Mark Urban, MD Pediatric Emergency Medical Director St. Luke’s Regional Medical Center

Objectives Review common pediatric fractures Review splinting techniques Review non-medicating techniques for pain control Ice, Elevation, Compression, Distraction Review common pain medications Questions

Pediatric CDC Data ( ) Injury related visits per 10,000 Under the age of Falls398.1 Struck by object239.2 MVC80.3 Cut or pierce74.8

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

Anatomy Review Diaphysis Metaphysis Physis (growth plate) Epiphysis Periosteum

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

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

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

Salter Harris Classification

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.

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

XRAY

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

Torus Fractures

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

Greenstick Fractures

Review of Distal Radius Fx’s Very common FOOSH Check neurovascular status If displaced or angulated >15 degrees, reduce ASAP Ortho follow up if suspected physeal injury

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.

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

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

Supracondylar Fracture Most are displaced and require surgery Type I can be managed with long arm cast/spint Important to monitor neurovascular status

Supracondylar Fracture

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

Lateral Condylar Fractures

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

Clavicle Fractures

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

Toddler’s 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 Xray’s are normal, may need repeat films in 3-5 days. Treatment Long-leg cast, weight bearing as tolerated

Toddler’s Fracture

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 <3yo = abuse Greater risk of abuse: first-born, premature infants, stepchildren, children with learning or physical disabilities Most common sites: femur, humerus, tibia (long- bone) Also: radius, skull, spine, ribs, ulna, fibula

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)

Fractures of Abuse

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.

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

SAM

Vacuum Splint

Pediatric Pain Score Wong-Baker Faces

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

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

Pain Control Pain is difficult to measure. We have SUBJECTIVE tools for measurement. One persons 2 is another’s 10. If a child is in obvious pain, treat appropriately. We historically UNDERTREAT Pediatric pain. Fear of overdosing Injury is “not” that bad

Common Medications Non-narcotic Acetaminophen Ibuprofen Opioids Morphine Hydromorphone Fentanyl Anxiolytics (Benzodiazepines) Midazolam (Versed) Diazepam (Valium)

Acetaminophen Route: PO/PR/IV Dose: 15 mg/kg orally 30 mg/kg rectally mg/kg IV Mechanism: not completely understood, inhibits COX, highly selective for COX-2 Limited anti-inflammatory activity

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

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

Hydromorphone Route: IV/IM/PO Dose: mg/kg IV 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

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

Midazolam (Versed) Route: IV/IM/PO/PR/IN Dose: 6 mos-5 years: mg/kg IV, mg/kg PO 6 years-12 years: mg/kg IV, 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

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

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.

Questions???