Mark Urban, MD Pediatric Emergency Medical Director St. Lukes
Regional Medical Center
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Objectives Review common pediatric fractures Review splinting
techniques Review non-medicating techniques for pain control Ice,
Elevation, Compression, Distraction Review common pain medications
Questions
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Pediatric CDC Data (2008-2009) Injury related visits per 10,000
Under the age of 181351.1 Falls398.1 Struck by object239.2 MVC80.3
Cut or pierce74.8
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Pediatric Fractures Close 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 childhood
Injury Patterns of Pediatric Fractures Bones tend to BOW
instead of BREAK TORUS force= COMPRESIVE force BUCKLE fracture Bone
may only break on one side of cortex, either by side impact or
compression GREENSTICK fracture Neither cortex may break, creating
a deformity without fracture (very young children) PLASTIC
deformation
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Injury Patterns continued Metaphysis/physis junction is an
anatomic point of weakness Tendons and ligaments are STRONGER than
bone in young children Bone more likely to be injured by force
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Physeal Injuries (growth plate) 20 % of all skeletal injuries
in children Can disrupt the growth of bone Injuries near but not
involving the physis can stimulate the bone to grow MORE
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Salter Harris Classification
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Physeal Injuries Most Common: Salter Harris II Then I, III, IV,
V Orthopedic referal for III, IV, V I and II managed with simple
splinting/casting. Important to discuss with family that with any
physeal injury, growth disturbance is possible.
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Distal Radius Peak injury time correlates with peak growth time
Most injuries result from a Fall On OutStretched Hand (FOOSH) Nerve
injury more likely if significant angulation or swelling Important
to check neurovascular status Examine joint above and below Elbow
Scaphoid-anatomic snuff box
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XRAY
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Torus Fracture Usually non-displaced Can be very subtle (soft
tissue swelling) May not be visualized on lateral X-ray NO
reduction needed Simple splinting or casting ER/Pre-Arrival: Volar
or sugar tong Ortho: short arm cast
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Torus Fractures
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Greenstick Fracture Compression of cortex with angulation
Treatment Non-displaced Splint or cast Displaced (>15 degrees)
Reduce and splint Immobilize in long arm splint/cast
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Greenstick Fractures
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Review of Distal Radius Fxs Very common FOOSH Check
neurovascular status If displaced or angulated >15 degrees,
reduce ASAP Ortho follow up if suspected physeal injury
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Elbow Fractures Account for roughly 10% of fractures in
children Diagnosis and management are complex Most elbow fractures
are supracondylar Check NEUROVASCULAR STATUS!!! (8-21%) Anterior
interosseous nerve Brachial Artery (5-13%) Immobilize BEFORE x-ray
to reduce chance of further injury.
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Supracondylar Fracture Weakest part of the elbow joint
Olecranon is driven into humerus with hyperextension (can opener)
Marked pain and swelling of the elbow Potential for vascular and
nerve compromise If pulses are absent-reduce ASAP
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Supracondylar Fracture Type I- non-displaced or minimally
displaced Type II- displaced distal fragment with intact posterior
cortex Type III- displaced with no contact between fragments
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Supracondylar Fracture Most are displaced and require surgery
Type I can be managed with long arm cast/spint Important to monitor
neurovascular status
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Supracondylar Fracture
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Lateral Condylar Fracture 2 nd Most common elbow fracture Most
common physeal elbow injury FOOSH +Varus force: avulsion of lateral
condyle Focal swelling of distal/lateral humerus (lateral condyle)
Intra-articular: requires open reduction/fixation Non-displaced:
posterior splint Complications: growth arrest, non-union
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Lateral Condylar Fractures
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Clavicle Fracture 80% occur in the MIDDLE third of the bone
FOOSH, fall or direct trauma Treatment: Sling vs. figure of eight
Warn parents of healed buldge If evidence of vascular compromise or
significant deformity, consult ortho early
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Clavicle Fractures
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Tibia Fractures Tibia and fibula fractures often occur together
Mechanisms: Falls, twisting motion of foot Usually not displaced
Refer for displaced fracture, angulation >15 degrees, tib/fib
fracture (both bone). Treatement: Non-displaced: posterior leg
spint Displaced: ortho referral
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Toddlers Fracture Children less than age 2 learning to walk No
specific fall or injury Presents with refusal to bear weight on
affected leg Exam the hip, thigh, knee Non-displace spiral fracture
If Xrays are normal, may need repeat films in 3-5 days. Treatment
Long-leg cast, weight bearing as tolerated
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Toddlers Fracture
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Fractures of Abuse Majority of fractures in a child < 1 year
are from abuse Bone is more elastic: kids bend before they break,
takes a significant amount of force to fracture a bone High
percentage of fractures
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Fractures of Abuse Unexplained fractures in different stages of
healing as shown on radiology Femoral fracture in child < 1 year
Scapular fracture in child without a clear history of violent
trauma Epiphyseal and metaphyseal fractures of the long bones
Corner or chip fractures of the metaphyses (Bucket handle
deformity)
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Fractures of Abuse
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Splinting Techniques Goal of pre-hospital splinting Reduce
chance of further trauma (neurovasular injury) Relieve muscle spasm
Reduce swelling Minimize chance for further displacement Always
check neurovascular status pre/post splinting and while in
transport.
