Pediatric Case of the Week 14: Take a break

During an evening shift you take a moment to check the latest NCAA Men's Basketball Tournament scores hoping that your picks will garner you praise and respect in the ECC NCAA Tournament Pick'em challenge.  The nurse comes to you wondering "should I order an xray for the kid in room 11,  I think he broke his arm?"  You say yes (having always encouraged aggressive triaging and rapid initiation of patient work ups).  You then return your attention to the latest score update only to find that half of your first round picks have lost and that you will likely be the laughing stock of the department.  (But at least you didn't pick the Lakers.)

The Xrays are completed more rapidly than you would have expected:

You decide it is time for you to evaluate the patient and proceed to room 11 where you find a healthy appearing 7 year old boy sitting with his right arm flexed and supported against his chest.

He also happens to be a basketball fan and reports that he injured his arm while, "trying to dunk." More specifically, two of his friends tried to "loft" him into the air by clasping their hands together and heaving, or rather jettisening, him towards the basket.  He "overshot" his target and "broke his fall"with his right arm.  He denies any other injuries.  Denies head strike and has full recall of the incident.  He is right handed.

His vitals are normal.  On exam you observe a swollen right forearm which is tender to palpation.  He has normal sensation distally and good capillary refill.  He has some tenderness at the distal radius. His motor function is limited by pain but seems to be intact. No other injuries are noted.

He asks you who you picked in the first round of the NCAA tournament, and you confess.   He replys, "seriously!?!?" then laughs dismissively while shaking his head and rolling his eyes simultaneously.


What is your next step or steps:

1.  Go to the break room to watch basketball while "unintentionally" withholding analgesia.
2.  Administer age/wt appropriate analgesia, get additional films of the wrist and if negative place him in a sling; then discharge to home with pcp follow-up in 1-2 weeks.
3. Administer analgesia, hem... haw...., call Orthopedic Surgeon and ask him/her to review the films (only to have them say..."I don't have access to the PACS system in my private jet.")
4.  Administer Ketamine and attempt to reduce the deformity.
5. Place him in a long arm splint, provide him with a sling, instruct him to elevate the arm 3x daily, and have him follow up with an orthopedic surgeon in 4 days.

Pediatric Fractures are often unique compared to adults.  What are some common pediatric fractures of the wrist/forearm and how should you manage them?