer R, Suppiah A, et al. Emergency ultrasound in the detection of pediatric long-bone fractures. Pediatr Emerg Care. 2012;28(11):1154-1157. (Prospective; 53 patients)
95. Hubner U, Schlicht W, Outzen S, et al. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000;82(8):1170-1173. (Prospective; 163 patients)
96. Dohi D. Confirmed specific ultrasonographic findings of pulled elbow. J Pediatr Orthop. 2013;33(8):829-831. (Prospective; 70 patients)
97. Lee YS, Sohn YD, Oh YT. New, specific ultrasonographic findings for the diagnosis of pulled elbow. Clin Exp Emerg Med. 2014;1(2):109-113. (Retrospective; 141 patients)
98. Roposch A, Reis M, Molina M, et al. Supracondylar fractures of the humerus associated with ipsilateral forearm fractures in children: a report of forty-seven cases. J Pediatr Orthop. 2001;21(3):307-312. (Retrospective; 47 patients)
99. Freed HA, Shields NN. Most frequently overlooked radiographically apparent fractures in a teaching hospital emergency department. Ann Emerg Med. 1984;13(10):900-904. (Retrospective; 162 fractures, 25 pediatric)
100. Chacon D, Kissoon N, Brown T, et al. Use of comparison radiographs in the diagnosis of traumatic injuries of the elbow. Ann Emerg Med. 1992;21(8):895-899. (Retrospective; 25 patients)
101. Skaggs DL, Mirzayan R. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81(10):1429-1433. (Prospective; 45 patients)
102. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010;41(8):862-868. (Prospective; 212 patients)
103. Rabiner JE, Khine H, Avner JR, et al. Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. Ann Emerg Med. 2013;61(1):9-17. (Prospective; 130 patients)
104. Barton KL, Kaminsky CK, Green DW, et al. Reliability of a modified Gartland classification of supracondylar humerus fractures. J Pediatr Orthop. 2001;21(1):27-30. (Prospective; 50 patients)
105. Oudjhane K, Newman B, Oh KS, et al. Occult fractures in preschool children. J Trauma. 1988;28(6):858-860. (Retrospective; 500 patients)
106. Green DW, Mogekwu N, Scher DM, et al. A modification of Klein’s Line to improve sensitivity of the anterior-posterior radiograph in slipped capital femoral epiphysis. J Pediatr Orthop. 2009;29(5):449-453. (Retrospective; 30 patients)
107. Mc Cabe A, McArdle S. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: is ultrasound or plain film radiography a more sensitive diagnostic modality for diagnosing slipped capital femoral epiphysis? Emerg Med J. 2014;31(1):80. (Review)
108. Tins B, Cassar-Pullicino V, McCall I. The role of pre-treatment MRI in established cases of slipped capital femoral epiphysis. Eur J Radiol. 2009;70(3):570-578. (Retrospective; 15 hips)
109. Letts RM. The hidden adolescent ankle fracture. J Pediatr Orthop. 1982;2(2):161-164. (Retrospective; 26 patients)
110. Brandser EA, Berbaum KS, Dorfman DD, et al. Contribution of individual projections alone and in combination for radiographic detection of ankle fractures. AJR Am J Roentgenol. 2000;174(6):1691-1697. (Retrospective; 556 fractures)
111. Eismann EA, Stephan ZA, Mehlman CT, et al. Pediatric triplane ankle fractures: impact of radiographs and computed tomography on fracture classification and treatment planning. J Bone Joint Surg Am. 2015;97(12):995-1002. (Retrospective; 25 fractures)
112. Liporace FA, Yoon RS, Kubiak EN, et al. Does adding computed tomography change the diagnosis and treatment of Tillaux and triplane pediatric ankle fractures? Orthopedics. 2012;35(2):e208-e212. (Retrospective; 24 fractures)
113. Lattermann C, Goldstein JL, Wukich DK, et al. Practical management of Lisfranc injuries in athletes. Clin J Sport Med. 2007;17(4):311-315. (Review)
114. * Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA Pediatr. 1993;269(9):1127-1132. (Prospective; 2342 adults)
115. * Stiell IG, Wells GA, Hoag RH, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA Pediatr. 1997;278(23):2075-2079. (Prospective; 3907 adults)
116. Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009;16(4):277-287. (Systematic review; 3130 patients)
117. Boutis K, Komar L, Jaramillo D, et al. Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: a prospective study. Lancet. 2001;358(9299):2118-2121. (Prospective; 581 patients)
118. Dayan PS, Vitale M, Langsam DJ, et al. Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle. Acad Emerg Med. 2004;11(7):736-743. (Prospective; 717 patients)
119. Gravel J, Hedrei P, Grimard G, et al. Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med. 2009;54(4):534-540. (Prospective; 245 patients)
120. Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa Knee Rule in children: a multicenter study. Ann Emerg Med. 2003;42(1):48-55. (Prospective; 750 patients)
121. Meyer JS, Gunderman R, Coley BD, et al. ACR Appropriateness Criteria^® on suspected physical abuse-child. J Am Coll Radiol. 2011;8(2):87-94. (Practice guideline)
122. American College of Radiology (ACR) Society for Pediatric Radiology (SPR). ACR–SPR practice guideline for skeletal surveys in children. Amended 2014, Resolution 39. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Skeletal_Surveys.pdf. Accessed August 15, 2017. (Practice guideline)
