RESCUE ME Pediatric Fractures and Pain Control

Report
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???

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