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Basic Principles of Reduction Maneuvers

The Three-Point Principle 1. Diaphyseal fractures ( Fig. 8.1 A ): a. The primary reductive force should be applied against the apex of the fracture. b. Counterforce applied in the opposite direction both proximal and distal to the apex stabilizes the limb. 2. Metaphyseal/epiphyseal fractures ( Fig. 8.1 B): a. The primary reductive force should be applied just distal to the fracture. b. Counterforce should be…

Intraarticular Ankle Block

When performing an intraarticular ankle block, an anterolateral approach is preferred. Indications for Use An intraarticular ankle block is used for ankle fracture reduction. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here

Ankle Block

Overview 1. The following five nerves are involved in an ankle block: posterior tibial, superficial peroneal, deep peroneal, saphenous, and sural. 2. The posterior tibial and deep peroneal nerves are deep to the fascia, whereas the remainder of the nerves are superficial. Indications for Use 1. Foot fracture reduction 2. Soft tissue injuries about the foot Precautions 1. Avoid intravascular and intraneural injections. 2. Do not…

Digital Block

Overview 1. Two techniques can be used to perform a digital block: a. Tendon sheath injection b. Web space injection 2. The web space injection technique is more painful but provides a complete digital block more reliably. Indications for Use A digital block is used for soft tissue injuries about the finger distal to the proximal interphalangeal joint. You’re Reading a Preview Become a Clinical Tree…

Wrist Block

Overview The following three nerves are involved in a wrist block: radial, median, and ulnar. 1. The ulnar nerve has a dorsal sensory branch that arises 5 cm proximal to the wrist crease. 2. Two techniques can be used to block the ulnar nerve. a. Proximal block: (1) A proximal block anesthetizes the ulnar nerve approximately 6 cm proximal to the wrist crease. (2) In most cases, a…

Elbow Block

Overview The following five nerves are involved in an elbow block: radial, median, ulnar, medial antebrachial cutaneous, and lateral antebrachial cutaneous. 1. The radial and lateral antebrachial cutaneous nerves are typically blocked at the same time because of their proximity to one another. 2. The ulnar and medial antebrachial cutaneous nerves are typically blocked at the same time because of their proximity to one another. Indications…

Hematoma Block

Overview 1. A hematoma block may be performed anywhere an acute fracture is present. 2. Typically, hematoma blocks are performed in regions where it is impractical to perform selective nerve blocks or regional blocks. 3. Hematoma blocks function on the principle that a fracture hematoma surrounds a fracture site. a. The fracture hematoma acts as a fluid medium; thus, injection of an anesthetic into the hematoma…

Basic Principles of Analgesia

Overview Review of Local Anesthetics 1. The two most commonly used local anesthetics are lidocaine (Xylocaine) and bupivacaine (Marcaine, Sensorcaine) ( Table 1.1 ). a. Recent studies have suggested that bupivacaine may be toxic to chondrocytes. b. Ropivacaine (Naropin) has been found to be significantly less toxic to chondrocytes. c. Whenever possible, ropivacaine should be used instead of bupivacaine when administering an intraarticular injection. Unfortunately, ropivacaine…

Classifications of Fractures, Dislocations, and Sports-Related Injuries

The musculoskeletal reaction to trauma can result in a variety of bone, muscle, and ligamentous disruptions; sometimes fracture and ligamentous injuries occur concurrently. The general types of musculoskeletal trauma are fractures, dislocations, subluxations, sprains, strains, and diastases. This chapter defines fractures and dislocations by sections. The first part contains general terms that are easily understood by the nonspecialist, followed by classic, descriptive, and eponymic terms by…

Rehabilitation of the Child with Multiple Injuries

Introduction Trauma is the most common cause of death and disability for children in the United States, with up to half of injuries resulting in long-term sequelae. Children with multiple injuries present particular challenges to both their families and the medical teams that care for them. The rehabilitation goal for children with multiple injuries is to maximize function and return them to their home and community…