123. Lindberg D, Makoroff K, Harper N, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009;124(2):509-516. (Prospective; 1272 patients)
124. Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013;131(2):268-275. (Retrospective; 2890 patients)
125. Fitch MT, Nicks BA, Pariyadath M, et al. Videos in clinical medicine. Basic splinting techniques. N Engl J Med. 2008;359(26):e32. (Review)
126. Halsey MF, Finzel KC, Carrion WV, et al. Toddler’s fracture: presumptive diagnosis and treatment. J Pediatr Orthop. 2001;21(2):152-156. (Retrospective; 59 patients)
127. Sendher R, Ladd AL. The scaphoid. Orthop Clin North Am. 2013;44(1):107-120. (Review)
128. Carpenter CR, Pines JM, Schuur JD, et al. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-121. (Meta-analysis; 75 studies)
129. Gholson JJ, Bae DS, Zurakowski D, et al. Scaphoid fractures in children and adolescents: contemporary injury patterns and factors influencing time to union. J Bone Joint Surg Am. 2011;93(13):1210-1219. (Retrospective; 351 patients)
130. Doornberg JN, Buijze GA, Ham SJ, et al. Nonoperative treatment for acute scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. J Trauma. 2011;71(4):1073-1081. (Systematic review; 523 patients)
131. Schramm JM, Nguyen M, Wongworawat MD, et al. Does thumb immobilization contribute to scaphoid fracture stability? Hand (NY). 2008;3(1):41-43. (Prospective; 6 specimens)
132. Beaty JH. Fractures of the proximal humerus and shaft in children. Instr Course Lect. 1992;41:369-372. (Review)
133. Do TT, Strub WM, Foad SL, et al. Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. J Pediatr Orthop B. 2003;12(2):109-115. (Retrospective; 34 fractures)
134. Boutis K, Willan A, Babyn P, et al. Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial. CMAJ. 2010;182(14):1507-1512. (Prospective; 96 patients)
135. Khan S, Sawyer J, Pershad J. Closed reduction of distal forearm fractures by pediatric emergency physicians. Acad Emerg Med. 2010;17(11):1169-1174. (Prospective; 103 patients)
136. McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med. 1999;6(7):715-718. (Prospective; 135 patients)
137. Green DA, Linares MY, Garcia Pena BM, et al. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg Care. 2006;22(4):235-238. (Prospective; 63 patients)
138. Bek D, Yildiz C, Kose O, et al. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial. Eur J Emerg Med. 2009;16(3):135-138. (Prospective; 66 patients)
139. Guzel M, Salt O, Demir MT, et al. Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation. Niger J Clin Pract. 2014;17(2):201-204. (Prospective; 71 patients)
140. Kircher J, Drendel AL, Newton AS, et al. Acute pediatric musculoskeletal pain management in North America: a practice variation survey. Clin Pediatr (Phila). 2014;53(14):1326-1335. (Survey)
141. Thompson RW, Krauss B, Kim YJ, et al. Extremity fracture pain after emergency department reduction and casting: predictors of pain after discharge. Ann Emerg Med. 2012;60(3):269-277. (Prospective; 202 patients)
142. Summary minutes of the Joint Pulmonary-Allergy Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee meeting. 2015. Available at: https://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/drugs/pulmonary-allergydrugsadvisorycommittee/ucm482005.pdf. Accessed August 15, 2017. (Report)
143. * Tobias JD, Green TP, Coté CJ. Codeine: time to say “no”. Pediatrics. 2016;138(4). (Statement)
144. Niesters M, Overdyk F, Smith T, et al. Opioid-induced respiratory depression in paediatrics: a review of case reports. Br J Anaesth. 2013;110(2):175-182. (Review of case reports; 27 patients)
145. Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987;58(1):71-74. (Prospective; 61 patients)
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147. American Academy of Orthopaedic Surgeons. Appropriate use criteria for the management of pediatric supracondylar humerus fractures. http://www.aaos.org/research/Appropriate_Use/PSHF_AUC.pdf. Accessed August 15, 2017 (Criteria)
148. Battaglia TC, Armstrong DG, Schwend RM. Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus. J Pediatr Orthop. 2002;22(4):431-439. (Retrospective; 29 patients)
149. Peterson MD, Weiner DS, Green NE, et al. Acute slipped capital femoral epiphysis: the value and safety of urgent manipulative reduction. J Pediatr Orthop. 1997;17(5):648-654. (Retrospective; 91 patients)
150. Sarraf KM, Sadri A, Thevendran G, et al. Approaching the ruptured anterior cruciate ligament. Emerg Med J. 2011;28(8):644-649. (Review)
151. Bauer JM, Lovejoy SA. Toddler’s fractures: time to weight-bear with regard to immobilization type and radiographic monitoring. J Pediatr Orthop. 2017. (Retrospective; 192 patients)
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153. Wenger DR, Ward WT, Herring JA. Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 1991;73(5):778-788. (Review)
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Pediatric Orthopedic Injuries: Evidence-Based Management in the Emergency Department - Calculated Decisions - Trauma CME

