RESCUE ME Pediatric Fractures and Pain Control

RESCUE ME Pediatric Fractures and Pain Control

RESCUE MEPediatric Fractures and Pain ControlMark Urban, MDPediatric Emergency Medical Director St. Lukes Regional Medical CenterObjectivesReview common pediatric fracturesReview splinting techniquesReview non-medicating techniques for pain controlIce, Elevation, Compression, DistractionReview common pain medicationsQuestionsPediatric CDC Data (2008-2009)Injury related visits per 10,000Under the age of 181351.1Falls398.1Struck by object239.2MVC80.3Cut or pierce74.8

Pediatric FracturesClose to 20% of pediatric patients who present with an injury will have a fracture.42% of boys and 27% of girls will sustain a fracture in childhoodAnatomy ReviewDiaphysisMetaphysisPhysis (growth plate)EpiphysisPeriosteum

Injury Patterns of Pediatric FracturesBones tend to BOW instead of BREAKTORUS force= COMPRESIVE forceBUCKLE fractureBone may only break on one side of cortex, either by side impact or compressionGREENSTICK fractureNeither cortex may break, creating a deformity without fracture (very young children)PLASTIC deformationInjury Patterns continuedMetaphysis/physis junction is an anatomic point of weaknessTendons and ligaments are STRONGER than bone in young childrenBone more likely to be injured by force

Physeal Injuries (growth plate)20 % of all skeletal injuries in childrenCan disrupt the growth of boneInjuries near but not involving the physis can stimulate the bone to grow MORESalter Harris Classification

Physeal InjuriesMost Common: Salter Harris IIThen I, III, IV, VOrthopedic referal for III, IV, VI and II managed with simple splinting/casting.Important to discuss with family that with any physeal injury, growth disturbance is possible. Distal RadiusPeak injury time correlates with peak growth timeMost injuries result from a Fall On OutStretched Hand (FOOSH)Nerve injury more likely if significant angulation or swellingImportant to check neurovascular statusExamine joint above and belowElbowScaphoid-anatomic snuff boxXRAY

Torus FractureUsually non-displacedCan be very subtle (soft tissue swelling)May not be visualized on lateral X-rayNO reduction neededSimple splinting or castingER/Pre-Arrival: Volar or sugar tongOrtho: short arm cast

Torus Fractures

Greenstick FractureCompression of cortex with angulationTreatmentNon-displacedSplint or castDisplaced (>15 degrees)Reduce and splintImmobilize in long arm splint/castGreenstick Fractures

Review of Distal Radius FxsVery commonFOOSHCheck neurovascular statusIf displaced or angulated >15 degrees, reduce ASAPOrtho follow up if suspected physeal injuryElbow FracturesAccount for roughly 10% of fractures in childrenDiagnosis and management are complexMost elbow fractures are supracondylarCheck NEUROVASCULAR STATUS!!! (8-21%)Anterior interosseous nerveBrachial Artery (5-13%)Immobilize BEFORE x-ray to reduce chance of further injury.Supracondylar FractureWeakest part of the elbow jointOlecranon is driven into humerus with hyperextension (can opener)Marked pain and swelling of the elbowPotential for vascular and nerve compromiseIf pulses are absent-reduce ASAPSupracondylar FractureType I- non-displaced or minimally displacedType II- displaced distal fragment with intact posterior cortexType III- displaced with no contact between fragments

20Supracondylar FractureMost are displaced and require surgeryType I can be managed with long arm cast/spintImportant to monitor neurovascular status

Supracondylar Fracture

Lateral Condylar Fracture2nd Most common elbow fractureMost common physeal elbow injuryFOOSH +Varus force: avulsion of lateral condyleFocal swelling of distal/lateral humerus (lateral condyle)Intra-articular: requires open reduction/fixationNon-displaced: posterior splintComplications: growth arrest, non-unionLateral Condylar Fractures

Clavicle Fracture80% occur in the MIDDLE third of the boneFOOSH, fall or direct traumaTreatment:Sling vs. figure of eight Warn parents of healed buldgeIf evidence of vascular compromise or significant deformity, consult ortho earlyClavicle Fractures

Tibia FracturesTibia and fibula fractures often occur togetherMechanisms: Falls, twisting motion of footUsually not displacedRefer for displaced fracture, angulation >15 degrees, tib/fib fracture (both bone).Treatement: Non-displaced: posterior leg spintDisplaced: ortho referral

Toddlers FractureChildren less than age 2 learning to walkNo specific fall or injuryPresents with refusal to bear weight on affected legExam the hip, thigh, kneeNon-displace spiral fractureIf Xrays are normal, may need repeat films in 3-5 days.TreatmentLong-leg cast, weight bearing as toleratedToddlers Fracture

Fractures of AbuseMajority of fractures in a child < 1 year are from abuseBone is more elastic: kids bend before they break, takes a significant amount of force to fracture a bone High percentage of fractures