Paediatric Skeletal Trauma

Paediatric Skeletal Trauma Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Guidelines for the Management of Paediatric Skeletal Trauma Contact Name and Job Title (author) Directorate & Speciality Contact Dr Clare Dieppe Author Dr Shafique Ahmad, Dr James Hunter, Dr Clare Dieppe Paediatric Emergency Department Acute Medicine and Family Health Directorate Date of submission Introduced Jan 2011 Reviewed June 2013 Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words June 2018 Children and young people presenting with musculoskeletal injuries to Paediatric Emergency Department This guideline describes the management and referral of musculoskeletal injuries in children., skeletal, paediatric, musculoskeletal Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasi-experimental study 3 well designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) 4 expert committee reports or opinions and / or al experiences of respected authorities 5 recommended best practise based on the al experience of the guideline developer Consultation Process 4 Audit, literature review and expert consultation between orthopaedic and emergency departments Many thanks to original contributions from Dhavapalani Alagappan & Mustafa Kendeel (Paediatric Emergency Specialist Registrars) & the paediatric emergency medical & nursing staff for comments and amendments. Target audience Medical and nursing staff working within the Emergency Department This guideline has been registered with the trust. However, al guidelines are guidelines only. The interpretation and application of al guidelines will remain the responsibility of the individual ian. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Dr Clare Dieppe p1 of 21 August 2013 1

Sections A. General B. Time critical conditions C. Juxta physeal injuries D. Open fractures E. Upper limb injuries 1. Shoulder girdle 2. Humerus 3. Elbow 4. Forearm 5. Wrist 6. Hand F. Lower limb injuries 1. Femur 2. knee 3. Lower leg 4. Ankle 5. Foot G. Cervical spine injuries. H. Thoracic and Lumbar spine injury. I. Joint aspirations J. Short Guide to Preferred Plasters and Splints for common injuries Dr Clare Dieppe p2 of 21 August 2013 2

A. GENERAL Remember to check and record the neurovascular status distal to any fracture. Choose analgesia appropriate to the injury. o Options to consider are: Oral paracetamol ibuprofen oramorph Intranasal diamorphine Intravenous morphine titrated to response Digital nerve blocks Fascia iliaca block/ femoral nerve block Always examine the joint above and below any injury and if necessary X ray these joints. Remember to consider NAI in all children with fractures, especially those less than 2 years of age. Mobility and developmental stage should be taken into account before you decide if the mechanism of injury is consistent with the fracture. If you have concerns seek senior ED/Paediatric advice. If you have any doubts about how to assess suspected #, diagnose or manage paediatric musculoskeletal injury speak to a senior ED doctor. Children under 2 years old usually require full limb POPs to avoid them coming off. If in doubt ask the ED nursing staff. Dr Clare Dieppe p3 of 21 August 2013 3

B. TIME CRITICAL CONDITIONS Some orthopaedic injuries must be recognised as time critical. Immediate attention to ABC and assessment of the following is required: Vascular compromise/lack of pulse / ischaemia of limb distal to injury (remember to document capillary refill time). Distal neurological deficit. Ischaemic skin tented over displaced or angulated fracture or a dislocated joint. Open fractures. Massive soft tissue damage. Dislocated joints. Dr Clare Dieppe p4 of 21 August 2013 4

C. JUXTA PHYSEAL INJURIES Salter Harris classification of juxta-physeal fractures The Salter-Harris Classification is: Type I - fracture through the physis( growth plate)- possible widening of growth plate Type II - fracture partway through the physis extending up into metaphysis (M) Type III -fracture partway through the physis extending down into the epiphysis (E) Type IV -fracture through the metaphysis, physis, and epiphysis - can lead to angulation and deformities when healing. (ME) Type V - crush injury to the physis. D. OPEN FRACTURES Aim to reduce risk of infection. Appropriate analgesia. Take photographs with the Polaroid camera. Apply a saline soaked gauze and plaster slab if possible IV cefuroxime ± metronidazole if not allergic to either. Check tetanus status refer to ED protocol. Think of compartment syndrome. Dr Clare Dieppe p5 of 21 August 2013 5

