Minor injuries Series: Episode 1 with thanks to Dr Jessica Spedding, PEM trainee, Royal London Hospital, UK

Introduction to minor injuries:

Minor injuries in children are common and mostly self limiting soft tissue injuries that heal with time. Some injuries are particular to paediatrics (pulled elbow) and others are simply much more common in children than adults (supracondylar fracture). Another consideration specific to children is consideration of growth plate involvement, which if does not heal in a good position could lead to asymmetry and growth problems. Injuries involving the growth plate are graded as Salter-Harris 1,2,3,4, or 5 and they will be discussed in more detail in a future episode of this minor injuries series.

Your assessment:

You need a systematic approach that assesses for important injuries that need specific management.  Your
assessment must always include consideration of non accidental injury (NAI). A sensible approach would include:

– Is the mechanism of injury described consistent with the injury sustained?

– Has the child reached the appropriate stage of development to have sustained the injury in the way described?

– Is there any delay in presentation?

– Has the child (or siblings) presented numerous times before with injuries?

– There is an excellent set of pamphlets that give evidence based guidance on when injuries point to abuse – go to www.core-info.co.uk or look out for the summaries on Paediatric Pearls

Upper limb injuries:

You may have come across the acronym FOOSH. This is a Fall On the Out-Stretched Hand. This mechanism is the natural response to a fall – in order to protect our head and trunk, the reflex is to put our arms out to break our fall. This mechanism causes a number of different injuries, each more prevalent in different age groups (but common in other age groups too).  Roughly speaking these could be sequenced as follows:

Age 1-3: distal radius fracture (usually greenstick or torus) or middle third clavicle fracture

Age 4-8: supracondylar fracture (varying degrees of severity, some of which require operative fixation)

Age 9-adulthood: distal radius fracture or scaphoid fracture

However one must still examine unclothed the whole limb to be sure that all sites of injury have been located. In the upper limb this would be from
fingers to shoulder, clavicle and possibly neck, in the lower limb this would be from toes to hips but also checking the pelvis and lower spine.

The first chapter in this series looks at a common elbow problem:

Pulled elbow: (see also http://www.paediatricpearls.co.uk/2012/02/pulled-elbow/)

Proper name – radial head subluxation, mechanism is usually a sudden pulling of the child by their hand (such as to stop them running into the road or swinging a child in play), child presents having cried initially, but soon settles but refuses to use the arm, holding it slightly flexed at the elbow with the arm by their side. When you go to assess them they have no swelling or bruising or distal neurovascular compromise, but are very apprehensive about you trying to bend or pronate/supinate the elbow. In up to half of cases there may not be a “pull” mechanism in which case be more cautious in assuming the diagnosis. Don’t forget a clavicle fracture may present this way. If you feel sure the diagnosis is pulled elbow, attempt a reduction as follows:

Hold their hand as though you were going to shake hands, with your other hand gently cupping underneath the elbow, with elbow partially flexed, then firmly pronate (rotate to palm up position). You should feel the clunk of a reduction, but if not, try a firm supination (back to palm down position).  Ideally do this half an hour after some analgesia. If you do not feel a clunk it is probably not reduced but either way stop after two attempts, and then allow the child to be somewhere relaxing and ask their parent to let you know if they start playing – if reduced most will soon realise the pain with movement has gone and start playing normally within a few minutes. If not reassess and consider a differential diagnosis which may include referral for xray.