Management of Pediatric Wrist Injuries

Case Study:
A 13-year-old boy fell on an outstretched hand during a soccer game and sat out the rest of the game. Afterwards he is brought to the ED for wrist swelling and pain. His swelling is localized to the wrist with tenderness to palpa¬tion of the snuffbox and distal radius.

The x-rays look normal to you but the amount of pain and swelling are concerning for fracture. Several ques¬tions come to mind. Do children get wrist sprains? Could he have a Salter-Harris I (SH I) fracture of the radius or a scaphoid fracture? Is additional imaging indicated? What is the best plan for management?

You immobilize the wrist in a forearm splint. The patient wants to know when he can return to practice and if he will be able to play in the game a week from today. When is it safe for children to return to sports activities? What kind of follow-up does he need?

Case Study Conclusion:
No fracture was noted on the soccer player’s x-rays. He had a thumb spica splint applied in the ED. On orthope¬dic follow-up 2 days later, his wrist remained tender and an MRI showed a fracture of the distal third of the scaph¬oid. A thumb spica cast was applied. His fracture healed without complications.

Risk Management Pitfalls:

“I don’t see any wrist tendon involvement.” Don’t be fooled. Short lacerations can conceal deep underlying injury. Physical examination tends to underestimate the amount of damage to tendons, arteries, and nerves. If there are localized findings or the examination is inconclusive, referring your patient for operative exploration is indicated.

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Management of Pediatric Ankle Injuries

Case Study:
A 14-year-old male is out in triage with an ankle injury. The nurse calls back to see if you want to send him di¬rectly to radiology. You decide to examine the patient first. On the way out to triage, you ask yourself some ques¬tions about ankle injuries in the pediatric patient. Do the Ottawa ankle rules apply? Are adolescents more likely to get a sprain or a fracture? Are there any differences in the fracture patterns seen in younger children, adolescents, and adults?

When you arrive in triage, you see a football player still in pads, with his ankle elevated. The patient tells you he was just standing when someone playfully pushed him down from the side. He reports no previous ankle injuries and has been unable to bear weight since the accident. You notice he has a large amount of swelling about the ankle, but his pulses and sensation are intact. His pain is diffuse around the ankle, but it appears most intense over the distal anterior tibia. You decide to provide him with some narcotic analgesia and send him to radiology.

Case Study Conclusion:
Your 14-year-old football player has made it back from radiology and is awaiting your interpretation of his films. He has an SH IV triplane fracture of the distal tibia with minimal displacement. You recall that this is one of the few instances where more advanced radiology is helpful in ankle injuries, so you send him back to radiology for a CT of the distal tibia and ankle. Fortunately, CT does not reveal any displacement or fragmentation, as can occur with these fractures. After orthopedic consultation, the patient is admitted to the hospital with a bulky posterior splint and no weight-bearing until definitive surgical repair can take place in the morning. You wish the family luck since the triplane fracture carries quite a bit of risk for growth dysfunction no matter what is done due to significant damage to the growth plate.

Risk Management Pitfall:

“My patient has anterior ankle pain but I don’t see any evidence of a fracture on her x-rays.” Always look closely at the mortise views to best see the distal tibia, and pay close attention to make sure spacing around the mortise is equal.

Ottawa Ankle Rules:

The Ottowa Ankle Rules state radiographs are only required when there is an ankle/midfoot injury with:
• Bony tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
• Bony tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
• Bone tenderness at the base of the fifth metatarsal (for foot injuries)
• Bone tenderness at the navicular bone (for foot injuries)
• An inability to bear weight both immediately and in the emergency department for 4 steps

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Management of Pediatric Knee Injuries

Case Study:
In the middle of a rather chaotic shift in the ED, you pick up a chart that notes a chief complaint of knee injury in a 14-year-old male. The adolescent and his family have emigrated from Nigeria and speak broken English, but they are able to explain he was playing basketball when this injury oc¬curred. You wonder if any further history is helpful or if you should just send him for radiographs. With a little more investigating you discover he was “faking” a shot when this injury occurred and there was no contact with another player. His physical exami¬nation reveals tenderness surrounding the patella and proximal tibia, but his pain appears out of proportion to the degree of acute swelling you notice. You explain to the family that pain control is going to be started with hydro¬codone, and radiographs will follow.

Is this adolescent more likely to have a fracture or a ligamentous injury based on his age, history, and physical examination? Do the clinical decision rules regarding knee injuries apply to the pediatric patient? Do the injury pat¬terns in this adolescent differ from those in an 8-year-old or a 17-year-old? If his knee radiographs are inconclusive, what should you do? What are the latest trends in treating pediatric anterior cruciate ligament (ACL) injuries?

Case Study Conclusion:
The 14-year-old Nigerian basketball player who presented to the ED with knee pain after playing basketball came back from radiology without an obvious finding on his radiograph. Further questioning revealed after “pump-faking” a shot, he had intense anterior knee pain and has been unable to ambulate since. He had previously been healthy without any chronic symptoms. His degree of ten¬derness with palpation around the patella and proximal tibia were still concerning. He was sent back for compari¬son views of the uninjured knee. Upon closer comparison, a slightly higher riding patella was noted in the injured knee, and there appeared to be a small “fleck” of bone where the inferior patella normally resides. With his pain now under better control, he was still unable to extend the knee which confirmed the diagnosis. This young athlete had a patellar “sleeve” fracture after a forceful contraction of his quadriceps. After consultation with orthopedics, he was discharged home in extension with a knee immobi¬lizer and instructions for no weight-bearing. Follow-up the next day confirmed the diagnosis and surgical repair was arranged.

Risk Management Pitfalls:

1. “I found a large, traumatic effusion of the knee in my patient who was involved in a motor vehicle accident, but I could not find any evi¬dence of a fracture.” Knee dislocations of the femur and tibia may spontaneously reduce before arriving to the ED. A high degree of suspicion should be main¬tained for this dislocation because of the risk of neurovascular injuries which may necessitate amputation. If a dislocation is suspected, ortho-pedic consultation and admission with frequent neurovascular checks are essential.

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