RESCUE ME Pediatric Fractures and Pain Control

1. RESCUE MEPediatric Fractures and Pain Control Mark Urban, MD Pediatric Emergency Medical Director St. Luke’s Regional Medical Center

2. Objectives • Review common pediatric fractures • Review splinting techniques • Review non-medicating techniques for pain control • Ice, Elevation, Compression, Distraction • Review common pain medications • Questions

3. Pediatric CDC Data (2008-2009) Injury related visits per 10,000 Under the age of 18 1351.1 Falls 398.1 Struck by object 239.2 MVC 80.3 Cut or pierce 74.8

4. Pediatric Fractures • Close to 20% of pediatric patients who present with an injury will have a fracture. • 42% of boys and 27% of girls will sustain a fracture in childhood

5. Anatomy Review • Diaphysis • Metaphysis • Physis (growth plate) • Epiphysis • Periosteum

6. Injury Patterns of Pediatric Fractures • Bones tend to BOW instead of BREAK • TORUS force= COMPRESIVE force • BUCKLE fracture • Bone may only break on one side of cortex, either by side impact or compression • GREENSTICK fracture • Neither cortex may break, creating a deformity without fracture (very young children) • PLASTIC deformation

7. Injury Patterns continued… • Metaphysis/physis junction is an anatomic point of weakness • Tendons and ligaments are STRONGER than bone in young children • Bone more likely to be injured by force

8. Physeal Injuries (growth plate) • 20 % of all skeletal injuries in children • Can disrupt the growth of bone • Injuries near but not involving the physis can stimulate the bone to grow MORE

9. Salter Harris Classification

10. Physeal Injuries • Most Common: Salter Harris II • Then I, III, IV, V • Orthopedic referal for III, IV, V • I and II managed with simple splinting/casting. • Important to discuss with family that with any physeal injury, growth disturbance is possible.

11. Distal Radius • Peak injury time correlates with peak growth time • Most injuries result from a Fall On OutStretched Hand (FOOSH) • Nerve injury more likely if significant angulation or swelling • Important to check neurovascular status • Examine joint above and below • Elbow • Scaphoid-anatomic snuff box

12. XRAY

13. Torus Fracture • Usually non-displaced • Can be very subtle (soft tissue swelling) • May not be visualized on lateral X-ray • NO reduction needed • Simple splinting or casting • ER/Pre-Arrival: Volar or sugar tong • Ortho: short arm cast

14. Torus Fractures

15. Greenstick Fracture • Compression of cortex with angulation • Treatment • Non-displaced • Splint or cast • Displaced (>15 degrees) • Reduce and splint • Immobilize in long arm splint/cast

16. Greenstick Fractures

17. Review of Distal Radius Fx’s • Very common • FOOSH • Check neurovascular status • If displaced or angulated >15 degrees, reduce ASAP • Ortho follow up if suspected physeal injury

18. Elbow Fractures • Account for roughly 10% of fractures in children • Diagnosis and management are complex • Most elbow fractures are supracondylar • Check NEUROVASCULAR STATUS!!!(8-21%) • Anterior interosseous nerve • Brachial Artery (5-13%) • Immobilize BEFORE x-ray to reduce chance of further injury.

19. Supracondylar Fracture • Weakest part of the elbow joint • Olecranon is driven into humerus with hyperextension (can opener) • Marked pain and swelling of the elbow • Potential for vascular and nerve compromise • If pulses are absent-reduce ASAP

20. Supracondylar Fracture • Type I- non-displaced or minimally displaced • Type II- displaced distal fragment with intact posterior cortex • Type III- displaced with no contact between fragments

21. Supracondylar Fracture • Most are displaced and require surgery • Type I can be managed with long arm cast/spint • Important to monitor neurovascular status

22. Supracondylar Fracture

23. Lateral Condylar Fracture • 2nd Most common elbow fracture • Most common physeal elbow injury • FOOSH +Varus force: avulsion of lateral condyle • Focal swelling of distal/lateral humerus (lateral condyle) • Intra-articular: requires open reduction/fixation • Non-displaced: posterior splint • Complications: growth arrest, non-union

24. Lateral Condylar Fractures

25. Clavicle Fracture • 80% occur in the MIDDLE third of the bone • FOOSH, fall or direct trauma • Treatment: • Sling vs. figure of eight • Warn parents of healed buldge • If evidence of vascular compromise or significant deformity, consult ortho early

26. Clavicle Fractures

27. Tibia Fractures • Tibia and fibula fractures often occur together • Mechanisms: Falls, twisting motion of foot • Usually not displaced • Refer for displaced fracture, angulation >15 degrees, tib/fib fracture (both bone). • Treatement: • Non-displaced: posterior leg spint • Displaced: ortho referral

28. Toddler’s Fracture • Children less than age 2 learning to walk • No specific fall or injury • Presents with refusal to bear weight on affected leg • Exam the hip, thigh, knee • Non-displace spiral fracture • If Xray’s are normal, may need repeat films in 3-5 days. • Treatment • Long-leg cast, weight bearing as tolerated

