Rosen & Barkin's 5-Minute Emergency Medicine Consult (250 page)

• Competitive and recreational injuries
  
• Traumatic injuries
  
• Child abuse
  
• Extreme cold
  
• Radiation injury
  
• Genetic, neurologic, and metabolic disease
  

DIAGNOSIS

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

• 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
    

• Radiographs to classify the extent of the injury
  
• Assess pulses and capillary filling distal to injury.
  
• Evaluate distal motor and sensory function.
  
• Verify integrity of skin overlying injury.
  
• Address and manage coexisting injuries.
  

• Plain radiography of injured extremity:
  
  • Type I fractures:
    
    • Usually normal
      
    • May appreciate a slightly separated physis or an associated joint effusion
      
    • Consider comparison views of contralateral joint to 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.
      
• Ultrasound can be helpful in infants whose cartilage has not ossified.
  
• CT scan: Helpful in assessing orientation of comminuted fragments
  
• 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
    

• Strain
  
• Sprain
  
• Contusion
  

TREATMENT

• Immobilize limb in position found if no compromise in vascular status
  
• Apply ice or cold packs to injury.
  
• Assess injured extremity for neurologic and vascular function.
  
• Consider concomitant injuries.
  

• Analgesia
  
• Apply sterile dressings to open wounds.
  
• Control bleeding of open wounds.
  

• Reduction/alignment required in displaced fractures:
  
  • Need to achieve anatomic alignment
    
• Vascular or neurologic compromise distal to injury requires immediate intervention.
  
• Immobilization of all suspected or radiographically confirmed physeal injuries:
  
  • Splint must immobilize joint proximal and distal to injury in anatomic alignment and neutral position.
    
  • Limit activity of the injured limb.
    
• Open fractures:
  
  • IV antibiotics for
    Staphylococcus aureus
    , group A streptococcus, and potential anaerobes depending on mechanism and after cultures are obtained
    
  • Copious irrigation with saline
    
  • Sterile dressing
    
  • Orthopedic consultation
    
• Consultation:
  
  • Open fractures
    
  • Type II with displacement and Types III and higher
    

Pain management:

• Fentanyl: 2–3 μg/kg IV; transmucosal lollipops 5–15 μg/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 h IM, or IV in 4–6 div. doses—has better strep and corynebacterium coverage—for farm injuries
  
• Gentamicin: 5–7.5 mg/kg/d—for obviously contaminated injuries
  

FOLLOW-UP

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

• 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
  

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

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

• Involves periodic physical exam and radiographic evaluation
  

• 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.
  

• RathjenKE,BirchJG. Physeal injuries andgrowth disturbances. In: BeatyJH,Kasser JR,eds.
  Rockwood & Wilkins’Fractures in Children
  . 6th ed.Philadelphia, PA:Lippincott Williams and Wilkins;2006:11.
  
• Rodríguez-Merchán EC. Pediatric skeletal trauma: A review and historical perspective.
  Clin Orthop Relat Res
  . 2005;432:8–13.
  
• Salter R, Harris W. Injuries involving the epiphyseal plate.
  J Bone Joint Surg
  . 1963;45:587–622.
  
• Wilkins KE, Aroojis AJ. Incidence of fractures in children. In: Beaty JH, Kasser JR, eds.
  Rockwood & Wilkins’ Fractures in Children
  . 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  

CODES

• 812.09 Other closed fracture of upper end of humerus
  
• 813.42 Other closed fractures of distal end of radius (alone)
  
• 813.43 Closed fracture of distal end of ulna (alone)
  

BASICS

• Nosebleeds are a common emergency presentation that is usually minor and self-limited but rarely may be life threatening:
  
  • Lifetime incidence of ∼60%:
    
    • The incidence decreases with age, with most cases seen in children <10 yr.
      
    • Male > female
      
    • Severe bleeds requiring surgical intervention are more common in patients >50 yr.
      
    • Occurs more frequently with low humidity during the winter, in northern climates, and at high altitude
      
• The nasal cavity is supplied with blood vessels originating from both the internal and external carotid arteries.
  
• Location of the hemorrhage determines therapy:
  
  • Anterior epistaxis (90% of cases): Bleeding can be visualized in anterior nose.
    
    • Most commonly bleeding is located at Kiesselbach plexus, an anastomotic network of vessels on the anteroinferior nasal septum.
      
    • Rarely, bleeding is found on the posterior floor of the nasal cavity or the nasal septum.
      
• Posterior epistaxis (10% of cases): Bleeding source not within range of direct visualization.
  
  • Posterolateral branch of sphenopalatine artery
    

• Idiopathic:
  
  • Dry nasal mucosa (low humidity)
    
• Nasal foreign body:
  
  • Children, mentally retarded patients, psychiatric patients
    
• Infection:
  
  • Rhinitis
    
  • Sinusitis
    
  • Nasal diphtheria
    
  • Nasal mucormycosis
    
• Allergic rhinitis
  
• Trauma:
  
  • Nose picking
    
  • Postoperative
    
  • Facial trauma
    
  • Barotrauma
    
• Environmental irritants:
  
  • Ammonia
    
  • Gasoline
    
  • Sulfuric acid
    
  • Glutaraldehyde
    
• Intranasal neoplasia: Most commonly Papilloma
  
• Coagulopathy:
  
  • Hemophilia A or B
    
  • Von Willebrand disease
    
  • Thrombocytopenia: Liver disease, leukemia, chemotherapy viral illness, or autoimmune disease.
    
  • Platelet dysfunction: Renal impairment or chronic alcohol consumption
    
• Drug induced:
  
  • Salicylates
    
  • NSAIDs
    
  • Heparin
    
  • Coumadin
    
• Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease)
  
• Atherosclerosis of nasal vasculature
  
• Endometriosis