RESCUE ME Pediatric Fractures and Pain Control

Mark Urban, MD
Pediatric Emergency Medical Director
St. Luke’s Regional Medical Center
 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
Struck by object
Cut or pierce
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
Anatomy Review
 Diaphysis
 Metaphysis
 Physis (growth plate)
 Epiphysis
 Periosteum
Injury Patterns of Pediatric
 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
 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
 Nerve injury more likely if significant angulation or
 Important to check neurovascular status
 Examine joint above and below
 Elbow
 Scaphoid-anatomic snuff box
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
 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
 Anterior interosseous nerve
 Brachial Artery (5-13%)
 Immobilize BEFORE x-ray to reduce chance of further
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
 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
 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
 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
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
 EMS splints:
 SAM splints
 Vacuum splint
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
 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)
 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
 Route: PO
 Dose: 10 mg/kg
 Mechanism: inhibits COX, prevents prostaglandin
 Adverse effects:
 Limited antiplatelet function
 Can act as a vasocontrictor
 May prevent bone healing
 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
 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
 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
 Adverse effects: respiratory depression, sedation,
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
 GREAT anticonvulsant
 Adverse effects: respiratory depression, sedation,
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.

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