The Ottawa Ankle Rule shows the areas of tenderness to be evaluated in ankle trauma patients to determine the need for imaging.The Ottawa Knee Rule describes criteria for knee trauma patients who are at low risk for clinically significant fracture and do not warrant knee imaging.

1. Ottawa Ankle Rule
2. Ottawa Knee Rule

Ottawa Ankle Rule

• Introduction
• Points & Pearls
• Advice
• Why and When to Use, Next Steps and Management
• Calculator Review Author
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References

Introduction

The Ottawa Ankle Rule shows the areas of tenderness to be evaluated in ankle trauma patients to determine the need for imaging.

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Points & Pearls

• The Ottawa Ankle Rule was derived to aid in the efficient use of radiography in the acute ankle and midfoot injuries.
• It has been prospectively validated on multiple occasions in different populations and in both children and adults.
• Sensitivities for the Ottawa Ankle Rule range from the high 90% to 100% range for “clinically significant” ankle and midfoot fractures. This is defined as a fracture or an avulsion > 3 mm.
• Specificities for the Ottawa Ankle Rule are approximately 41% for the ankle and 79% for the foot, although the rule is not designed or intended to make a specific diagnosis.
• The Ottawa Ankle Rule is useful in ruling out fracture (high sensitivity), but does poorly at ruling in fractures (many false positives).

Advice

Tips from the creators at the University of Ottawa:

• Palpate the entire distal 6 cm of the fibula and tibia.
• Do not overlook the importance of medial malleolar tenderness.
• “Bearing weight” counts even if the patient limps.
• Use with caution in patients aged < 18 years.

Precautions from the creators at the University of Ottawa:

• Clinical judgment should prevail if the examination is unreliable due to:
  » Intoxication
  » Uncooperative patient
  » Distracting painful injuries
  » Diminished sensation in legs
  » Gross swelling that prevents palpation of malleolar tenderness
• Always provide written instructions.
• Encourage followup in 5 to 7 days if pain and ability to walk do not improve.

