Pediatric emergency medicine trisk 3461 3461
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Consensus opinion of the American Academy of Orthopedic Surgeons supports
emergent closed reduction of displaced injuries with decreased perfusion of the
hand and/or urgent evaluation for those with perfused hands without palpable
distal pulse. Vascular consults/vascular studies should not delay attempted
repositioning for the nonperfused hand. If the limb is pulseless and nonperfused,
and emergent orthopedic consultation is hours away, the potential benefit of
immediate manipulation must be weighed against potential delay in transfer to
definitive care. If the ED clinician determines emergent manipulation is
necessary, gentle traction and repositioning of the elbow in slight flexion with
reassessment of the pulse may be considered. If this fails to improve vascular
status, immediate consultation with an orthopedic and/or vascular surgeon is
indicated. For the patient with a perfused hand, but no distal pulse detected by
Doppler, immediate evaluation by or transfer to a facility with vascular or
microsurgery services should be obtained.
Disposition . Nondisplaced type I supracondylar fractures may be discharged
after placement in a long arm splint, with urgent orthopedic follow-up for casting.
If casted in the ED, children may be discharged with orthopedic follow-up as
directed. Gartland type II and type III supracondylar fractures and displaced
flexion fractures require orthopedic consultation. Many of these injuries need
emergent operative repair, as noted above, or admission for observation of
neurologic and vascular status prior to going to the operating room typically
within 24 hours. However, there is institutional variability on disposition for
Gartland type II injuries. If neurovascularly intact and only minimally displaced,
then it is reasonable to discuss with the orthopedic consultant about splinting with
discharge to scheduled outpatient management. Patients with concern for vascular
injuries should be referred for emergent orthopedic evaluation as noted above.
Often the patient is flexed slightly at the elbow upon presentation. For transport,
it is generally best to splint the patient in the position of comfort. If flexion is
increased during splint application, the patient may develop neurovascular
compromise; if this occurs, gently lessen the degree of flexion while assessing for
return of the pulse.
Lateral Condyle Fractures
CLINICAL PEARLS AND PITFALLS
