Acute and Non-acute Lower Extremity Pain in Pediatrics
Acute and Non-acute Lower Extremity Pain in Pediatrics
Definition A foreign object is found imbedded in soft tissue or bone.
History of Present Illness
Physical Examination
Diagnostic Tests Anteroposterior, lateral, and potentially oblique radiographs of the affected site should be obtained.
Treatment
Definition A fracture is an injury to the bone causing a break in the cortical surface. It can include both sides with disruption of alignment.
Characteristics of Pediatric Fractures
Common Pediatric Fractures
History of Present Illness A fracture usually presents with a history of trauma. The patient may report pain over a bony prominence. Swelling and bruising may be visible. The patient may limp or be non–weight bearing.
Physical Examination
Diagnostic Tests
Treatment
Definition Non-accidental trauma (NAT) is a non-accidental injury to a minor younger than 18 years.
History of Present Injury
Detailed Medical History
Child Development
Social History
Physical Examination
General Assessment
Skin Evaluation
Skeletal Evaluation
Neurologic
Thoracoabdominal
Diagnostic Tests
Treatment
Definition A strain or sprain is an injury to the muscle (strain) or ligaments (sprain); it most commonly affects the ankle and is caused by a plantar flexion and inversion injury where the lateral ligaments are affected, including the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. A strain or sprain is caused when the ligaments or muscles are stretched beyond their normal limits and tearing of the fibers occurs.
History of Present Illness
Physical Examination
Diagnostic Tests
Treatment
Prevention
(American Academy of Orthopaedic Surgeons, 2011,Morrissy and Weinstein, 2006,Omey and Micheli, 1999, Sullivan and Anderson, 2000)
Traumatic Conditions
Foreign Body
Definition A foreign object is found imbedded in soft tissue or bone.
History of Present Illness
The patient or his or her parents may report a traumatic history of a foreign object being imbedded in the skin, puncture wounds, a skin wound, or even a limp (if the foreign object is in the foot)
Signs of redness or swelling may be reported
A thorough history of the incident should be obtained, including the nature, timing, any known foreign materials involved in the accident, and the amount of wound contamination
The patient should be evaluated for the type, location, and radiation of pain, any redness, swelling, or discharge from the wound, and neurologic symptoms
The patient should be evaluated for immunization status, specifically tetanus, allergies, current medications, and preexisting medical conditions
Physical Examination
The wound should be evaluated for signs of a foreign object, redness, swelling, or discharge
A musculoskeletal and neurovascular examination of the affected area should be performed
Diagnostic Tests Anteroposterior, lateral, and potentially oblique radiographs of the affected site should be obtained.
Treatment
Most cases are treated successfully in the emergency department
Often both a physical examination and radiographs are needed to sufficiently exclude the presence of a foreign object
Antibiotics are sometimes prescribed
The patient may be referred to general surgery if the object is in soft tissue and is not easily visible and removable
The patient may be referred for orthopedic surgery if the injury involves bone (Bass and Levis, 2010,Levine et al., 2008)
Fracture
Definition A fracture is an injury to the bone causing a break in the cortical surface. It can include both sides with disruption of alignment.
Characteristics of Pediatric Fractures
Biomechanical considerations
Decreased mineralization and increased vascular channels
Decreased modulus of elasticity causing the same stress to result in increased strain
Plastic deformity can occur
Anatomic considerations
Presence of growth plates
Apophysis
Secondary growth center
Site of tendon attachment
Thick periosteum
Assists with reduction and decreased angulation
May become interposed between fracture fragments
Potential for remodeling ( Mathison & Agrawal, 2001)
Common Pediatric Fractures
Fractures involving the physis (i.e., growth plate), Salter Harris (SH) classification: Pose risk of growth arrest
SH1: Involves only the zone of cartilage between the epiphysis and the metaphysis; separation may not be visible on radiographs
SH2: Transcends the metaphysis and physis
SH3: Transcends the epiphysis and physis
SH4: Transcends the epiphysis, physis, and metaphysis
SH5: Compression of physis
Buckle (torus) fractures
Plastic deformation
Greenstick fractures
History of Present Illness A fracture usually presents with a history of trauma. The patient may report pain over a bony prominence. Swelling and bruising may be visible. The patient may limp or be non–weight bearing.
Physical Examination
Point tenderness to palpation over the affected area
Redness, swelling, or bruising may be visible
The patient may be limping if the lower extremity is involved
Perform a neurovascular examination
Be aware of the possibility of compartment syndrome, especially in acute lower extremity fractures
Pain out of proportion to injury, tight swollen tissue planes, and most specifically, significant pain with passive/active pain with toe motion
Requires emergent evaluation
Open fractures must be evaluated emergently ( Morrissy & Weinstein, 2006)
Diagnostic Tests
Multiview radiographs of the affected area
If no obvious fracture is found but point tenderness is present over the physis, consider an SH1 fracture if the child is skeletally immature
Treatment
Splint the injury initially
Refer to an orthopedic surgeon if you are not comfortable with casting and/or if the fracture involves physis, evidence of displacement, or angulation
If the fracture involves physis or may require surgical intervention, refer within the first week (i.e., before the beginning of callous formation, which may make any treatment more complex) (Beaty and Kasser, 2001,Canale and Beaty, 2007,Mathison and Agrawal, 2001,Morrissy and Weinstein, 2006)
Non-accidental Trauma
Definition Non-accidental trauma (NAT) is a non-accidental injury to a minor younger than 18 years.
