Evaluation and treatment of acute musculoskeletal injuries can be rewarding for primary care providers. They are common presenting complaints, and with appropriate management, many patients make a full recovery in a short period of time. This article reviews basic principles of evaluation of acutely injured children, treatment strategies, and common injuries, and gives an overview of similar but more dangerous conditions that require referral.
Key points
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History and examination should be focused.
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Radiographs should be obtained if the diagnosis is in question.
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Most pediatric injuries can be treated with office-based modalities.
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It is important for primary care providers to be able to distinguish the common stable injuries from those that require urgent orthopedic referral.
Introduction
Evaluation and treatment of acute musculoskeletal injuries can be rewarding for primary care providers. They are common presenting complaints and, with appropriate management, many patients make a full recovery in a short period of time. This article reviews basic principles of evaluation of acutely injured children, treatment strategies, and common injuries, and gives an overview of similar but more dangerous conditions that require referral.
Introduction
Evaluation and treatment of acute musculoskeletal injuries can be rewarding for primary care providers. They are common presenting complaints and, with appropriate management, many patients make a full recovery in a short period of time. This article reviews basic principles of evaluation of acutely injured children, treatment strategies, and common injuries, and gives an overview of similar but more dangerous conditions that require referral.
Location of evaluation: office or hospital?
Many pediatric musculoskeletal injuries are the result of ground-level falls, recreational sports, and other low-energy mechanisms. Most of these injuries can be treated nonoperatively with readily available supplies, especially in young children in whom skeletal growth is still occurring.
In general, low-energy injuries can usually be managed an office setting, whereas moderate-energy or high-energy injuries are more appropriate for hospital-based evaluation and management. Factors that increase the energy associated with an injury include increasing age, weight, and size of the child. Falls from heights, bicycles, trampolines, and bunk beds are often moderate-energy injuries and occasionally require advanced care. Injuries from motorized vehicles (motorcycle, car, all-terrain vehicle, snowmobile) should be evaluated in a hospital setting.
History
For children presenting with acute injuries, the history should be focused and not overly broad. The limited history should contain the mechanism of injury, location of pain, and any associated injuries. Injuries occasionally are associated with a pop, snap, or deformity. Details regarding the position of the limb at the time of maximal injury or displacement can reveal the energy imparted during injury. An important aspect of the history is the ability to bear weight after the injury. Inability to bear weight is often an indicator of severe injury, and should have a lower threshold for referral. Patients often do not try to bear weight after the injury. If radiographs are negative for fracture, patients should be encouraged to attempt weight bearing after a short period (2–3 days) of rest. Fractures may be evident as bent or crumpled bones; Box 1 and Fig. 1 give examples of plastic deformation.
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History and physical examination
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The history and physical examination should be focused and not overly broad
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Inability to bear weight may indicate a severe injury
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The point of maximum tenderness should be identified
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Joints proximal and distal to the point of maximum tenderness should be palpated
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Office-based treatments
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Stable injuries can be treated with readily available medical supplies
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Slings, removable splints, rigid plastic boots, tape, and crutches
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Treatment is symptom directed and can be discontinued when symptoms subside
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Knee injuries
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Key: ability to bear weight
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Radiographs are not always needed
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Minor injuries can be treated with rest, ice, and observation
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Severe injuries should be referred to an orthopedic surgeon
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Ankle injuries
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Key: ability to bear weight
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Radiographs are not always needed
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Minor injuries can be treated with removable walking boots
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Proximal humerus and clavicle fractures
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Most are treated in a simple sling with return to activities as tolerated
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Adolescents with displaced or angulated fractures should be referred
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Elbow fractures
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Low threshold for referral to a pediatric orthopedic surgeon
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Proper radiographs, with careful inspection of the radiographs to avoid missing injuries
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Hand fractures
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Metacarpal fractures should be referred
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Finger fractures can often be treated with buddy taping
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Thumb fractures can often be treated in removable thumb spica splints
Physical examination
Much like the history, the physical examination should be focused on the area of injury and not be overly broad. Inspection and palpation are often all that is needed to make an accurate diagnosis.
Begin with inspection for deformity, swelling, and ecchymosis. In order to gain trust with injured children, first ask them to show where they hurt and to show their active range of motion. Carefully palpate for tenderness above and below the point of maximum tenderness. If the patient tolerates it, passive range of motion can be assessed.
As with all injuries, a focused and vascular examination should be performed. Function of the major nerves of the extremities as well as palpation for pulses should be performed. Any neurologic or vascular deficit should immediately be referred to the emergency department for evaluation.
Provocative maneuvers should not be performed in acutely injured patients, because these maneuvers are often painful and can be falsely negative, which is misleading in an acute swollen joint. These maneuvers include the Lachman test, anterior and posterior drawer tests, and stressing of injured joints. If major ligamentous injury is suspected, the patient should receive initial treatment and reexamination in a delayed manner.
Radiographs
Radiograph examination of the injured anatomic area is an important aspect of acute injury evaluation. With modern radiographic techniques, the radiation dose is minimal, and every consideration ought to be given to obtaining appropriate radiographs of the affected area. Radiographic diagnosis is often straightforward and there are many clinically indistinguishable injuries that are easily discernible with proper radiographs (eg, a pelvic apophyseal avulsion from a slipped capital femoral epiphysis [SCFE]). Whenever the pelvis or hips are being examined radiographically, bilateral views, including frog laterals, are necessary.
However, some common injuries do not necessitate radiographs either at initial evaluation or at follow-up. Low-risk ankle injuries (which are usually simple sprains) do not require radiographs. A low-risk ankle injury includes an injury with tenderness and swelling isolated to the distal fibula and/or the ligaments immediately adjacent to the fibula. In these cases, an ankle radiograph is unnecessary, and the clinical diagnosis of ankle sprain can be made. Acute knee injuries wherein the patient can bear weight similarly do not necessitate radiographs. After initial radiographic diagnosis, buckle fractures and most foot, toe, and finger fractures do not need radiographs at follow-up if there is no clinical deformity.
Plastic deformity
Pediatric bone is physiologically different from adult bone because of a myriad of biochemical and histologic factors. Injury often involves plastic deformation of the bone with or without adjacent fracture. Most of these plastic deformations and fractures are stable and require no specific intervention, but it is important to understand the full injury and not miss an associated dislocation. A common location for plastic deformation is the forearm. In some cases, the ulna may be deformed and the radial head dislocated (Monteggia variant).
Office-based treatments
Many minor injuries in children can be treated with readily available off-the-shelf medical equipment including slings, removable splints, tape (for finger and toe fractures), crutches, and off-the-shelf rigid walking boots. A small supply of these items can be stocked in the office, or patients can be referred to local pharmacies and instructed in their use.
Slings
Simple slings are a common treatment of upper extremity injuries. They are the preferred treatment of most shoulder, proximal humerus, and clavicle fractures. A simple sling is equivalent to more sophisticated alternatives in clavicle fractures. Slings should be used judiciously in young children, because often they are an encumbrance rather than an aid. In adolescents, slings are less problematic. Slings are for comfort and may be discontinued when symptoms subside.
Removable Splints
Removable splints are commercially available in a wide range of sizes and are an appropriate treatment of wrist ( Fig. 2 ), thumb, finger, and toe fractures. The general goal of the removable splint is to provide a moderate amount of comfort and immobilization while allowing easy bathing and hygiene. These splints provide support and reassurance and are generally best for stable fractures. Removable splints can generally be discontinued when symptoms subside.
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