Anesthesia and Analgesia for the Ambulatory Management of Children’s Fractures

Acknowledgment The authors would like to acknowledge and thank Dr. Eric C. McCarty and Dr. Gregory A. Mencio for their contributions to the previous versions of this chapter. Introduction The goal of anesthesia in the management of fractures in children is to provide analgesia and relieve anxiety so that successful closed treatment of the skeletal injury is facilitated. Optimal pain management in the emergency department or…

Nonaccidental Trauma: Inflicted Skeletal Injuries or Child Physical Abuse

Introduction Inflicted physical abuse to children is a grotesque act that no one likes to diagnose. This phenomenon accounts for nearly 20% of all child maltreatment cases, which encompass a spectrum of offenses including neglect, sexual and physical abuse, and psychological maltreatment. Many terms have been used to describe the orthopedic manifestations of physical abuse and include battered child syndrome, nonaccidental trauma, and the current convention…

Skeletal Trauma in Young Athletes

Introduction In the words of Mercer Rang, “children are not small adults.” Epidemiology of Youth Sports The popularity of youth sports continues to grow and increasing participation of children at younger ages is being seen. Approximately 30 to 44 million preadolescents and adolescents are involved in organized sports, and an estimated 7.6 million students are involved in high school athletics. This participation is beneficial to the…

Fractures and Dislocations of the Forearm, Wrist, and Hand

Introduction Upper extremity injury is one the most common presenting complaints after trauma in the pediatric population. Fractures of the forearm represent 40% of fractures in all age groups of children. Upper extremity fractures and dislocations are slightly more common in boys than in girls. There is a higher incidence from ages 4 to 14 years as children begin to independently interact with their environment and…

Fractures and Dislocations about the Elbow

Acknowledgment The authors would like to acknowledge and thank Dr. Neil E. Green and Dr. Nathan L. Van Zeeland for their contributions to the previous versions of this chapter. Introduction Fractures about the elbow are extremely common, and injuries about the elbow occur more frequently in the skeletally immature than they do in adults. It is estimated that upper extremity injuries account for 65% of all…

Fractures and Dislocations about the Shoulder

Clavicle Relevant Anatomy The clavicle, or collar bone, is an S-shaped bone anterior to the base of the neck. Through articulations with the sternum medially and with the scapula at the acromion process laterally, it serves as an osseous connection between the axial skeleton and the upper extremity. In cross section, the medial portion of the clavicle is rounded or prismatic, and the lateral third is…

Fractures and Dislocations of the Foot and Ankle

Acknowledgement The expertise and contribution of this chapter’s prior authors (Drs. Alvin C. Crawford and Charles T. Mehlman) are greatly appreciated. Introduction Fractures and injuries about the foot and ankle in children are common and can have an important functional impact. Foot and toe fractures are among the top 10 pediatric orthopedic injuries, and physeal injuries about the ankle are the second most common growth plate…

Fractures of the Tibia and Fibula

Introduction Nonphyseal fractures of the tibia and fibula are among the most common injuries involving the lower extremities in children and adolescents. They are second only to fractures of the femur as a cause for hospital admissions for pediatric trauma. Most can be treated nonoperatively with satisfactory long-term results and minimal complications. However, certain tibial fractures pose unique problems that must be carefully evaluated and treated…

Fractures Around the Knee in Children

Introduction Traumatic forces applied to an immature knee result in fracture patterns that differ from those seen in adults. As in other anatomic regions in a growing child, the cartilaginous structures around the knee are weaker than the ligaments and tendons that insert onto them, making them more vulnerable to injury. Fractures involving the epiphyses require accurate reduction to minimize the risk of growth disturbances that…

Fractures of the Femoral Shaft

Introduction: Scope and Purpose The treatment of pediatric femur fractures continues to evolve similarly to other pediatric fracture management trends, highlighted by utilization of more invasive methods and the rising percentage of surgical implant fixation. One exception is the use of external fixation, which appears to be on the decline and is not mentioned in the latest American Academy of Orthopaedic Surgeons (AAOS) guidelines. This increase…