E-UPPER LIMB FRACTURES 1.SHOULDER GIRDLE Site Notes Treatment Referral / Follow Up Sterno-clavicular Requires significant Urgent Senior ED dislocation force. May be associated advice. with major injuries. Analgesia Broad arm sling if isolated injury Acromio-clavicular Analgesia. dislocation BAS Clavicular fracture Uncomplicated Analgesia. BAS Skin tented, or evidence Urgent senior ED/. of neuro-vascular compromise Ortho input Scapular fracture Unusual injury requiring significant force. Other Analgesia BAS if isolated. Anterior Shoulder dislocation. injuries likely. Check axillary and radial nerve function and distal pulses. injury Children over 12 years- Manipulation with sedation and analgesia supervised by senior ED doctors in resus area. Shoulder immobiliser Re-X-ray. Posterior Shoulder dislocation Shoulder dislocation with fracture Rare in children Easily missed Light bulb sign on X-ray Children under 12 years BAS Analgesia Admission for manipulation. Analgesia BAS Analgesia BAS for admission/reduction for admission/reduction for admission/reduction Dr Clare Dieppe p6 of 21 August 2013 6

2. HUMERUS Site Notes Treatment Referral d neck of Check axillary nerve Minimally displaced- humerus function. Collar and cuff (C&C) Analgesia. Displaced ED Senior d shaft of humerus Check radial nerve function. Minimally displaced- Collar and cuff (C&C) 90 O flexion Analgesia May need U slab for comfort Displaced fracture- May need manipulation ± fixation Dr Clare Dieppe p7 of 21 August 2013 7

E- 3. ELBOW INJURIES A small piece of bone about the elbow joint may represent an avulsion fragment or an ossification centre. A guide to remember the ages at which these ossification centres appear is given below: Ossification centre Age at which they appear C- capitulum 2 years R- radial head 4 years I- internal ( medial) epicondyle 6 years T- trochlea 8 years O- olecranon 10 years E- external (lateral) epicondyle 12years Dr Clare Dieppe p8 of 21 August 2013 8

3. ELBOW Site Notes Treatment Referral Supracondylar Check brachial artery and Undisplaced fracture: fracture median nerve function. Collar and cuff in > 100 o High risk of neurovascular flexion damage Analgesia Displaced fracture: Rest on pillow Analgesia. No fracture but This indicates a joint BAS obvious anterior effusion- suspect bony Analgesia. and posterior fat injury. pads visible. Isolated anterior fat pad can be a normal finding Fat pads must be raised off bone to warrant referral not merely visible Lateral Rare in children, check it Collar and cuff epicondyle isn t lateral condyle Analgesia. Lateral condyle Undisplaced BAS Displaced BAS & admit Medical Risk of ulnar nerve damage. Collar and cuff epicondyle fragment could be Analgesia +/- fracture displaced- Actively look for the fragment. Olecranon Generally the elbow should be placed at 90 degrees Dislocated radial head Radial head or neck The radial head should always be in line with the capitulum. The radial head should always be in line with the capitulum Look for ulnar fracture may be a plastic deformity Pulled Elbow History of being pulled / tugged by the arm X-ray not needed if no definite history of trauma Undisplaced fracture: Analgesia Above elbow back slab Displaced fractures: BAS Analgesia BAS Analgesia BAS Analgesia Manipulation Observe the child to ensure child is using the limb as normal. Advice parents not pull/lift child by their hands/wrist. If still not using despite manipulation arrange ED review within 48 hours. Discharge Dr Clare Dieppe p9 of 21 August 2013 9

4-FOREARM Site Notes Treatment Referral Ulnar shaft Isolated fractures of the ulna Undisplaced fracture: are rare. Above elbow back slab. 90 Look for associated radio degrees at elbow ulnar joint dislocations or a Analgesia radial fracture. Displaced or complex fractures:. Analgesia Back slab Monteggia Analgesia of proximal 1/3 of ulna in association with anterior dislocation of radial head- Unstable injury Radial shaft Isolated fracture is rare, look for an associated fracture of ulna or dislocation of radio ulnar joint Galeazzi of radial shaft( junction between mid and distal 1/3) with inferior radio ulnar joint dislocation.- unstable injury Above elbow Back slab, 90 degrees at elbow Undisplaced fracture: Above elbow back slab. 90 degrees at elbow Analgesia Displaced fracture: Above elbow back slab. 90 degrees at elbow Analgesia Analgesia Above elbow back slab. 90 degrees at elbow Dr Clare Dieppe p10 of 21 August 2013 10

