Disclosure. Pediatric Orthopedic Emergencies. I have no actual or potential conflict of interest in relation to this program or presentation.

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1 Pediatric Orthopedic Emergencies Robin Pearce MSN, RN-BC Trauma Performance Improvement Manager Henrico Doctors Hospital, Forest Disclosure I have no actual or potential conflict of interest in relation to this program or presentation. 1

2 Objectives Review epidemiology of pediatric orthopedic emergencies Review differences from adults Review injury types seen exclusively in children Review factors impacting injury severity Review most common pediatric orthopedic emergencies Objectives Discuss what damage control orthopedics means Review pediatric orthopedic injuries that look emergent Discuss basic management and nursing implications Discuss injury prevention 2

3 Pediatric Trauma Injury is the most common cause of death in children over one year in age Unintentional injury leading cause of non-fatal ED visits 20-30% of trauma patients have an orthopedic injury CDC, National Center for Injury Prevention and Control Pediatric Orthopedic Injury Before age 16: Boys have a 42% chance of fracture Girls have a 27% chance of fracture Fractures severe enough to require hospitalization 7% EB Medicine 9/28/17 3

4 Pediatric Orthopedic Injury Upper extremity more common than lower Lower more likely to require surgical repair Most fractures sustained after a fall Incidents related to competitive sports increasing Differences from Adults Long bones less dense and more porous-tend to bow or buckle under stress Periosteum is thicker-less likely to have an open fracture and less displaced than same injury in an adult 4

5 Differences from Adults Ligaments are stronger than the bone-thus ligamentous injuries are less frequent Impact on Injury Pattern Differences result in 4 unique injury patterns Plastic deformation (bowing) Torus (buckle fractures) Greenstick fractures Physeal fractures (Salter-Harris fractures) 5

$radial fracture$

6 Plastic deformation Radial bowing Bowing of radius and ulna Torus Incomplete radial fracture Proximal humeral buckle fracture 6

7 Greenstick fracture Salter-Harris 7

8 Salter-Harris II Predicting Injury Severity Injury Mechanism High Impact MVA Fall from height Motorcycle/ATV Low Impact Ground level fall Sports accidents 8

9 Predicting Injury Severity Concurrent Injuries Head injuries Visceral injuries Burns Soft tissue Predicting Injury Severity Associated Injuries Vascular Neurologic Comorbidities Systemic Musculoskeletal 9

$fracture of humerus Usually resolve$ $on their own Pelvic fractures$

10 Neurologic Most commonsupracondylar fracture of humerus Usually resolve on their own Pelvic fractures Compartment syndrome So is Ortho No Big Deal? 10

11 When is it an EMERGENCY? Open fractures Compartment syndrome Vascular compromise Worsening neurologic exam Femoral neck fractures Acute dislocation of major joints Open or septic joints Open Fracture Open fractures occur when a fractured bone is exposed to contamination from the external environment through a disruption of the skin and subcutaneous tissues and are susceptible to infection. 11

$Types of Open Fractures Type I wound < 1 cm Type II 1-10cm Type III A > 10 cm, high energy adequate tissue for coverage includes segmental / comminuted fractures even if wound <10cm$

12 Types of Open Fractures Type I wound < 1 cm Type II 1-10cm Type III A > 10 cm, high energy adequate tissue for coverage includes segmental / comminuted fractures even if wound <10cm farm injuries are automatically Gustillo III Type IIIB extensive periosteal stripping and requires free soft tissue transfer Type IIIC vascular injury requiring vascular repair Type I 12

13 Type II Type IIIC 13

$Management To OR for surgical irrigation and debridement within 24 hours Goal-skin closed over fracture during first OR visit Coverage$

14 Management To OR for surgical irrigation and debridement within 24 hours Goal-skin closed over fracture during first OR visit Coverage completed within 7 days from time of injury Nursing Care Assessment Splint Pain medication IV Antibiotics Prepare for washout in ED if delay to OR 14

15 Compartment Syndrome Increased pressure within a closed anatomical space. any area of the body which contains a compartment can be affected hand, forearm, upper arm, entire lower extremity, abdomen, and buttocks. As the intra-compartmental pressures increase and exceed the perfusion pressure, tissues become ischemic and may become necrotic 15

16 Nursing Assessment The Traditional 6 P s Pain Paresthesia Paresis Pallor Pulselessness Poikilothermia ***intracompartment Pressure Measuring Pressure 16

17 Treatment Treatment 17

$Fractures with Vascular Compromise Biggest risk-supracondylar Fractures 60-80% of all pediatric elbow fractures Peak incidence 5-7 years Presents with swollen, painful elbow, LROM, may have obvious$