Why and When to Use, Next Steps and Management

Calculator Review Author

Calvin Hwang, MD

Critical Actions

Patients who fulfill none of the Ottawa Ankle Rule criteria do not need an ankle or foot x-ray. Patients who fulfill either the foot or ankle criteria need an xray of the respective body part. Many experts would consider this score “one directional.” Because the rule is sensitive and not specific, it provides a clear guide of which patients do not need x-ray if all criteria are met; however, if a patient fails the criteria, the need for x-ray can be left to clinical judgment.

Evidence Appraisal

The original derivation study in 1992 included nonpregnant patients aged > 18 years who presented to Ottawa civic and general hospitals with a new injury < 10 days old. The initial pilot study included 155 patients, while the full-scale study included 750 patients. Any fracture that was not an avulsion of ≤ 3 mm was considered a clinically significant fracture. This resulted in the initial criteria: aged ≥ 55 years, inability to bear weight immediately after the injury and for 4 steps in the emergency department, or bone tenderness at the posterior edge or tip of either malleolus for the ankle. For the foot, criteria included pain in the midfoot and bone tenderness at the navicular bone, cuboid, or the base of the fifth metatarsal.

Further validation and refinement was completed in 1993, through a prospective study of 1032 patients in the validation and refinement phase of the study with 121 clinically significant fractures. The rules were further refined by removing the age cutoff from the ankle rule and cuboid tenderness from the foot rule, but the weight-bearing criterion was added to the foot rule. Sensitivity of the refined rule for both foot and ankle fractures was 100%, and ankle specificity increased to 41% and foot specificity to 79%.

An additional 453 patients were then prospectively enrolled in the second phase of the study, where the refined rules were validated, yielding a sensitivity of 100% for both ankle and midfoot fractures.

A study of 670 children aged 2 to 16 years at 2 separate sites found that the Ottawa Ankle Rule again had a sensitivity of 100% for both clinically significant ankle and midfoot fractures. This study also found that ankle x-rays could be reduced by 16% and foot x-rays by 29% if the rules were in use at the time of the study. Subsequent meta-analysis of the Ottawa Ankle Rule in children found 12 studies with 3130 patients and 671 fractures, with a pooled sensitivity of 98.5% and an overall reduction in x-ray utilization by 24.8%.

Calculator Creator

Ian Stiell, MD, MSc, FRCPC

References

Original/Primary Reference

• Stiell IG, Greenberg GH, McKnight RD, et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384-390.

Validation

• Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9):1127- 1132.

Other References

• Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827- 832.
• Stiell IG, Wells G, Laupacis A, et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. BMJ. 1995;311(7005):594-597.
• Plint AC, Bullock B, Osmond MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999;6(10):1005-1009.
• Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417.

Ottawa Knee Rule

• Introduction
• Points & Pearls
• Advice
• Why and When to Use, and Next Steps
• Calculator Review Author
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References

Introduction

The Ottawa Knee Rule describes criteria for knee trauma patients who are at low risk for clinically significant fracture and do not warrant knee imaging.

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Points & Pearls

• The Ottawa Knee Rule was derived to aid in the efficient use of radiography in acute knee injuries.
• It has been prospectively validated on multiple occasions in different populations and in both children and adults.
• Numerous studies found sensitivities for the Ottawa Knee Rule of 98% to 100% for clinically significant knee fractures. One study did find a sensitivity of just 86%.
• Specificities for the Ottawa Knee Rule typically range from 19% to 50%, although the rule is not designed or intended for specific diagnosis.
• When the Ottawa Knee Rule is used appropriately, the number of knee x-rays obtained can be reduced by 20% to 30%.
• The Ottawa Knee Rule is useful in ruling out fracture when negative (high sensitivity), but does poorly at ruling in fractures (many false positives).

Advice

Tips from the creators at the University of Ottawa:

• Tenderness of the patella is significant only if it is an isolated finding.
• Use only for injuries with a duration of < 7 days.
• “Bearing weight” counts even if the patient limps.

Precautions from the creators at the University of Ottawa:

• Clinical judgment should prevail if the examination is unreliable due to:
  » Intoxication
  » Uncooperative patient
  » Distracting painful injuries
  » Diminished sensation in legs
• Always provide written instructions.
• Encourage followup in 5 to 7 days if pain and ability to walk do not improve.