5.WRIST Site Notes Treatment Referral Distal radius The following injuries do not need a POP but need a futura splint: Dorsal buckle Minor buckle Dorsal green stickvolar cortex intact Futura splint Angulated/displaced fractures. May be suitable for manipulation in department. See poster in plaster room and guideline Colles backslab Colles backslab Undisplaced Green stick fractures involving both cortices Scaphoid Injuries Other carpal bones Carpal dislocation Bruised or sprained wrists Rare in children under 10 yrs. Normal X-ray (but al Assess for ASB tenderness, wrist suspicion): pain on axial thumb compression Futura splint and tenderness in scaphoid tubercle. Analgesia Request X-ray scaphoid views DO NOT REFER possible scaphoid # s without full Positive X-ray: scaphoid series Futura splint Unusual injuries. Avulsion fracture: Futura splint Other fractures: Futura splint Wrist will usually be very Analgesia swollen. Senior ED input- urgent Frequently overlooked- reduction needed if median high index of suspicion nerve injury suspected needed. Below elbow back slab High risk of median nerve injury. No demonstrable fractures Analgesia, future Discuss with ED senior re: follow up if concerned. > 10 yr < 10 yr discharge, return 2 weeks if probs Discharge with advise Dr Clare Dieppe p11 of 21 August 2013 11

6.HAND Site Notes Treatment Referral Thumb metacarpophalangeal joint dislocation Attempt reduction in all cases. Button holing of the capsule by the metacarpal head common and closed reduction frequently fails if reduction successful. If reduction fails refer to SpR on for hands Thumb metacarpal head Assess for ulnar collateral ligament laxity- gamekeeper s thumb. Minimally displaced or undisplaced fractures, Ulnar collateral laxity:- futura with thumb extension 1 st metacarpal head has an ossification centre which could be mistaken for a fracture. Displaced fractures, especially those involving the joint Refer for manipulation. Thumb metacarpal base Look for fracturedislocation (Bennett s fracture) at the carpometacarpal joint Reduce in ED-seek senior ED input. futura with thumb metacarpal in extension Failed reduction requires referral. +/- fracture Other metacarpals Neck fractures Shaft / base fractures Proximal and middle phalanges Assess for rotational deformity, extension lag. If considerable swelling/crush injuries- consider compartment syndrome Bedford splint, +/- bandage, HAS Check for rotational deformity and extension lag. Minor Minimally displaced fractures, minor flakes and buckles - Bedford splint. Significant displacement: May need manipulation, discuss with senior ED doctor Multiple metacarpal fractures: Often require assessment and elevation for compartment syndrome, discuss with senior ED doctor. Avulsion fractures and buckles: bedford splint Other fractures: bedford splint.. Clinic # Dr Clare Dieppe p12 of 21 August 2013 12

Proximal and middle phalanges displacements can be manipulated in ED discuss with the senior ED doctor. Fingertip injuries Remember to consider nail bed injury. D/W senior ED doctor for nail bed repair Significant displacement or rotation/ spiral fractures: D/W senior ED doctor for referral for possible MUA. Nail bed repair /plastics input as appropriate. Many do not need repair in children Senior ED doctor F. Lower limb injuries 1.FEMUR Site Notes Treatment Referral Slipped Upper Femoral Epiphysis Occurs as a chronic problem or acutely as a Salter Harris I fracture. Analgesia (SUFE) Remember that knee pain could be from a hip pathology. Femoral shaft IV Fluids/cross match blood Check for distal neurovascular status. Consider NAI, detailed history and documentation is vital Intravenous/intranasal opiate analgesia prior to X-ray / splint application. D/W senior ED doctor regarding traction, splinting and appropriate nerve blocks. Femoral condylar and supracondylar fractures If displaced, high incidence of neuro vascular injury Intravenous/intranasal opiate analgesia prior to X-ray / splint application. Consider long leg slab for comfort. Dr Clare Dieppe p13 of 21 August 2013 13

