TABLE 41.3 CRITERIA FOR DISCHARGE WITH HOME OBSERVATION Traumatic force not life threatening Glasgow Coma Scale score of 15 Nonfocal neurologic examination No significant symptoms No history of prolonged loss of consciousness (or normal CT if it did occur) No intracranial abnormalities on CT (if obtained) Reliable caregivers who are able to return, if necessary No suspicion of abuse or neglect CT, computed tomography Most children presenting to the ED after blunt head trauma will not require advanced imaging or observation These remaining children, who sustained impact of minor force, had no LOC, and are alert and asymptomatic with normal examinations, likely have only minor head trauma with or without extracranial injuries, including contusions and lacerations Home observation is appropriate management for the majority of these patients Rarely, intracranial complications develop in these children, causing symptoms hours after the traumatic event; therefore, the caregiver should be given a printed list of signs and symptoms (reviewed verbally by the clinician) indicative of increased ICP with instructions to check the child at regular intervals and to return to the ED if symptoms occur Postconcussive counseling (especially with regard to return to sports), when indicated, should also be given The caregivers must be reliable and able to return with the child if necessary, and there must be no suspicion of abuse or neglect— otherwise admission for observation in the hospital should be considered ( Table 41.3 ) Suggested Readings and Key References Babl FE, Borland ML, Kochar A, et al Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study Lancet 2017;389:2393–2402 Badawy MK, Dayan PS, Tunik MG, et al Prevalence of brain injuries and recurrence of seizures in children with posttraumatic seizures Acad Emerg Med 2017;24(5):595–605 Brenner D, Elliston CD, Hall EJ, et al Estimated risks of radiation-induced fatal cancer from pediatric CT AJR Am J Roentgenol 2001;176(2):289–296 Dunning J, Daly JP, Lomas JP, et al Derivation of the children’s head injury algorithm for the prediction of important clinic events decision rule for head injury in children Arch Dis Child 2006;91:885–891 Greenes DS, Schutzman SA Clinical significance of scalp abnormalities in headinjured infants Pediatr Emerg Care 2001;17:88–92 Hennelly KE, Mannix R, Nigrovic LE, et al Pediatric traumatic brain injury and radiation risks: a clinical decision analysis J Pediatr 2013;162(2):392–397 Kuppermann N, Holmes JF, Dayan PS, et al Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Lancet 2009;374:1160–1170 McCrory P, Meeuwisse W, Dvorak J Consensus statement on concussion in sport–the 5th international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med 2018;51:838–847 Osmond MH, Klassen TP, Wells GA, et al CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury CMAJ 2010;182:341–348 Pearce MS, Salotti JA, Little MP, et al Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study The Lancet 2012;380:499–505 Schunk JE, Schutzman SA Pediatric head injury Pediatr Rev 2012;33(9):398– 411 Zonfrillo M, Nadel F, Corwin D Children’s Hospital of Philadelphia ED clinical pathway for evaluation/treatment of acute head trauma 2010 Available online at https://www.chop.edu/pathways?search=head±trauma Accessed July, 2019 CHAPTER 42 ■ INJURY: KNEE CYNTHIA A GRAVEL INTRODUCTION Acute pain or injury to the knee is a common complaint in the emergency department (ED) Many injuries are minor and require only limited therapy; others, however, require consultation with an orthopedist, either in the ED or as an outpatient after pain and inflammation subside The emergency physician can provide appropriate therapy or determine the need for consultation, based on a comprehensive history, physical examination, and an appropriate radiographic evaluation DIFFERENTIAL DIAGNOSIS The differential diagnosis of acute and subacute knee injuries is summarized in Table 42.1 The pertinent anatomy is illustrated in Figures 42.1 and 42.2 Acute Injuries Fractures Preadolescents with open growth plates (physes) are especially susceptible to fractures Since pediatric bone strength may be less than pediatric ligament strength in some cases, an injury that would cause a ligamentous injury in adults may cause a Salter–Harris type physeal fracture in children For bones around the knee, the epiphyses close by 17±1 years in females and by 18±1 years in males