Why and When to Use, and Next Steps

Calculator Review Author

Calvin Hwang, MD

Critical Actions

Patients who do not have any of the Ottawa Knee Rule criteria present do not need an x-ray. If 1 or more of the conditions are met, then an x-ray is recommended.

Many experts would consider this score “one directional.” Because the rule is sensitive and not specific, it provides a clear guide of which patients do not need x-ray if all criteria are met; however, if a patient fails the criteria, the need for x-ray can be left to clinical judgment.

Evidence Appraisal

The original derivation study by Stiell et al was done in 1995 and included non-pregnant patients aged > 18 years who presented to Ottawa civic and general hospitals with a new injury < 7 days old as a result of acute blunt trauma to the knee. The study enrolled 1054 subjects, of whom 68 had fractures, with 66 of them deemed to be clinically significant (not a simple avulsion fragment of < 5 mm in breadth without associated complete tendon or ligament disruption). Using recursive-partitioning techniques, the authors derived the 5 variables of their decision rule. If applied to the study population, their decision rule had sensitivity of 100% and specificity of 54% for identifying fractures and would lead to a 28% relative reduction in x-ray utilization.

Stiell et al then prospectively validated their decision rule in the same patient population. They performed telephone followup 14 days after the emergency department visit to determine the possibility of a missed fracture. Sensitivity of the decision rule was again 100%, identifying 63 clinically important fractures out of 1096 patients. Specificity was similar to the derivation study at 49%, and there was a 28% relative reduction in x-ray utilization.

Stiell et al prospectively implemented the decision rule in different teaching and community emergency departments. They found a relative reduction in x-ray usage of 26.4%, while maintaining a sensitivity of 100% for detecting 58 knee fractures out of 3907 patients, and a specificity of 48%. Moreover, there was a significant reduction in time to discharge and total medical charges in patients who did not get an x-ray.

The Ottawa Knee Rule has also been prospectively validated in populations outside of Canada. Two studies, 1 done in Spain and another in the United States, found that the Ottawa Knee Rule had a sensitivity of 100% and 98%, specificity of 52% and 19%, and a reduction in x-ray usage by 49% and 17%.

The rule was applied to children aged 2 to 16 years in a prospective, multicenter validation study in 2003. That study found the decision rule to be 100% sensitive in finding 70 fractures out of 750 children, with a specificity of 42.8% and a potential reduction in x-ray usage by 31.2%.

The Ottawa Knee Rule has also been compared to the Pittsburgh Decision Rule, another wellvalidated clinical decision rule. A cross-sectional comparison of the 2 rules showed that both had sensitivities of 86%, although the Pittsburgh Decision Rule was significantly more specific. However, this study only included patients aged 18 to 79 years and excluded pediatric patients.

Calculator Creator

Ian Stiell, MD, MSc, FRCPC

References

Original/Primary Reference

• Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26(10):405-413.

Validation

• Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996;275(8):611-615.
• Emparanza JI, Aginaga JR. Validation of the Ottawa knee rules. Ann Emerg Med. 2001;38(4):364-368.

Other References

• Steill IG, Wells GA, Hoag RG, et al. Implementation of the Ottawa knee rule for the use of radiography in acute knee injuries. JAMA. 1997;278(23):2075-2079.
• Bachmann LM, Haberzeth S, Steurer J, et al. The accuracy of the Ottawa knee rule to rule out knee fractures. Ann Intern Med. 2004;140(2):121-124.
• Nichol G, Stiell IG, Wells GA, et al. An economic analysis of the Ottawa knee rule. Ann Emerg Med. 1999;34(4):438-447.
• Stiell IG, Wells GA, McKnight RD. Validating the “real” Ottawa knee rule. Ann Emerg Med. 1999;33(2):241-243.
• Tigges S, Pitts S, Mukundan S Jr, et al. External validation of the Ottawa knee rules in an urban trauma center in the United States. AJR Am J Roentgenol. 1999;172(4):1069- 1071.
• Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa knee rule in children: A multicenter study. Ann Emerg Med. 2003;42(7):48-55.
• Cheung TC, Tank Y, Breederveld RS, et al. Diagnostic accuracy and reproducibility of the Ottawa knee rule vs the Pittsburgh decision rule. Am J Emerg Med. 2013;31(4):641-645

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