2. KNEE Tips Lipohaemarthrosis implies a fracture Locking suggestive of meniscal tear or loose body. Giving way suggestive of ligamentous / meniscal tear or patella instability. Immediate swelling indicates haemarthrosis therefore? bony / ligamentous injury. In a child with knee pain always assess hips Poor fitting, or too large Richard s splint use wool & crepe Site Notes Treatment Referral Patellar fractures Check for extensor mechanism integrity(slr) Patellar Usually dislocates dislocation laterally. Often reduced spontaneously before arrival. Can be reduced in Tibial spines fractures Meniscal injuries. Osgood- Schlatter s ED with Entonox. Associated with Cruciate ligament tears lipohaemarthrosis Often caused by twisting injuries with knee flexed and weight bearing. Traction apophysitis of proximal tibia Tiny avulsions: Richard splint, crutches, analgesia. Reduction, Richard s splint and crutches. Recurrent dislocations can be treated with analgesics following reduction Analgesia- Richard s Splint Analgesia, if knee locked needs referral to Ortho Registrar Clinical diagnosis. X-ray not usually required, Analgesia follow- GP up. Dr Clare Dieppe p14 of 21 August 2013 14

3.LOWER LEG Sites Notes Treatment Referral Tibial shaft High risk of compartment Minor buckles: above knee backslab syndrome, if in doubt Undisplaced fracture: discuss with senior ED above knee backslab doctor Toddler s lower 1/3 of tibial shaft May need admission, elevation and observation. Most tibial shaft # s following significant injury are admitted in a full cast for observation. Often with minimal trauma, which may not even be elicited The child presents with a limp or refusal to weight bear. X-ray changes may take 10 days to occur. Fibular fractures Proximal fractures are associated with ankle injuries.( maisonneuve fracture) Look for ankle diastasis Check for common peroneal nerve injury. Displaced fracture: Back slab, analgesia. Normal X-ray and minimal symptoms: Normal X-ray but significant pain & non wb or abnormal xray - above knee backslab or buggy or full cast if unlikely to stay on Distal injuries below knee backslab Proximal injuries above knee backslab discharge with advice Dr Clare Dieppe p15 of 21 August 2013 15

OTTAWA ANKLE RULES for Ankle Injury Radiography In children give some thought to applicability of Ottawa ankle rules Indications for an ankle X-ray- Ottawa ankle rules The patient complains of pain in the malleolar zone and any of the following: bone tenderness at A, or bone tenderness at B, or inability to weight bear both immediately after the injury and in the Emergency Dept. Indications for a foot X-ray The patient complains of pain in the midfoot zone and any of the following: bone tenderness at C, or bone tenderness at D, or inability to weight bear both immediately after the injury and in ED. Dr Clare Dieppe p16 of 21 August 2013 16

4.ANKLE Site Notes Treatment Referral Ankle Sprain Consider physiotherapy referral in grossly swollen ankles Occasionally crutches are required. Discharge Lateral malleolus Avulsion fracture Aim to mobilise early Malleolar fractures Look for talar shift. Tillaux fracture is avulsion of the anterolateral epiphysis of the lower end of tibia by the tibio fibular ligaments Triplane fracture - typically occurs in adolescents, refers to three fractures of the tibia: a vertical fracture through the epiphysis, a horizontal fracture through the physis, and an oblique fracture through the metaphysis. Twisting injuries produce this type of fracture. These are effectively sprains and are treated symptomatically Undisplaced fracture: - Below knee backslab and crutches. Displaced fractureslook for dislocation, any sign of impending ischaemia of skin and distal neurovascular deficit. Discharge if minor avulsion to GP with advise /. 5.FOOT Site Notes Treatment Referral Calcaneal Usually following a.below knee walking cast fractures fall from a height. Displaced or intra articular Check for associated knee, hip and spinal injuries. fractures: Need elevation to prevent swelling, may need surgery Request specific calcaneal views. 1 st Metatarsal Buckle fracture: Can be treated symptomatically. Below Knee walking POP Undisplaced / displaced fracture: Below knee POP. Dr Clare Dieppe p17 of 21 August 2013 17

