Rosen & Barkin's 5-Minute Emergency Medicine Consult (656 page)

Patient should be immobilized for transport, as with suspected hip fracture or dislocation.

• Immobilize hip; keep nonweight bearing
  
• Do not attempt reduction.
  

• SCFE is an urgent orthopedic condition; delay in diagnosis may lead to chronic irreversible hip joint disability.
  
• Consult orthopedics immediately for definitive immobilization or operative intervention.
  

Pain management as indicated; avoid oral medications if operative intervention is planned

FOLLOW-UP

• Acute, acute on chronic and bilateral SCFE requires orthopedic admission for urgent operative fixation (usually insitu single cannulated screw fixation)
  
• Chronic SCFE may be managed with delayed operative fixation
  

None (no role for observation or attempts at closed reduction due to risk of complications, including osteonecrosis and/or chondrolysis)

Should be arranged by orthopedic specialist

• Klein line can be a helpful tool in picking up the abnormality on plain radiograph
  
• Remember to examine the hip when a child presents with knee or thigh pain
  

• Aronsson DD, Loder RT, Breur GJ, et al. Slipped capital femoral epiphysis: Current concepts.
  J Am Acad Orthop Surg
  . 2006;14(12):666–679.
  
• Gholve PA, Cameron DB, Millis MB. Slipped capital femoral epiphysis update.
  Curr Opin Pediatr
  . 2009;21(1):39–45.
  
• Kay RM. Slipped capital femoral epiphysis. In: Morrisey RT, Weinstein SL, eds.
  Lovell & Winter’s Pediatric Orthopaedics.
  6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:1085–1124.
  
• Lehmann CL, Arons RR, Loder RT, et al. The epidemiology of slipped capital femoral epiphysis: An update.
  J Pediatr Orthop.
  2006;26(3):286–290.
  
• Loder RT. Controversies in slipped capital femoral epiphysis.
  Orthopedic Clin North Am
  . 2006;37(2):211–221.
  
• Loder RT, Dietz FR. What is the best evidence for the treatment of slipped capital femoral epiphysis?
  J Pediatr Orthop
  . 2012;32(suppl 2):S158–S165.
  

CODES

• 732.2 Nontraumatic slipped upper femoral epiphysis
  
• 732.9 Unspecified osteochondropathy
  

BASICS

2 general causes:

• Blunt visceral trauma
  
• Penetrating: Visceral injury (96% of gunshot wounds, 50% of stabbings)—serosal tear, bowel wall hematoma, perforation, bowel transection, mesenteric hematoma/vascular injury
  

• Blunt:
  
  • 3rd most commonly injured organ (5–10% of all blunt trauma victims)
    
  • Motor vehicle accidents
    
  • Nonvehicular trauma: Abuse/assault, bicycle handlebars, large-animal kick
    
  • Blast victims
    
• Mortality rate from small-bowel injury is 33%.
  
• Mesenteric tears may initially be asymptomatic:
  
  • Deceleration injury at fixed points (e.g., ligament of Treitz)
    
  • Shearing mechanisms near fixed points (e.g., ileocecal junction, adhesions)
    
  • Compressive force against anterior spine
    
  • Bursting or “blowout” at antimesenteric margin from sudden closed-loop intraluminal pressure rise
    
• Associated injuries:
  
  • Liver and splenic lacerations; thoracic and pelvic fractures
    
  • Seatbelt syndrome: Abdominal wall ecchymosis, small-bowel injury; Chance fracture of L1, L3
    
• Penetrating:
  
  • Small bowel is the 2nd most commonly injured organ (32%) in anterior abdominal stabbing.
    
  • Small-bowel injury is most common in gunshot wounds (49%).
    

• Blunt:
  
  • Less common in children (1–8% of all blunt pediatric trauma)
    
  • Lower chance of intestinal injury in vehicular accidents when both shoulder and lap belts are worn.
    
  • Be cautious of nonpenetrating trauma: Airgun accidents at close range (<10 ft)
    
  • Consider the possibility of nonaccidental trauma.
    

