Extremity Injuries

1

You are en route to the local children’s emergency department having picked up a 3-year-old male who fell off the monkey bars at a playground. The patient has a left elbow deformity ( Fig. 44.1 ). What are key characteristic features of pediatric bones compared to adult bones that can affect presentation and management?

• The presence of a growth plate or physis. The growth plate is the manufacturing center of long bone growth. It is also an area of weakness and is more susceptible to fracture.

• Thicker, more vascular, and more elastic periosteum. The periosteum helps stabilize the bone when a fracture occurs. The periosteum allows many pediatric fractures to be managed through closed reduction rather than open surgery.

• Remodeling. Pediatric bones will remodel extremely well compared to adults. Therefore, timely, appropriate reduction or splinting is paramount.

2

What fractures are unique to the pediatric population?

Most pediatric fractures fall into five categories: plastic deformation/bowing, buckle/torus, greenstick, complete fracture, and physeal injury.

3

While preparing to transport a 9-year-old female patient who sustained a left ankle injury, you are told by the referring general emergency department that her x-rays show a Salter-Harris type IV growth plate injury. What is the Salter-Harris classification system? (See Fig. 44.2 .)

• Salter I—The fracture extends through the physis

• Salter II—The fracture extends through the physis and metaphysis

• Salter III—The fracture extends through the physis and epiphysis

• Salter IV—The fracture extends through the physis and both the epiphysis and metaphysis

• Salter V—Crush or compression of the physis

4

What is the most common Salter-Harris fracture?

Salter-Harris II

5

Which Salter-Harris fracture has high risk for growth plate injury, which can affect bone growth?

Salter-Harris V

6

You have been called to assess and transport a 17-year-old football player. He is complaining of right shoulder and clavicular pain after being tackled. What questions should you ask regarding any pediatric extremity injury as part of your initial assessment?

• Mechanism of injury

• Location of the injury

• Coexistent injuries

• Prior injuries

• Chronic medical conditions and medications

• Allergies

• Last meal (with consideration of the patient being kept nil by mouth)

7

How should pediatric extremity injuries be examined?

General assessment includes palpating the area around the injury including at least one joint above and below, evaluating neurovascular function and looking for soft tissue damage or breaks in the skin.