Other Metatarsals Look for intermetatarsal joint disruption- Lis franc s fracture Compartment syndrome could occur in crushed/swollen feet Phalanges Xrays are only required if you suspect the MTPJ is involved or dislocation of an IP joint or rotational deformity Buckle fracture: Can be treated symptomatically Minimally displaced fracture: Treated symptomatically with crutches±below knee walking POP. Displaced or multiple fracture Analgesia, elevation Neighbour strapping only if very displaced, otherwise d/c with advice Dr Clare Dieppe p18 of 21 August 2013 18

G. CERVICAL SPINE INJURIES Injury to the cervical spine is rare in children, but should always be considered following significant trauma. The cervical spine should be presumed to be injured until proven otherwise, especially if there is obvious injury above the clavicle. In a co-operative or unconscious child immediate in-line manual immobilisation of the head and neck should be applied until a stiff-neck semi-rigid collar with sandbags and tape can be fitted. If the child is uncooperative or combative, sandbags and tape should not be used as this may do more harm than good. Children who have experienced trauma, who are: - alert and conversant, - not intoxicated, - have no neurological abnormality, - no midline cervical tenderness, - no painful distracting injury (e.g. long bone fracture, visceral injury, burns etc.) are at very low risk of cervical spine injury and do not require cervical spine X-rays. Children who have experienced trauma who cannot meet these criteria will require lateral, AP c-spine and open mouth X-rays. Remember the lateral view must include upper border of T1. If inadequate views are obtained, a CT should be considered rather than repeated X-rays. A collar should only be removed if a doctor is confident there is no al or radiological evidence of c-spine injury. If there is any doubt ask for a senior ED opinion. Remember SCIWORA-Spinal Cord Injury Without Radiological Abnormality. It is rare but it does occur in children, hence the need for al as well as radiological clearance. Dr Clare Dieppe p19 of 21 August 2013 19

H. INJURIES OF THE THORACIC AND LUMBAR SPINE Injuries to the thoracic and lumbar spine are rare in children. They are most common in the multiply injured child. When an injury does occur, it is not uncommon to find multiple levels of involvement because the force is dissipated over many segments in the child s mobile spine. This increased mobility may also lead to neurological involvement without significant skeletal injury. The most common mechanism of injury is hyperflexion, and the most common radiographic finding is a wedge- or beak-shaped vertebra resulting from compression. The most important al sign is a sensory level. Neurological assessment is difficult in children, and such a level may only become apparent after repeated examinations. Log roll as soon as is practicable and remove spinal board to transfer child onto a firm emergency department trolley. Refer all spinal fractures to the spinal team for further assessment/opinion I. JOINT ASPIRATIONS Seek senior ED /Orthopaedic advice prior to aspiration. Perform under aseptic conditions in ED theatre. The indications in ED are Diagnostic: Suspected septic/infected joint Therapeutic: Tense painful haemarthrosis (aspiration of fat globules indicates a possible underlying fracture) Dr Clare Dieppe p20 of 21 August 2013 20

J. Short Guide to Preferred Plasters and Splints for common injuries Obvious bent arm or leg POP slab for initial analgesia immediately (not plastic splint) Undisplaced fractures of distal radius and ulna- not involving volar cortex - Futura Splint Minimally displaced or undisplaced distal radius and ulna involving volar cortex - Colles backslab. Minimally displaced mid/proximal radius and ulna fractures above elbow backslab Scaphoid fractures futura splint for both suspected and confirmed scaphoid Displaced metacarpal fractures bedford and high arm sling Minimally displaced metacarpal fractures - bedford Thumb - all into futura with thumb extension unless orthopaedic SpR wants Bennets - and then they need to arrange with plaster room to do cast or do it themselves Distal tibia and/or fibula and metatarsal fractures below knee backslab Minimally displaced mid/proximal tibia and fibula fractures above knee backslab, or full cast Toddler fractures above knee backslab, otherwise buggy cast or full cast Knee problems Richard splints, unless not one small enough and then wool and crepe ankle and direct blow distal fibular - below knee back slab foot - below knee walking cast Dr Clare Dieppe p21 of 21 August 2013 21