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Fractures are one of the most common emergency department presenting symptoms in children. Although the injury is often obvious, a thorough history and physical is necessary to identify specific injury patterns or concerns for abuse. In general, the primary objective of an initial visit to care should include
Muscle groups in extremities are contained within specific facial "compartments". When there is an increase in intra-compartmental pressure (due to bleeding, etc.) that is greater than the arterial perfusion pressure, ischemia may develop within the compartment. Early identification and relief of pressure in these cases is key to prevention of further injury.
Symptoms:
Examination findings:
Injuries that result in fracture may also injury adjacent arterial blood supply, especially when there are sharp bone fragments. Without proper blood supply further injury to the extremity or poor wound healing may occur.
All suspected fractures should include a distal vascular and neurologic evaluation immediately upon presentation. Immediate reduction and immobilization is required for any fracture associated with neurovascular compromise (lack of pulses, cool extremity, mottled color or loss of sensation)
Making the diagnosis of child abuse can be very difficult. The core tool to correctly identify children at risk for abuse is the clinical history and physical.
The history of a traumatic event was absent in 64 – 97% of cases of abusive head injury in a retrospective series. In fact, the absence of history of trauma has a high specificity 97% and high positive predictive value for abuse. In addition, 60% of victims of abusive head injury have a history or clinical evidence of previous abuse.
Behavioral clues
Symptom clues
Physical clues
The Ottawa ankle rules are a validated decision rule that has very high sensitivity and moderate specificity giving it a good negative predictive value for fracture. Use of the rule has shown significant (36%) reduction in unnecessary x-ray usage.
The Ottawa knee rules are a clinical decision rule to evaluate for the need for x-rays. They have good sensitivity (98-100%), but poor specificity and thus a good negative predictive value which is good for ruling out a fracture.