18 Fractures with Vascular Compromise Biggest risk-supracondylar Fractures 60-80% of all pediatric elbow fractures Peak incidence 5-7 years Presents with swollen, painful elbow, LROM, may have obvious deformity Significant bruising a risk factor for compartment syndrome Potential injury to brachial artery, radial, median and/or ulnar nerve A) Type I supracondylar fracture showing anterior fat pad (sail sign) and posterior fat pad sign with normal anatomic alignment of anterior humeral line (black line). (B) Type II posteriorly displaced supracondylar fracture with large effusion. (C) Type 3 supracondylar fracture with severe and complete displacement of the distal segment. 18

19 Vascular Structures at Risk in Orthopedic Trauma Signs of Vascular Injury 19

20 Treatment Patient presents with no pulse Reduce If perfusion not restored, patient to the OR Pulse lost after reduction The vessel is caught in the fracture site, patient to the OR Deteriorating Neurologic Exam Stable neurologic exam Observe or explore at time of treatment Deteriorating neurological deficit Nerve is compressed, stretched or entrapped Reduce and explore before permanent disability 20

21 Common Nerve Injuries Radial nerve palsy Ulnar nerve Common Nerve Injuries 21

22 Nursing Care Assessments with documentation Splinting Elevation Ice Pain Control Frequent reassessments Femoral Neck Fractures 22

23 Dislocations Shoulder Elbow Hip Knee Ankle Elbow dislocations 6 months to 6 years Left elbow most common Lacks swelling and point tenderness X-rays are normal Recurrence in 30% 23

24 Open Joint Injury Soft tissue injury that penetrates the joint space Increase risk of joint infection Damage Control Surgery Goal to eliminate death threats in trauma Metabolic acidosis Hypothermia Coagulation disorder Seen in multi-trauma patients Injuries that need to rest 24

$fractures Femur$

25 External Fixator Things that make you nervous if you used to be an Adult nurse Pelvic fractures Femur fractures Badly displaced fractures 25

26 Pelvic Fractures In adults high risk for blood loss More force required for child to break pelvis More likely to have single fracture Lower rate of vascular disruption and bleeding Intrapelvic viscera not well protected Pelvic Fractures Rare in children, 0.3-4% of pediatric injuries 20% of poly-trauma victims have pelvic ring injuries 58-87% of children with pelvic fractures have associated injuries Death most commonly due to head injury, rarely to exsanguination 26

27 Femur Fractures Causes Infants under a year Child abuse 1-4 Child abuse Adolescents Motor vehicle accidents- cars, bikes or pedestrian Femur Fracture 27

28 Displaced Fractures Child Abuse Considerations Have a high index of suspicion Children need an advocate Higher fatality rate 28

Injury Prevention Proper fitting equipment Appropriate safety

29 Injury Prevention MVCs Correct use of restraints Bikes Helmet use Driver awareness Pedestrian Driver awareness Sports Injuries Injury Prevention Proper fitting equipment Appropriate safety devices Falls Parent/care giver awareness Baby gates, window bars 29

Questions? References American College of Surgeons (n.d.). ACS TQIP Best Practices in the Management of Orthopaedic Trauma. Retrieved from: https://www.facs.

30 Questions? References American College of Surgeons (n.d.). ACS TQIP Best Practices in the Management of Orthopaedic Trauma. Retrieved from: Arora R. (May 2014). Pediatric Upper-Extremity Fractures. Pediatric Annals 43 (5): Retrieved from: Bickle I, Jones J. ( ). Bowing fracture. Radiopaedia. Retrieved from: EB Medicine (9/28/2017). An Evidence-Based Approach to Pediatric Orthopedic Emergencies. Retrieved from: Gallared F, Weerakkody Y. ( ). Torus fracture. Radiopaedia. Retrieved from: Mavrogenis A, et al.(july/august 2016). Vascular Injury in Orthopedic Trauma. Orthopedics 39 (4): Retrieved from: Murugappan K. (August 8, 2017). Pediatric Femur Fractures. Medscape. Retrieved from: No author. (n.d.) Femoral Neck Fractures. Pediatric Orthopaedic Society of North America. Retrieved from: Guide/Femoral-Neck-Fractures Swensen S. (n.d.). Pelvic Fractures. Pediatric Orthopaedic Society of North America. Retrieved from: Weerakkody Y, Radswiki, et al.( ). Greenstick fracture. Radiopaedia. Retrieved from: 30

Pediatric Fractures. Objectives. Epiphyseal Complex. Anatomy and Physiology. Ligaments. Bony matrix

Pediatric Fractures. Objectives. Epiphyseal Complex. Anatomy and Physiology. Ligaments. Bony matrix 1 Pediatric Fractures Nicholas White, MD Assistant Professor of Pediatrics Eastern Virginia Medical School Attending, Pediatric Emergency Department Children s Hospital of The King s Daughters Objectives