Case 1
A mother presented to the ED with her 8-year-old daughter after she witnessed the child fall off her bicycle onto the sidewalk. When she fell, the girl landed onto her outstretched arms and sustained minor abrasions to her palms and knees, but did not hit her head or lose consciousness. Upon falling, the child immediately cried that her left arm hurt and kept holding it guarded near her body.
She was seated on her mother’s lap in the examination room, appearing anxious but in no acute distress. The treating EP observed the superficial abrasions from across the room and obtained a detailed history.
The patient was afebrile, and her vital signs were stable with the exception of mild tachycardia. After a couple of minutes, the EP slowly approached the child and was able to perform a basic examination. There was no obvious deformity to her left upper extremity, and only mild swelling over the wrist. She was able to move her fingers well and had excellent capillary refill distally. The child remained calm during manual palpation of the anatomic snuff box. However, she immediately pulled away and began to cry upon palpation more proximally over the distal forearm. The EP discussed his concerns with the child’s mother and explained that further evaluation was necessary.
Case 2
A mother and father presented to the ED carrying their 6-year-old boy, stating that the child had been limping since they picked him up from a neighbor’s house an hour earlier and was now refusing to walk. The father noted that a group of children had been jumping on a trampoline unsupervised, but he did not witness any injury to his son. Both parents said that the boy had been well up until that day.
At presentation, the child was afebrile and his vital signs were stable. The EP asked the parents to coax the child to walk across the room. During the walk, the boy was reluctant to bear weight on his right foot. Careful inspection of his lower limb revealed no external signs of trauma, and it appeared neurovascularly intact. Careful palpation elicited tenderness directly over the physis at the distal fibula and near the lateral malleolus. While considering the broad differential for a limping child, the physician was primarily concerned with point tenderness on examination and informed the parents that radiographic imaging was warranted.
Overview
Pediatric musculoskeletal (MSK) injury and orthopedic trauma now comprise more than 10% of visits to the ED.1 Fractures in particular are becoming more commonplace with the increasing number of children actively involved in athletic sports and high-risk activities.
The general approach to acute-care management of these children has evolved, trending more toward splinting the fractured extremity and away from traditional casting. There are many benefits to splinting. The most important is arguably the reduced risk of developing compartment syndrome due to a splint’s ability to expand with accompanied swelling.2 This article reviews the unique characteristics of pediatric bone development and initial management of pediatric fractures, as well as basic splinting techniques and unique indications that require further orthopedic consultation.
Physiological Differences in Children
The MSK system of a child differs greatly from that of an adult. The bones themselves are much more porous and malleable during childhood, making them more susceptible to traumatic injury. The growing periosteum and the developing physes are particularly vulnerable, accounting for up to 20% of pediatric fractures (see the Figure illustrating the Salter-Harris classification in the next section).3 This is particularly true at a young age, when ligamentous adherence out-performs the bony integrity itself, making fractures more common than sprains and tears. The opposite is true in adults, who are much more likely to experience sprains before succumbing to fracture. Furthermore, since the periosteum is still very active in children, the fractured bone is much more likely to remodel, lending to less deformity and overall better outcomes in most cases.3 Nonunion is extremely rare in children.
Initial Management
Approaching the Pediatric Patient
Special consideration should be given when initially approaching an injured child, so as not to cause additional undue fear or anxiety to the patient. It is helpful to take an extra moment upon entering the room to simply observe the child’s positioning, posture, or reluctance to move a particular limb. Obtaining a careful, detailed history from a distance is recommended before too quickly approaching the patient. In addition, asking the caregiver to serve as proxy during the initial physical examination may also prove helpful in localizing the pain. In the obscure case, such as the child refusing to bear weight, it is good to keep a broad differential and inspect for non-MSK injury (eg, painful hernia, testicular torsion, foreign body lodged in the bottom of the foot). Utilizing a “log-rolling” technique with the palms of one’s hands on the patient’s thigh may reveal hip pathology. Simply observing the preoccupied child walk around the unit while watching from behind may also aid in the evaluation.