Children present with different musculoskeletal injuries than are commonly seen in adults. Because ligamentous attachments are stronger than bony attachments in children, fractures are more prevalent than sprains, dislocations, and strains. This chapter discusses orthopedic injuries that are unique to the pediatric population.
The following terms are typically used in pediatric orthopedics:
Physis: The cartilaginous growth plate that appears lucent on radiographs.
Epiphysis: A secondary ossification center at the ends of long bones that is separated by the physis from the remainder of the bone.
Apophysis: A secondary ossification center at the insertion of tendons onto bones.
Diaphysis: The shaft of a long cortical bone.
Metaphysis: The widened portion at the ends of a bone adjacent to the physis.
It is important to carefully palpate the uninjured extremity first to obtain the child's confidence. It is also important to determine whether the history that is given by the parents or guardians is consistent with the observed injuries or whether there is a suggestion of child abuse.
A subtle fracture may be difficult to find in an injured child who is crying. On physical examination, palpation of areas that are not fractured will generally hurt less than areas that are injured. Palpation should be gentle, but with enough pressure so as to make a comparison between the normal and abnormal.
Neurologic evaluation of the extremity is often difficult. A generalized withdrawal response can be evaluated by using pinprick. Two-point discrimination testing is also useful in determining distal neurologic function in hand and finger injuries. In addition, wrinkling of the skin when the digit is submerged in warm water for approximately 10 minutes suggests that the nerve is intact. In assessing the vascular status of the extremity, palpation of pulses may be difficult because of the subcutaneous fat, and therefore, it is important to assess and document capillary refill time.
When performing plain radiographs of children, at least two views that are perpendicular to one another must be obtained. In addition, views of the entire extremity, including both joints at the end of the long bones, are integral to the patient's evaluation. Comparison views are invaluable, particularly when looking for a subtle fracture. The growth plates in comparison views taken in exactly the same position should be closely evaluated. Anterior and posterior fat pad signs will help identify subtle fractures (Fig. 6–1). The epiphyseal centers can often be a challenge when reading plain films and therefore it is imperative that the practitioner knows when these centers begin to appear (Fig. 6–2).
A subtle Salter III fracture of the elbow is shown on the lateral view. Notice the anterior fat pad and posterior fat pad.