September- Pediatrics Part 2

[Kyle Feldman]

A 9 year old female presents to your clinic with complaints of left elbow and wrist pain after she landed on the left side while skiing with her cousins over the weekend. Her parents (your neighbors) decided to take her to you for an initial consult and advice of the next steps. She’s very fearful of moving the left elbow and wrist. She also will not use the left arm to lift her backpack or even books. No bruising or abnormal skeletal deformities present.
Please read the below articles to assist with this case.

Questions for thought:

What additional information during your subjective and objective clinical evaluation can guide your differential diagnoses?

What other factors must you consider with this patient in regards to her age?

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[awilson12]

Subjective questions- history of previous orthopedic injuries and fractures, activity level and nutrition, PMH (specifically looking for anything that may alter BMD), what able to use arm for if anything, swelling after injury, specifics about the fall
Objective- palpation, ROM, tuning fork, ligamentous testing to determine irritability and (+) findings to guide treat or refer

Because of age have to consider patients ability to communicate and level of understanding, coping mechanisms for pain, motivating factors (to use or not use arm), emotional status

[Steven Lagasse]

Subjective:
– Further questioning about the fall: FOOSH vs. direct impact on elbow/wrist; was she skiing at a fast speed or slow?
– Past medical history, specifically wanting to know of any possible MSK diagnoses that may move fracture higher up the differential list.
– Attempting to inquire if the patient is having pain or is just scared of experiencing potential pain.
– Was there a previous elbow/wrist injury that was worsened by this fall? And/or prior fractures?

Objective:
Start with AROM and, if tolerated, then move into passive and resisted ROM. I may then move to palpating between extremities (if tolerated), asking if pressure felt different between sides at common fracture sites.

I agree with Anna regarding the patient’s age. It could be the case that a direct line of questioning may not be as helpful. I feel this patient would require a more slow and deliberate examination. Depending on the patient’s affect, I may also opt for a less detailed, so the patient does not feel I am trying to inflict pain. Establishing rapport quickly may also be helpful i.e. making the patient laugh, performing the tests/measures on her parent first, etc.

[Kyle Feldman]

great points

what guidelines could you use to help determine if an x-ray should be prerformed?
Does age, pain, ROM factor into this decision?

Also, would you contact any other providers in this case?

[Steven Lagasse]

Kyle,

I’m unaware of specific guidelines to help me in ruling in a fracture similar to that of Ottawa knee/ankle rules.

I believe the more classic signs/symptoms would be pain at rest/night, fracture quality pain with palpation, unwillingness to perform AROM (pronation/supination), exquisite pain with PROM (pronation/supination), etc. Are there specific guidelines that you’ve come by?

I feel age does play a role. With the pediatric population having more difficulty with communication, especially a 9 year old, I feel playing cautious is the best bet. With that I would likely refer back to the PCP and see if he/she feels xrays are warranted.

[Kyle Feldman]

Steven
you are correct

I tend to use communication with the pediatrician and err on the side of caution and get an image.

There is sadly a lot of data showing missed fx’s from x-rays in PEDS.
So if they do not improve an MRI may be warranted.
I just had a 3 year old the other week with a negative x-ray and there are concerns of a fracture. An MRI is being scheduled in the next month or so if PT does not improve symptoms.

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