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Splinting Techniques DO NOT attempt to reduce deformity, unless
vascular compromise is present. Before splinting, make sure to
identify open fracture if present EMS splints: SAM splints Vacuum
splint
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SAM
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Vacuum Splint
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Pediatric Pain Score Wong-Baker Faces
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Rest, ICE, Compression, Elevation Immobilize injury Reduce
movement, displacement, further injury Apply ice Reduce swelling,
pain Compression Reduce swelling, pain, be cautious to not
OVERCOMPRESS and thus reduce blood flow Elevation Reduce
swelling
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Distraction Stranger DANGER High stress situation Injured
child, concerned parent, chaotic scene Have parent(s) sit with
child, hold them if possible Perform interventions if possible with
parents soothing child (holding hand, in arms, etc.) Reduces
anxiety, better assessment Use distracters such as stuffed animals,
toys TALK to the child on their level Avoid using terms that would
invoke fear/anxiety
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Pain Control Pain is difficult to measure. We have SUBJECTIVE
tools for measurement. One persons 2 is anothers 10. If a child is
in obvious pain, treat appropriately. We historically UNDERTREAT
Pediatric pain. Fear of overdosing Injury is not that bad
Acetaminophen Route: PO/PR/IV Dose: 15 mg/kg orally 30 mg/kg
rectally 7.5-15 mg/kg IV Mechanism: not completely understood,
inhibits COX, highly selective for COX-2 Limited anti-inflammatory
activity
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Ibuprofen Route: PO Dose: 10 mg/kg Mechanism: inhibits COX,
prevents prostaglandin formation Adverse effects: Limited
antiplatelet function Can act as a vasocontrictor May prevent bone
healing
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Morphine Route: IV/IM/PO Dose: 0.1 mg/kg IV/IM Mechanism: binds
to mu-opioid receptor in brain Agonist Activation of these
receptors causes sedation, analgesia, euphoria, respiratory
depression, and dependence. Adverse effects: Constipation,
respiratory depression, dependence
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Hydromorphone Route: IV/IM/PO Dose: 0.015 mg/kg IV 0.03-0.08
mg/kg PO Mechanism: same as morphine (all opioids) higher lipid
solubility and ability to cross the blood brain barrier and,
therefore, more rapid and complete central nervous system
penetration Adverse effects: same as morphine
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Fentanyl Route: IV/IM/IN Dose: 1-2 mcg/kg IV or IM 1.5 mcg/kg
IN (sedation) Mechanism: same as other opioids Shorter half-life,
requires more frequent dosing GREAT for sedation Adverse effects:
same as other opioids
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Midazolam (Versed) Route: IV/IM/PO/PR/IN Dose: 6 mos-5 years:
0.05-0.1 mg/kg IV, 0.25-1 mg/kg PO 6 years-12 years: 0.025-0.05
mg/kg IV, 0.25-1 mg/kg (max of 20 for sedation, 5 for anxiolysis)
Intranasal: 0.5 mg/kg Mechanism: Short acting benzodiazepine GABA
receptor agonist Sedative, hypnotic, anxiolytic, anticonvulsant,
and muscle relaxant Adverse effects: respiratory depression,
sedation, dependence
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Diazepam (Valium) Route: IV/PO/PR Dose: 0.2 mg/kg IV 0.5 mg/kg
PR (Diastat) Mechanism: long acting benzodiazepine GABA receptor
agonist Sedative, hypnotic, anxiolytic, anticonvulsant, and muscle
relaxant GREAT anticonvulsant Adverse effects: respiratory
depression, sedation, dependence
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Special Considerations Pediatric patients are more sensitive to
centrally active drugs (benzodiazepines, opioids) Dose
conservatively to avoid adverse effects Pediatric pain scales are
very subjective, use immobilization, elevation, ice, distraction
first, then dose with medications. Constantly REASSESS!!! Injuries
will continue to swell, monitor neurovascular status closely.