Fractures and dislocations may damage adjacent blood vessels and nerves. The most common location is the distal humerus (supracondylar fracture) and the knee (dislocation and physeal fracture). It is necessary to perform and document a careful neurovascular examination distal to the fracture (pulse, sensory, and motor function).
Compartment syndrome is an orthopedic emergency that results from hemorrhage and soft tissue swelling within the tight fascial compartments of an extremity. This can result in muscle ischemia and neurovascular compromise unless it is surgically decompressed. The most common sites are the lower leg (tibial fracture) and arm (supracondylar fracture).
Affected patients have severe pain and will eventually have decreased sensation in the dermatomes supplied by the nerves located in the compartment. Swollen and tight compartments and pain with passive stretching are present. This can happen underneath a cast and may actually occur when a cast is applied too tightly. It is important to educate all patients with fractures on the signs of compartment syndrome and ensure that they realize it is an emergency.
Figure 198-2 The types of growth plate injury as classified by Salter and Harris. See text for descriptions of types I to V. (From Salter RB, Harris WR: Injuries involving the epiphyseal plate, J Bone Joint Surg Am 45:587–622, 1963.)
This is an oblique fracture of the distal tibia without a fibula fracture. There is often no significant trauma. Patients are usually 1 to 3 years old, but can be as old as 6 and present with limping and pain with weight bearing. There may be minimal swelling and pain. Initial radiographs do not always show the fracture; if symptoms persist, a repeat x-ray in 7 to 10 days may be helpful.
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Child abuse must always be considered in the differential diagnosis of a child with fractures, especially in those younger than 3 years (see Chapter 22). Common fracture patterns that should increase the index of suspicion include multiple fractures in different stages of radiographic healing, metaphyseal corner fractures (shaking), fractures too severe for the history, or fractures in nonambulatory infants. Although spiral fractures of long bones were historically considered pathognomic for abuse, they can be seen in nonabuse situations.
When there is concern for child abuse, the child should have a full evaluation, which may include admission to the hospital. A thorough and well-documented physical examination should focus on soft tissue injuries, the cranium, and a funduscopic examination for retinal hemorrhages or detachment. A skeletal survey or a bone scan may be helpful in identifying other fractures.
The hip is a ball (femoral head) and socket (acetabulum) joint that is important for skeletal stability. The femoral head and acetabulum are interdependent for normal growth and development. The femoral neck and head, which contain the capital femoral epiphysis, are intra-articular. The blood supply to this region is unique because the blood vessels are extraosseous and lie on the surface of the femoral neck, entering the epiphysis peripherally. Thus, the blood supply to the femoral head is vulnerable to trauma, infection, and other causes that may increase intra-articular pressure. Damage to the blood supply can lead to avascular necrosis.