Pediatric Orthopedic Injuries: Evidence-Based Management in the Urgent Care (Trauma CME and Pain Management CME)

Table of Contents

 

About This Issue

Orthopedic injuries in children can be challenging to diagnose and treat in the urgent care setting due to the physiologic and skeletal differences between infants, children, adolescents, and adults. In this issue, you will learn:

The most common upper and lower extremity fractures in children

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

Which x-ray views to order based on the location of the injury

Key radiographic features associated with common pediatric fractures

Guidance on choosing emergent orthopedic consultation or ED referral versus urgent care management

Recommended splints and casts based on the type and location of the injury

Injury patterns and history that should raise suspicion for nonaccidental trauma

CHARTING & CODING: Learn how to select the appropriate level of service for the management of pediatric fractures.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
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 and Humeral Shaft Fractures
      3. Elbow Fractures
      4. Radial Head Subluxation
      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. Urgent Care Evaluation
   1. History
   2. Physical Examination
      1. Upper Extremity Examination
      2. Lower Extremity Examination
8. Diagnostic Studies
   1. Imaging of Injuries to Upper Extremities
   2. Imaging of Injuries to Lower Extremities
   3. Clinical Decision Rules
   4. Imaging in Suspected Nonaccidental Injury
9. Treatment
   1. Splints and Casts
   2. Reduction
   3. Pain Control
   4. Other Treatments/Techniques
   5. Management of Nonaccidental Injury
10. Special Circumstances
    1. Pre-existing Conditions
    2. Legg-Calvé-Perthes Disease
    3. Open Fractures
    4. Compartment Syndrome
11. Controversies and Cutting Edge
12. Disposition
13. Summary
14. Time- and Cost-Effective Strategies
15. Risk Management Pitfalls in the Management of Pediatric Patients With Orthopedic Emergencies
16. Critical Appraisal of the Literature
17. Case Conclusions
18. Coding & Charting: What You Need to Know
    1. Medical Decision Making
       1. Number and Complexity of Problems Addressed
       2. Amount and/or Complexity of Data to be Reviewed and Analyzed
       3. Risk of Morbidity and/or Mortality of Patient Management
19. Clinical Pathway for the Evaluation of the Pediatric Patient With Traumatic Limb Pain
20. References

Abstract

Upper and lower extremity injuries are common in 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 urgent care 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 boy presents to urgent care with 1 week of progressively worsening right hip pain...

• He has no fever or history of trauma. He saw his primary care pediatrician 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 obese 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 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 is brought to the clinic after a fall onto her outstretched left hand...

• The patient's mother reports that the girl 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 supracondylar humerus fracture. 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 urgent care by his mother, who states that he seems to be moving his right arm less than usual today…

• The 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?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for the Evaluation of the Pediatric Patient With Traumatic Limb Pain

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

5. * Shah AS, Guzek RH, Miller ML, et al. Descriptive epidemiology of isolated distal radius fractures in children: results from a prospective multicenter registry. J Pediatr Orthop. 2023;43(1):e1-e8. (Prospective longitudinal cohort study; 1951 patients) DOI: 10.1097/BPO.0000000000002288

16. * Khan AZ, Zardad S, Adeel M, et al. Median nerve injury in children aged 2-11 years presenting with closed supracondylar fracture of humerus. J Ayub Med Coll Abbottabad. 2019;31(Suppl 1)(4):S656-S659. (Prospective, descriptive cross-sectional study; 171 patients) PMID: 31965769/

78. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2021. February 9, 2023. Accessed August 10, 2023. (Review)

79. * Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707. (Retrospective; 401 patients) DOI: 10.1542/peds.2012-2780

83. * Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014;133(2):e477-489. (Review) DOI: 10.1542/peds.2013-3793

86. * Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-1354. (Clinical report) DOI: 10.1542/peds.2015-0356

106. * 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. (Prospective; 2342 adults) DOI: 10.1001/jama.269.9.1127

107. * Stiell IG, Wells GA, Hoag RH, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA. 1997;278(23):2075-2079. (Prospective; 3907 adults) DOI: 10.1001/jama.1997.03550230051036

113. * Wootton-Gorges SL, Soares BP, Alazraki AL, et al. ACR Appropriateness Criteria(®) Suspected Physical Abuse-Child. J Am Coll Radiol. 2017;14(5s):S338-s349. (Guidelines) DOI: 10.1016/j.jacr.2017.01.036

114. American College of Radiology, Society for Pediatric Radiology. ACR–SPR Practice Parameter for the performance and interpretation of skeletal surveys in children. 2021. Accessed August 10, 2023. (Practice guideline)

115. * Hansen J, Terreros A, Sherman A, et al. A system-wide hospital child maltreatment patient safety program. Pediatrics. 2021;148(3). (Retrospective; 7698 forms) DOI: 10.1542/peds.2021-050555

116. * Shum M, Asnes AG, Leventhal JM, et al. The impact of a child abuse guideline on differences between pediatric and community emergency departments in the evaluation of injuries. Child Abuse Negl. 2021;122:105374. (Obervational; 321 infants) DOI: 10.1016/j.chiabu.2021.105374

130. Food and Drug Administration, Center for Drug Evaluation and Research. Summary minutes of the Joint Pulmonar. (FDA Meeting Minutes)

131. * Tobias JD, Green TP, Coté CJ. Codeine: time to say “no”. Pediatrics. 2016;138(4): e20162396. (Position statement) DOI: 10.1542/peds.2016-2396

139. * Bauer JM, Lovejoy SA. Toddler’s fractures: time to weight-bear with regard to immobilization type and radiographic monitoring. J Pediatr Orthop. 2019;39(6):314-317. (Retrospective; 192 patients) DOI: 10.1097/BPO.0000000000000948

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Keywords: orthopedic, injury, fracture, sprain, plastic deformation, greenstick fracture, torus fracture, physeal fracture, apophyseal injury, radial head subluxation, slipped capital femoral epiphysis, supracondylar humerus fracture, tibial spine fracture, toddler fracture, compartment syndrome, fracture, Legg-Calve-Perthes, Lisfranc, Salter-Harris, nonaccidental trauma, child abuse, x-ray, radiograph, splint