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Key Points

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  1. Accurate diagnosis of injuries to the growth plate in extremity injuries is critical to avoiding growth arrest in pediatric extremity injuries.

  2. Vascular injuries are associated with knee and elbow injuries. Patients with stable orthopaedic injuries should undergo repair of the vascular injury first. With unstable injuries, temporary arterial bypass can provide time for stabilization of the bony injury followed by definitive vascular repair.

  3. In children, compartment syndrome is characterized by analgesia, agitation, and anxiety. Normal pulses and capillary refill do not rule out compartment syndrome.

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Introduction

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This chapter discusses a broad array of injuries to the extremities, covering general principles, specific injuries, and complications, and highlighting in particular the areas in which the fields of pediatric surgery and pediatric orthopaedic surgery intersect. The content is divided into 7 sections: (a) general principles (b) vascular injuries; (c) compartment syndrome; (d) fractures and dislocations of the upper extremity; (e) fractures and dislocations of the lower extremity; (f) the mangled extremity and amputation; and (g) nonaccidental trauma (NAT). This chapter will provide a framework for approaching the child with an extremity injury as well as specific strategies for treating common injuries and their complications. Familiarity with an overall approach to the identification, classification, and management of various injuries, as well as with certain unique aspects of growing bone in children, is essential to an understanding of the content presented. Thus, we briefly discussed this information below.

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General Principles

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Patient Evaluation

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Initial evaluation requires that all injured extremities be completely exposed. The presence of wounds, the shape, size, and deformity of the extremity, as well as its color and any spontaneous movement should be noted. If present, shortening of the lower extremities with external rotation should also be noted. Areas of localized pain, crepitus, or instability often herald an underlying fracture. The vascular evaluation includes assessment of the temperature, color, and capillary refill. While the motor examination may be significantly limited in certain types of injuries secondary to pain, spontaneous movement should be noted and attempts must be made to assess nerve-specific motor function in the awake patient. Similarly, sensory function should be examined in the conscious patient, although it is often difficult to assess reliably in the young child. The patient should be asked to move through the range of motion at each joint, proceeding from the proximal to the distal aspect of the extremity. Radiographic assessment should include anterior/posterior and lateral views. Additionally, it is sometimes necessary to obtain bilateral extremity views to avoid confusion between injury and the normal growth pattern.

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Multiple Injuries

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Although individual extremity fractures may not be threatening to life or limb, multiple fractures in an extremity increase the risk of complications synergistically, and the coexistence of concomitant skeletal and visceral injuries increases overall morbidity and mortality. The probability of death in a child ...

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