29. Toddler’s Fracture

30. Fractures of Abuse • Majority of fractures in a child < 1 year are from abuse • Bone is more elastic: kids bend before they break, takes a significant amount of force to fracture a bone • High percentage of fractures <3yo = abuse • Greater risk of abuse: first-born, premature infants, stepchildren, children with learning or physical disabilities • Most common sites: femur, humerus, tibia (long-bone) • Also: radius, skull, spine, ribs, ulna, fibula

31. Fractures of Abuse • Unexplained fractures in different stages of healing as shown on radiology • Femoral fracture in child < 1 year • Scapular fracture in child without a clear history of violent trauma • Epiphyseal and metaphyseal fractures of the long bones • Corner or “chip” fractures of the metaphyses (Bucket handle deformity)

32. Fractures of Abuse

33. Fractures of Abuse

34. Splinting Techniques • Goal of pre-hospital splinting • Reduce chance of further trauma (neurovasular injury) • Relieve muscle spasm • Reduce swelling • Minimize chance for further displacement • Always check neurovascular status pre/post splinting and while in transport.

35. Splinting Techniques • DO NOT attempt to reduce deformity, unless vascular compromise is present. • Before splinting, make sure to identify open fracture if present • EMS splints: • SAM splints • Vacuum splint

36. SAM

37. Vacuum Splint

38. Pediatric Pain Score • Wong-Baker Faces

39. Rest, ICE, Compression, Elevation • Immobilize injury • Reduce movement, displacement, further injury • Apply ice • Reduce swelling, pain • Compression • Reduce swelling, pain, be cautious to not OVERCOMPRESS and thus reduce blood flow • Elevation • Reduce swelling

40. Distraction • Stranger DANGER • High stress situation • Injured child, concerned parent, chaotic scene • Have parent(s) sit with child, hold them if possible • Perform interventions if possible with parents soothing child (holding hand, in arms, etc.) • Reduces anxiety, better assessment • Use distracters such as stuffed animals, toys • TALK to the child on their level • Avoid using terms that would invoke fear/anxiety

41. Pain Control • Pain is difficult to measure. • We have SUBJECTIVE tools for measurement. • One persons 2 is another’s 10. • If a child is in obvious pain, treat appropriately. • We historically UNDERTREAT Pediatric pain. • Fear of overdosing • Injury is “not” that bad

42. Common Medications • Non-narcotic • Acetaminophen • Ibuprofen • Opioids • Morphine • Hydromorphone • Fentanyl • Anxiolytics (Benzodiazepines) • Midazolam (Versed) • Diazepam (Valium)

43. Acetaminophen • Route: PO/PR/IV • Dose: • 15 mg/kg orally • 30 mg/kg rectally • 7.5-15 mg/kg IV • Mechanism: not completely understood, inhibits COX, highly selective for COX-2 • Limited anti-inflammatory activity

44. Ibuprofen • Route: PO • Dose: 10 mg/kg • Mechanism: inhibits COX, prevents prostaglandin formation • Adverse effects: • Limited antiplatelet function • Can act as a vasocontrictor • May prevent bone healing

45. Morphine • Route: IV/IM/PO • Dose: 0.1 mg/kg IV/IM • Mechanism: • binds to mu-opioid receptor in brain • Agonist • Activation of these receptors causes sedation, analgesia, euphoria, respiratory depression, and dependence. • Adverse effects: • Constipation, respiratory depression, dependence

46. Hydromorphone • Route: IV/IM/PO • Dose: • 0.015 mg/kg IV • 0.03-0.08 mg/kg PO • Mechanism: same as morphine (all opioids) • higher lipid solubility and ability to cross the blood–brain barrier and, therefore, more rapid and complete central nervous system penetration • Adverse effects: same as morphine

47. Fentanyl • Route: IV/IM/IN • Dose: • 1-2 mcg/kg IV or IM • 1.5 mcg/kg IN (sedation) • Mechanism: same as other opioids • Shorter half-life, requires more frequent dosing • GREAT for sedation • Adverse effects: same as other opioids

48. Midazolam (Versed) • Route: IV/IM/PO/PR/IN • Dose: • 6 mos-5 years: 0.05-0.1 mg/kg IV, 0.25-1 mg/kg PO • 6 years-12 years: 0.025-0.05 mg/kg IV, 0.25-1 mg/kg (max of 20 for sedation, 5 for anxiolysis) • Intranasal: 0.5 mg/kg • Mechanism: Short acting benzodiazepine • GABA receptor agonist • Sedative, hypnotic, anxiolytic, anticonvulsant, and muscle relaxant • Adverse effects: respiratory depression, sedation, dependence

49. Diazepam (Valium) • Route: IV/PO/PR • Dose: • 0.2 mg/kg IV • 0.5 mg/kg PR (Diastat) • Mechanism: long acting benzodiazepine • GABA receptor agonist • Sedative, hypnotic, anxiolytic, anticonvulsant, and muscle relaxant • GREAT anticonvulsant • Adverse effects: respiratory depression, sedation, dependence

50. Special Considerations • Pediatric patients are more sensitive to centrally active drugs (benzodiazepines, opioids) • Dose conservatively to avoid adverse effects • Pediatric pain scales are very subjective, use immobilization, elevation, ice, distraction first, then dose with medications. • Constantly REASSESS!!! Injuries will continue to swell, monitor neurovascular status closely.