Rosen & Barkin's 5-Minute Emergency Medicine Consult (285 page)

Immobilization

• Resuscitation for concurrent injuries
  
• Immobilization
  

• Management of life-threatening concurrent injuries
  
• Pain control
  
• Dislocations require immediate assessment and attention to neurovascular compromise:
  
  • Mechanism helps in understanding the direction of the force required to reduce.
    
• Alignment is essential, particularly when fracture involves a joint surface.
  
• Appropriate reporting of NAT
  

• Type I and type II fractures require immobilization and orthopedic follow-up.
  
• Type II distal femur fractures, type III, and type IV require urgent orthopedic consultation for anatomic reduction.
  
• Type V fractures require immobilization and consultation.
  
• Anatomic reduction does not eliminate possibility of growth disturbance.
  

• Figure-of-8 splint or sling for comfort
  
• Distal 3rd clavicle fractures should be referred with initial sling and swathe or shoulder immobilizer.
  

• >50% are supracondylar
  
  • 10–15% have neural injury
    
• May present with only posterior effusion on lateral radiograph
  
• Orthopedic consultation because of potential neurovascular complications
  
• Brachial artery injury, median nerve injury possible
  
• Volar compartment syndrome of forearm (results in Volkmann contracture)
  
• Epiphyseal injury with long-term growth abnormalities
  

• Most common site of pediatric fracture: Distal radius
  
• Reduce angulated fractures >15°
  
• Pronator fat pad along volar radius may indicate occult fracture
  
• Colles fracture:
  
  • Reduce by traction in the line of deformity to disimpact the fragments, followed by pressure on the dorsal aspect of the distal fragment and volar aspect of the proximal fragment.
    
  • Correct radial deviation.
    
  • Immobilize wrist and elbow (sugar-tong splint)
    
  • Orthopedic consultation
    
• Torus fracture (incomplete fracture; buckling or angulation on the compression side of the bone only):
  
  • Most often in distal forearm
    
• Greenstick fracture (incomplete fracture of diaphysis of long bone with fracture on tension side of cortex):
  
  • Immobilize.
    
  • Reduction if angulation >30° in infants, >15° in children
    

• Isolated fibular fractures: Short-leg walking cast
  
• Nondisplaced tibial fracture: Long-leg posterior splint, nonweight bearing
  
• Displaced tibial fracture and complex fractures require consultation.
  
• Toddler’s fractures:
  
  • Nondisplaced, oblique, distal tibia fracture
    
  • May need tangential view radiograph or bone scan to diagnose
    
  • Splint if suspect and repeat radiograph in 7–10 days.
    
• May apply Ottawa Ankle Rules to children
  

• Disruption though capital femoral epiphysis
  
• Need AP and frog-leg x-rays
  
• Overweight adolescent boys
  
• May have referred pain to knee, thigh, or groin
  
• Nonweight bearing with prompt orthopedic follow-up
  
• Often bilateral
  

• Most common long-bone fracture
  

• Increasingly common
  
• Insidious onset
  
• Vague, achy pain
  
• Usually associated with rigorous activity
  
• Treatment:
  
  • Selective bracing
    
  • Activity modification
    

• Irrigate and dress with moist saline gauze
  
• Immobilize
  
• Cefazolin if only small laceration and minimal contamination
  
• Gentamicin if moderate contamination, high-energy injury, or significant soft tissue injury
  
• Consider penicillin if concern for clostridia infection (farm injury, fecal or soil contamination)
  
• Small wounds with minimal soft tissue injury may be treated with oral antibiotics and immobilization in consultation with orthopedist
  

• Careful exam and review of systems for signs of rheumatologic disease, infection, or malignancy
  
  • Pediatric patients with leukemia may present with limp as their initial complaint
    
• CBC, ESR, CRP, arthrocentesis may be indicated
  
• Transient synovitis vs. septic hip
  
  • More likely septic if:
    
    • Fever
      
    • Elevated ESR/CRP
      
    • WBC elevation
      
    • Refusal to bear weight
      

• Acetaminophen: 10–15 mg(kg PO(PR (per rectum) q4–6h; Do not exceed 5 doses/24 h
  
• Cefazolin: 25–100 mg/kg daily IM/IV q8h
  
• Gentamicin: 2.5 mg/kg IV/IM q8h or 6.5–7.5 mg/kg IV/IM q24h
  
• Hematoma block: 1% lidocaine without epinephrine (max. 3–5 mg/kg)
  
• Ibuprofen: 10 mg/kg PO q6–8h (first-line treatment)
  
• Morphine: 0.05–0.2 mg/kg SC/IM/IV q2–4h
  

FOLLOW-UP

• NAT (or per social services)
  
• Open fracture
  
• Potential neurovascular compromise/compartment syndrome:
  
  • Condylar or supracondylar humerus fracture
    
  • Femoral shaft
    

• Uncomplicated fracture: No concurrent injury or neurovascular/compartment compromise
  
• Follow-up arranged and parents understand injury and management
  

All Salter–Harris fractures should have orthopedic follow-up.

• History is essential in evaluation of NAT
  
• Undress patient fully especially if suspicion for NAT
  
• Have a low threshold to splint and/or consult orthopedist
  
• Pain control is essential and often underdosed.
  
• Distal radius is often associated with other fractures: Ulna, elbow, carpal bones
  

• Boutis K. Common pediatric fractures treated with minimal intervention.
  Pediatr Emerg Care
  . 2010;26:152–157.
  
• Chasm RM, Swencki SA. Pediatric orthopedic emergencies.
  Emerg Med Clin North Am
  . 2010;28:907–926.
  
• Laine JC, Kaiser SP, Diab M. High-risk pediatric orthopedic pitfalls.
  Emerg Med Clin North Am
  . 2010;28:85–102.
  
• Mathison DJ, Agrawal D. An update on the epidemiology of pediatric fractures.
  Pediatr Emerg Care
  . 2010;26:594–603.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Conscious Sedation
  
• C-spine Fractures, Pediatric
  
• Fractures, Open
  
• Nursemaid’s Elbow
  
• Shoulder Dislocation
  
• Slipped Capital Femoral Epiphysis
  

CODES

• 803.00 Other closed skull fracture without mention of intracranial injury, unspecified state of consciousness
  
• 807.00 Closed fracture of rib(s), unspecified
  
• 829.0 Fracture of unspecified bone, closed
  

BASICS

• Tissue damage caused by cold temperature exposure
  
• Mechanism:
  
  • Tissue damage results from:
    
    • Direct cell damage: Intracellular ice crystal formation
      
    • Indirect cell damage: Extracellular ice crystal formation leads to intracellular dehydration and enzymatic disruption.
      
    • Reperfusion injury: Occurs upon rewarming. Fluid rich in inflammatory mediators (prostaglandin and thromboxane) extravasates through damaged endothelium promoting vasoconstriction and platelet aggregation.
      
    • Clear blisters form from extracellular exudation of fluid.
      
    • Hemorrhagic blisters occur when deeper subdermal vessels are disrupted, indicating more severe tissue injury.
      
    • The end result is arterial thrombosis, ischemia, and ultimately, necrosis.
      
  • Devitalized tissue demarcates as the injury evolves over weeks to months, hence the phrase “frostbite in January, amputate in July.”
    

• Cold exposure: Duration of exposure, wind chill, humidity, and wet skin and clothing all increase the likelihood of frostbite.
  
• Predisposing factors:
  
  • Extremes of age
    
  • Altered mental status (intoxication or psychiatric illness)
    
  • Poor circulatory status