Pediatric emergency medicine trisk 3421 3421

A history of a traumatic event with physical examination findings of a painful
extremity or body part with swelling, obvious deformity, or the inability to use
the extremity all suggest a significant musculoskeletal injury. Less severe injuries
may be more difficult to diagnose as they may present with only mild swelling or
a history of not using the extremity normally. For long bone injuries, the joints
above and below the injured extremity must be examined for possible associated
injuries.
Triage Considerations
Children presenting with significant pain or with a grossly deformed extremity
should be evaluated immediately by the emergency clinician. A focused
neurovascular assessment should be performed. Those children with a more
subacute presentation (e.g., trauma occurred the day prior), and those with
minimal pain may be seen less urgently.
Clinical Assessment
The injured extremity should be inspected for swelling and deformity, and the
joints above and below the injury should be examined. The skin should be
examined for ecchymosis, abrasions, lacerations, soft tissue defects, or exposed
bone. If an open wound is present, the location, degree of contamination, and rate
of active bleeding should be documented. The neurovascular status should be
determined by examining the motor and sensory function distal to the fracture
site. The pulses should be palpated and capillary refill assessed.
Management
Imaging. In addition to the physical examination, the history and knowledge of
the most common injuries for a specific age group can guide the choice of
radiographic studies. The radiographs should generally include the joints
proximal and distal to the fracture, particularly when examination may be limited
by pain or immobilization. At least two views taken at 90 degrees to one another
(i.e., anteroposterior and lateral views) should be obtained. When routine views
do not identify a fracture, but clinical suspicion is high, oblique or other
additional views may be useful. With the degree of normal variability, especially
with the immature bone, comparison views of the contralateral extremity may be

helpful to determine if a radiographic finding is a traumatic injury,
developmentally normal, or an anatomic variant.
In addition to plain radiography, advanced imaging may be indicated for
further evaluation of the injury. For complex, intra-articular, or spine injuries,