Acute and Non-acute Lower Extremity Pain in Pediatrics

Traumatic Conditions

Foreign Body

Definition A foreign object is found imbedded in soft tissue or bone.

History of Present Illness

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  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)
  
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  Signs of redness or swelling may be reported
  
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  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
  
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  The patient should be evaluated for the type, location, and radiation of pain, any redness, swelling, or discharge from the wound, and neurologic symptoms
  
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  The patient should be evaluated for immunization status, specifically tetanus, allergies, current medications, and preexisting medical conditions
  

Physical Examination

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  The wound should be evaluated for signs of a foreign object, redness, swelling, or discharge
  
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  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

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  Most cases are treated successfully in the emergency department
  
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  Often both a physical examination and radiographs are needed to sufficiently exclude the presence of a foreign object
  
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  Antibiotics are sometimes prescribed
  
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  The patient may be referred to general surgery if the object is in soft tissue and is not easily visible and removable
  
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  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

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  Biomechanical considerations
  
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  Decreased mineralization and increased vascular channels
  
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  Decreased modulus of elasticity causing the same stress to result in increased strain
  
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  Plastic deformity can occur
  
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  Anatomic considerations
  
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  Presence of growth plates
  
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  Apophysis
  
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  Secondary growth center
  
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  Site of tendon attachment
  
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  Thick periosteum
  
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  Assists with reduction and decreased angulation
  
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  May become interposed between fracture fragments
  
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  Potential for remodeling ( Mathison & Agrawal, 2001)
  

Common Pediatric Fractures

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  Fractures involving the physis (i.e., growth plate), Salter Harris (SH) classification: Pose risk of growth arrest
  
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  SH1: Involves only the zone of cartilage between the epiphysis and the metaphysis; separation may not be visible on radiographs
  
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  SH2: Transcends the metaphysis and physis
  
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  SH3: Transcends the epiphysis and physis
  
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  SH4: Transcends the epiphysis, physis, and metaphysis
  
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  SH5: Compression of physis
  
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  Buckle (torus) fractures
  
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  Plastic deformation
  
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  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

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  Point tenderness to palpation over the affected area
  
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  Redness, swelling, or bruising may be visible
  
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  The patient may be limping if the lower extremity is involved
  
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  Perform a neurovascular examination
  
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  Be aware of the possibility of compartment syndrome, especially in acute lower extremity fractures
  
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  Pain out of proportion to injury, tight swollen tissue planes, and most specifically, significant pain with passive/active pain with toe motion
  
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  Requires emergent evaluation
  
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  Open fractures must be evaluated emergently ( Morrissy & Weinstein, 2006)
  

Diagnostic Tests

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  Multiview radiographs of the affected area
  
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  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

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  Splint the injury initially
  
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  Refer to an orthopedic surgeon if you are not comfortable with casting and/or if the fracture involves physis, evidence of displacement, or angulation
  
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  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

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  Description of injury
  
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  Detailed description including timing of injury, witnesses, caregivers present, and the mechanism of injury
  
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  The following details of the history are a cause for concern:
  
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  An explanation inconsistent with child's developmental level
  
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  An explanation inconsistent with the level of injury severity
  
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  No history of trauma or a vague explanation for significant trauma
  
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  A description inconsistent with the pattern, age, or severity of the injury or injuries
  
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  Variable explanations among witnesses regarding the injury
  
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  A previous referral to child protective services
  
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  A history of abuse in any family member ( Kellog & The Committee on Child Abuse and Neglect, 2007)
  

Detailed Medical History

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  Prior injuries, hospitalizations, and chronic illnesses
  
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  Family history of bony syndromes, fragile bones, bleeding disorders, and genetic syndromes
  
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  Pregnancy (including complications, expected/unexpected, postpartum pregnancy) ( Kellog & The Committee on Child Abuse and Neglect, 2007)
  

Child Development

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  Gross/fine motor and language milestones ( Kellog & The Committee on Child Abuse and Neglect, 2007)
  

Social History

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  Caregivers involved in the child's care
  
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  Family beliefs regarding discipline
  
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  The child's temperament
  
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  Stressors in the home (e.g., financial or social)
  
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  Family support and resources available to them
  
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  Violence among family members ( Kellog & The Committee on Child Abuse and Neglect, 2007)
  

Physical Examination

General Assessment

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  Height/weight/head circumference
  
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  Overall temperament
  
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  Nutritional state
  
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  Overall appearance, paying attention to signs of neglect
  

Skin Evaluation

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  Identify the location/size/shape of marking/bruising/bites of various ages/"pattern" injuries
  
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  Evaluate the entire body including the mouth, extremities, buttocks, and torso
  
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  Identify any unusual locations for accidental injuries
  
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  Photograph skin injuries
  

Skeletal Evaluation

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  Test the range of motion of all extremities
  
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  Palpate and inspect all long bones, the spine, and ribs for pain to palpation, deformity, erythema, and bruising
  

Neurologic

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  Evaluate for any cranial injuries
  
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  Perform an ophthalmic evaluation for retinal hemorrhage
  
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  Evaluate deep tendon reflexes, muscle tone, Babinski sign, and clonus
  

Thoracoabdominal

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  Perform an abdominal examination to evaluate for acute intraabdominal injuries
  
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  Perform a cardiopulmonary examination ( Kellog & The Committee on Child Abuse and Neglect, 2007)
  

Diagnostic Tests

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  Perform a skeletal survey, especially in children younger than 5 years
  
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  "Bucket handle" or corner metaphyseal fractures are considered specific for NAT given the significant shearing, pulling force required to cause these injuries
  
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  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.)
  
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  Multiple fractures of various ages and rib and skull fractures are a concern for NAT ( Di Pietro et al., 2009)
  
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  Order aspartate aminotransferase, alanine aminotransferase, amylase, lipase, and urinalysis tests
  
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  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)
  
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  Perform an ophthalmology examination
  

Treatment

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  All acute/non-acute injuries should be treated with involvement of subspecialists as needed
  
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  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)
  
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  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)
  
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  Referral to Child Protective Services
  
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  Notify the child's primary care provider
  
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  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

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  Swelling
  
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  May have significant pain or refuse to bear weight
  

Physical Examination

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  Tender to palpation over soft tissue, but no tenderness over bony areas or growth plates
  
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  May have laxity on the anterior/posterior drawer test
  
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  Tender over the anterior talofibular ligament, calcaneofibular ligament, or posterior talofibular ligament
  

Diagnostic Tests

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  Negative radiographs of ankle if obtained (anteroposterior, lateral, and mortise views)
  

Treatment

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  Conservative treatment initially: non-steroidal anti-inflammatory drugs (NSAIDs) as needed
  
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  R.I.C.E.:
  
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  Rest the injury by not using it
  
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  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
  
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  Compression dressings, bandages, or Ace wraps immobilize and support the injured joint
  
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  Elevate the injured joint above heart level for 48 hours
  
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  Consider immobilizing in a brace if the patient has pain with ambulation and increase weight bearing as tolerated
  
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  Physical therapy, including proprioception therapy
  
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  If no resolution occurs with conservative treatment, or if the patient has recurrent sprains, consider referring him or her to an orthopedic surgeon
  

Prevention

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  The best way to prevent ankle sprains is to maintain good strength, muscle balance, and flexibility
  
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  Warm up before doing exercises and vigorous activities
  
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  Pay attention to walking, running, or working surfaces
  
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  Wear good shoes
  
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  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)