History of Present Injury
Description of injury
Detailed description including timing of injury, witnesses, caregivers present, and the mechanism of injury
The following details of the history are a cause for concern:
An explanation inconsistent with child's developmental level
An explanation inconsistent with the level of injury severity
No history of trauma or a vague explanation for significant trauma
A description inconsistent with the pattern, age, or severity of the injury or injuries
Variable explanations among witnesses regarding the injury
A previous referral to child protective services
A history of abuse in any family member ( Kellog & The Committee on Child Abuse and Neglect, 2007)
Detailed Medical History
Prior injuries, hospitalizations, and chronic illnesses
Family history of bony syndromes, fragile bones, bleeding disorders, and genetic syndromes
Pregnancy (including complications, expected/unexpected, postpartum pregnancy) ( Kellog & The Committee on Child Abuse and Neglect, 2007)
Child Development
Gross/fine motor and language milestones ( Kellog & The Committee on Child Abuse and Neglect, 2007)
Social History
Caregivers involved in the child's care
Family beliefs regarding discipline
The child's temperament
Stressors in the home (e.g., financial or social)
Family support and resources available to them
Violence among family members ( Kellog & The Committee on Child Abuse and Neglect, 2007)
Physical Examination
General Assessment
Height/weight/head circumference
Overall temperament
Nutritional state
Overall appearance, paying attention to signs of neglect
Skin Evaluation
Identify the location/size/shape of marking/bruising/bites of various ages/"pattern" injuries
Evaluate the entire body including the mouth, extremities, buttocks, and torso
Identify any unusual locations for accidental injuries
Photograph skin injuries
Skeletal Evaluation
Test the range of motion of all extremities
Palpate and inspect all long bones, the spine, and ribs for pain to palpation, deformity, erythema, and bruising
Neurologic
Evaluate for any cranial injuries
Perform an ophthalmic evaluation for retinal hemorrhage
Evaluate deep tendon reflexes, muscle tone, Babinski sign, and clonus
Thoracoabdominal
Perform an abdominal examination to evaluate for acute intraabdominal injuries
Perform a cardiopulmonary examination ( Kellog & The Committee on Child Abuse and Neglect, 2007)
Diagnostic Tests
Perform a skeletal survey, especially in children younger than 5 years
"Bucket handle" or corner metaphyseal fractures are considered specific for NAT given the significant shearing, pulling force required to cause these injuries
Long bone spiral fractures, especially in a non-ambulatory child, are a concern for NAT, but the mechanism of injury must be evaluated (lower extremity spiral fractures occasionally can occur from exersaucers, cribs, etc.)
Multiple fractures of various ages and rib and skull fractures are a concern for NAT ( Di Pietro et al., 2009)
Order aspartate aminotransferase, alanine aminotransferase, amylase, lipase, and urinalysis tests
Order a computed tomography (CT) scan of the head and consider a CT scam of the abdomen, especially with abnormal laboratory results ( Di Pietro et al., 2009)
Perform an ophthalmology examination
Treatment
All acute/non-acute injuries should be treated with involvement of subspecialists as needed
Specific state laws are provided by the Children's Bureau: www.childwelfare.gov/systemwide/laws_policies/search/index.cfm (Child Welfare Information Gateway, 2007, Child Welfare Information Gateway, 2008)
Involvement of local community child abuse team(s) who have expertise in evaluation of suspected child abuse may be required; if they are not available, identify local resources with pediatric experience in the evaluation of suspected child abuse case(s), such as a social worker or pediatric health care provider (Kellog and The Committee on Child Abuse & Neglect, 2007,Stoodley, 2002,Sugar, Taylor, Feldman, 1999)
Referral to Child Protective Services
Notify the child's primary care provider
Admission to a local hospital experienced in caring for and evaluating children in cases of suspected child abuse (Child Welfare Information Gateway, 2007,Child Welfare Information Gateway, 2008; Di Pietro et al., 2009; Stoodley, 2002; Sugar, Taylor, Feldman, 1999)
Strain/Sprain
Definition A strain or sprain is an injury to the muscle (strain) or ligaments (sprain); it most commonly affects the ankle and is caused by a plantar flexion and inversion injury where the lateral ligaments are affected, including the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. A strain or sprain is caused when the ligaments or muscles are stretched beyond their normal limits and tearing of the fibers occurs.
History of Present Illness
Swelling
May have significant pain or refuse to bear weight
Physical Examination
Tender to palpation over soft tissue, but no tenderness over bony areas or growth plates
May have laxity on the anterior/posterior drawer test
Tender over the anterior talofibular ligament, calcaneofibular ligament, or posterior talofibular ligament
Diagnostic Tests
Negative radiographs of ankle if obtained (anteroposterior, lateral, and mortise views)
Treatment
Conservative treatment initially: non-steroidal anti-inflammatory drugs (NSAIDs) as needed
R.I.C.E.:
Rest the injury by not using it
Ice should be immediately applied to reduce swelling; it can be used for 20 to 30 minutes, three or four times daily; combine ice with wrapping to decrease swelling, pain, and dysfunction
Compression dressings, bandages, or Ace wraps immobilize and support the injured joint
Elevate the injured joint above heart level for 48 hours
Consider immobilizing in a brace if the patient has pain with ambulation and increase weight bearing as tolerated
Physical therapy, including proprioception therapy
If no resolution occurs with conservative treatment, or if the patient has recurrent sprains, consider referring him or her to an orthopedic surgeon
Prevention
The best way to prevent ankle sprains is to maintain good strength, muscle balance, and flexibility
Warm up before doing exercises and vigorous activities
Pay attention to walking, running, or working surfaces
Wear good shoes
Pay attention to your body's warning signs and slow down when you feel pain or fatigue
(American Academy of Orthopaedic Surgeons, 2011,Morrissy and Weinstein, 2006,Omey and Micheli, 1999, Sullivan and Anderson, 2000)