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Basics

[Section Outline]

Author:

EricaLash

NehaRaukar


Description!!navigator!!

Pediatric bone consists of four segments: The diaphysis or shaft, the metaphysis (the widest region, where bone growth occurs), the physis or growth place, the epiphysis (distal to the growth plate, site of secondary ossification)

Fractures through the physis account for 21-30% of pediatric long bone fractures; 30% leading to a growth disturbance:

Etiology!!navigator!!

Diagnosis

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Signs and Symptoms!!navigator!!

History

  • Most commonly occurs after a fall
  • Extreme cold and radiation can injure the physeal plate

Physical Exam

  • Focal tenderness
  • Swelling
  • Limited mobility
  • If lower extremity involved, patient may be nonweight-bearing
  • Joint laxity:
    • Can be due to physeal injury and not ligamentous injury

Essential Workup!!navigator!!

Diagnostic Tests & Interpretation!!navigator!!

Imaging

  • Plain radiography of injured extremity:
    • Type I fractures:
      • Usually normal
      • May appreciate a slightly separated physis or an associated joint effusion
      • Comparison views of contralateral joint can help detect small defects
      • Callus may be present on follow-up films
    • Types II-IV: Films diagnostic of fracture
    • Type V:
      • Initial film often normal
      • Subsequent radiographs may reveal premature bone arrest
  • US can be helpful in infants whose cartilage has not ossified
  • CT scan: Helpful in assessing orientation of comminuted fragments, usually does not change management
  • MRI:
    • Most accurate in the acute phase of injury
    • Can identify physeal arrest lines
    • Recommended if diagnosis remains equivocal and identification of a specific fracture would alter management

Differential Diagnosis!!navigator!!

Treatment

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Prehospital!!navigator!!

Initial Stabilization/Therapy!!navigator!!

ED Treatment/Procedures!!navigator!!

Medication!!navigator!!

First Line

Pain management:

  • Fentanyl: 2-3 mcg/kg IV; transmucosal lollipops 5-15 mcg/kg, max 400 mg, contraindicated if <10 kg
  • Morphine: 0.1 mg/kg IV/IM

If open:

  • Cefazolin: 25-50 mg/kg/d IV/IM q6-8h
  • Penicillin G: 100,000-300,000 U/kg/24 hr IM/IV in 4-6 DD - has better strep and corynebacterium coverage - for farm injuries
  • Gentamycin: 5-7.5 mg/kg/d - for obviously contaminated injuries

Follow-Up

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Disposition!!navigator!!

Admission Criteria

  • Open fractures
  • Open surgical reduction required
  • Consider with type III and IV fractures

Discharge Criteria and Instructions

  • Low-grade fractures and fractures with higher grade if follow-up is definite
  • Splint
  • Analgesics
  • Ice packs
  • Elevation of affected limb
  • Orthopedic follow-up within 1 wk

Issues for Referral

All injuries involving the physis should follow-up with a musculoskeletal specialist

Follow-up Recommendations!!navigator!!

Usually necessary, especially with higher-grade injuries, to monitor limb length:

Pearls and Pitfalls

  • Long-term complications:
    • Limb length discrepancy if entire growth plate affected
    • Angulation if only a part of the physis is affected
  • In patients with suspected SH fracture and negative radiograph, immobilization with follow-up in a few days is appropriate

Additional Reading

Codes

ICD9

ICD10

SNOMED