DIAGNOSIS

• Physical signs and symptoms are unreliable
  
• Delays in diagnosis are common
  
• Presence of a “seatbelt sign” doubles the risk for small-bowel injury.
  
• Initial presentation may be mild:
  
  • Uniformly, patients will progress to serious signs/symptoms.
    
• Delays in diagnosis add to morbidity and mortality:
  
  • Mortality is 2% when diagnosis is made within 8 hr; 31% when made after 24 hr.
    

• History of blunt or penetrating abdominal trauma
  
• Must consider in ill children without a definite history of trauma (child abuse)
  

• In awake, alert patients look for:
  
  • Abdominal tenderness (87–98%)
    
  • Abdominal pain (85%)
    
  • Peritoneal signs (67%)
    
• Many patients will have:
  
  • Abdominal wall bruising (54%)
    
  • Hypotension (38%)
    
  • Guaiac-positive rectal exam (5%)
    
• Small-bowel injury may initially be obscured by abnormal mental status, severe associated injuries.
  
• Small-bowel injury not initially apparent may be indicated by:
  
  • Progressive abdominal pain
    
  • Intestinal obstruction
    
  • Decreased urine output
    
  • Tachycardia
    

• Initial physical exam should note all wounds and areas of tenderness.
  
• CT for all medically stable patients
  
• For patients with a negative CT scan in which there is high suspicion of bowel injury, further evaluation or serial exams are indicated.
  
• For medically unstable patients, diagnostic peritoneal lavage (DPL) is superior to US in determining presence of a hollow viscus injury.
  

• No diagnostic test has proven highly sensitive in the prediction of small-bowel injury.
  
• Serum amylase, lipase, and liver function tests have poor sensitivity for acute injury.
  

• Plain radiography of chest/abdomen:
  
  • Not useful for small-bowel injury
    
  • Incidence of pneumoperitoneum visible on plain radiograph is only 8%.
    
• CT:
  
  • Diagnostic standard for solid-organ injury and head trauma but is less sensitive for hollow viscus injuries
    
  • Newest-generation helical CT scanners have a sensitivity of 88% and a specificity of 99%.
    
  • The benefits of oral contrast are controversial; it is acceptable to use IV contrast only
    
  • Blunt trauma:
    
    • Used in stable patients
      
    • Indications for CT in blunt trauma include abdominal tenderness, hypotension, altered mental status (GCS <14), costal margin tenderness, abnormal CXR, HCT <30% and hematuria
      
    • Specific signs for small-bowel injury on CT are pneumoperitoneum (sensitivity 50–75%) and extravasation of contrast (sensitivity 12%).
      
    • Signs on CT suggestive of small-bowel injury include unexplained free intraperitoneal fluid (most sensitive 93%), thickened bowel wall >3 mm (61% sensitive), intramural hematomas (75–88% sensitive), interloop fluid, mesenteric streaking.
      
  • Penetrating: CT is not recommended because sensitivity is only 14%; false-negative result rate is 18%.
    
• US: Not sensitive in hollow viscus injury because air in bowel makes visualization difficult
  

• DPL:
  
  • Invasive but may be helpful in unstable patients or in patients with clinically suspicious but nondiagnostic abdominal CT
    
  • Sensitive for hemoperitoneum but not source of bleeding
    
  • Positive if RBC count of >100,000/mm
    ³
    
  • Lavage amylase >20 IU/L and leukocyte count >500/mm
    ³
    (late markers of small-bowel injury)
    
  • Lavage microscopy for succus/vegetable matter/feces is specific for small-bowel injury but not sensitive.
    
  • Lavage alkaline phosphatase (>3 IU/L) is reported to be a useful immediate marker of small-bowel injury.
    
• Laparoscopy: Plays a key role in diagnosing small-bowel injury in stable patients with progressive signs or symptoms
  

• Hemoperitoneum owing to vascular insult
  
• Solid visceral organ injury or gastric/colon/rectum perforation
  
• Vertebral injury and associated ileus