Establishing an accurate diagnosis is the most important step in managing childhood injuries. Most major management errors are due to an inaccurate diagnosis. The evaluation of the injured child is difficult because injuries are sometimes multiple, the child is frequently uncooperative, and the emergency situation makes a thorough evaluation difficult.
Diagnostic errors are most significant in the child sustaining polytrauma, as subtle fractures are easily overlooked and musculoskeletal injuries are the common cause of residual disability. In the polytraumatized child, musculoskeletal injuries seldom cause death but are a common cause of residual disability.
Make the first priority the evaluation of the pulmonary, cardiovascular, and neurologic status. Musculoskeletal priorities include cervical spine injury, joint dislocations (especially the hip), and unstable and open fractures.
The history should include the situation, velocity, mechanism, and any unique features of the accident. Be aware that a history of trauma may cloud the diagnosis of a more serious problem.
Most diagnostic errors are due to an incomplete physical examination. Perform a screening examination first. Look at the whole child. Look for obvious deformity and spontaneous movement. Pseudoparalysis in the child or infant is commonly due to trauma.
Remove any splints or bandages so the examination can be complete. Look for deformity and swelling, and localize the point of maximum tenderness (PMT). Identifying the site of injury by physical examination is very important because much of the immature skeleton is unossified and difficult to image. Determining the PMT is one of the most important steps in diagnosing occult injuries in children.
Evaluate the vascular status. Be aware that the pulse is inadequate as a test of circulation. Observe the capillary refill rate and observe the child’s reaction while extending the fingers or toes. Pain on passive stretching is an early sign of ischemia. Compartment syndromes may be silent in children.
Imaging for Trauma
The vast majority of trauma problems can be satisfactorily imaged by conventional radiographs. Comparative radiographs of the opposite side are rarely necessary in evaluating injuries in the child. Order comparative views only for special needs, such as assessing ossification irregularities. Subtle fractures are often identified by an unexpected change in the cortical contour. Soft tissue swelling may indicate the presence of a fracture that may not otherwise be apparent.
Ordering special imaging First consider additional radiographic views. Oblique radiographs may show a fracture that is suspected from the physical findings but not seen in the standard AP and lateral screening radiographs. Displacement of articular or physeal fractures must be determined. Additional oblique projections may provide further information that may be helpful in deciding whether to accept the current reduction. Special imaging studies are indicated in certain situations when conventional radiographs provide insufficient information. The selection of the type of imaging is based on the examination findings and on a knowledge of common injury types typical in the childs age group.
Arthrography may be useful in assessing cartilagenous injuries.
Bone scans are useful in screening for injuries. Order a highresolution study to pinpoint the exact location of a suspected fracture. For example, if “gsnuff-box” tenderness is found on physical examination and the radiographs are negative, order a high-resolution scan to determine if the scaphoid is fractured.
MRI studies require deep sedation of the infant and younger child and therefore have limited indications. Order these studies when suspecting such serious problems as spinal or nonaccidental injury.
Ultrasound studies are underutilized. Consider ultrasonography when evaluating such conditions as a possible physeal separation of the distal humeral epiphyseal complex in the newborn.
Arthroscopy may be helpful for evaluation of articular injuries when radiographic studies are negative.