RESCUE ME Pediatric Fractures and Pain Control
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Transcript RESCUE ME Pediatric Fractures and Pain Control
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 (2008-2009)
Injury related visits per 10,000
Under the age of 18
Falls
Struck by object
MVC
Cut or pierce
1351.1
398.1
239.2
80.3
74.8
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
2nd 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 (longbone)
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
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
7.5-15 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:
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
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: 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
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???