Pediatrics Case #2

History and Physical11 yo male presents to

ED after sustaining an injury to his right leg after being kicked by a cow. Per the pt’s mother, he has not been able to bear weight on the extremity since the accident and he is c/o excruciating pain. No other injuries to report.

T: 98.3 P: 96 BP: 110/74 R:20 O2: 100%

Gen: NADHENT: no traumatic abnCV/Resp: RRR, CTAMSK: swelling /

ecchymosis involving medial portion of R ankle.

Ext: 2+ DP/PT pulse, pain with dorsi/plantar flexion

Mild swelling noted to medial malleolus (R).

Imaging

Diagnosis: Salter Harris IV

M

P

E

Fracture noted to extend from metaphysis though epiphysis

Good neurovascular examReduce significant angulation or obvious

deformity in combination with good analgesia or sedation +/- hematoma block.

For displaced fractures, get ortho involved as will likely need ORIF

For non-displaced fractures, splint and ortho follow up.

Repeat neurovascular exam after splinting

ED Management

Crosses physis as fracture involves both epiphysis and metaphysis

Associated with a worse outcome than type I-III.

If any displacement, involve ortho as ORIF is required

Even with perfect reduction growth may still be affected.

Pearls

Additional Images

http://www.feinberg.northwestern.edu/emergencymed/residency/ortho-teaching/pediatrics/case23/case23diagnosis.html

http://www.parkhurstexchange.com/challenge/analyze/may08/salter-harris

http://www.wheelessonline.com/ortho/salter_harris_type_iv

Menkes, J.S. Orthopedic Injuries. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide Chapter 267

References