Fractures of the distal femoral epiphysis are classified by the Salter–Harris pattern (see Chapter 111 Musculoskeletal Trauma ) and by the displacement of the epiphysis (usually lateral or medial) The injury usually follows significant trauma (e.g., being struck by a car with the knee hyperextended or during contact sports when sustaining a lateral hit with the foot fixed by cleats) Distal neurovascular status should be assessed because compromise of the popliteal artery occurs in 1% of cases and peroneal nerve injury occurs in 3% of cases Fractures of the proximal tibial epiphysis are rarer than those of the distal femoral epiphysis but are more likely to involve vascular compromise because of the proximity of the popliteal artery to the posterior aspect of the tibial epiphysis With both fracture types, the patient will have severe pain, refusal to bear weight, extensive soft tissue swelling, limited range of motion (ROM), and commonly, hemarthrosis For both injuries, radiographs are usually diagnostic but may be normal if the injury is a nondisplaced Salter–Harris type I fracture Although not necessary as part of the ED evaluation, magnetic resonance imaging (MRI) may be needed when the physis is tender or a large effusion is present Acute traumatic avulsion of the tibial tuberosity is caused by acute stress on the knee’s extensor mechanism The quadriceps muscle group extends the knee by way of the patellar ligament The patellar ligament inserts on the tibial tuberosity and may avulse it during sudden acceleration (e.g., beginning a jump) or deceleration (e.g., landing after a jump) The patient will have tenderness and swelling over the tibial tubercle and be unable to extend the knee fully (or perform a straight leg raise) A lateral radiograph is diagnostic Fractures of the patella are rare in younger children because the patella does not ossify until to years of age, leaving it with a thick cartilage layer that protects it from direct trauma In addition, the soft tissue anchors of the patella are flexible which diffuses blunt forces However, a direct impact on the patella into the distal femur can cause transverse or comminuted fractures Much more common in children are avulsion fractures of the patella resulting from forceful contraction of the quadriceps With patellar fractures, the patient’s knee will be swollen, the patella tender, and knee extension painful A radiograph is usually diagnostic although care must be taken not to miss small avulsion fragments including sleeve fractures which are unique to pediatrics (egg-shell–like bony fragment that dislocates with avulsed soft tissue) Bipartite patellae are a normal variant and may be confused with an acute fracture Osteochondral fractures are fractures of articular cartilage and underlying bone not associated with ligamentous attachments These fractures often involve the femoral condyles or the patella The injury may follow a direct blow to the knee, a twisting injury, or patellar dislocation The patient will have severe pain, immediate swelling, and will hold the knee partially flexed Hemarthrosis may be present Knee radiographs should include an intercondylar view because the fracture fragment may be in the intercondylar notch Osteochondral fractures can be missed because only the small ossified portion of the osteochondral fragment is radiopaque MRI may be necessary for diagnosis Analogous to an adolescent who ruptures the anterior cruciate ligament (ACL), patients to 16 years old may sustain avulsion fractures of the tibial spine at the point where the ACL inserts The tibial spine is incompletely ossified and may avulse before the ligament ruptures The patient may have a hemarthrosis and will be unable to bear weight If the patient tolerates an examination, the Lachman test (see Fig 42.3 ) may be positive because the injury is similar mechanically to an ACL tear AP, lateral, and intercondylar or tunnel-view radiographs will show the ... with open growth plates (physes) are especially susceptible to fractures Since pediatric bone strength may be less than pediatric ligament strength in some cases, an injury that would cause a ligamentous... headinjured infants Pediatr Emerg Care 2001;17:88–92 Hennelly KE, Mannix R, Nigrovic LE, et al Pediatric traumatic brain injury and radiation risks: a clinical decision analysis J Pediatr 2013;162(2):392–397... brain tumours: a retrospective cohort study The Lancet 2012;380:499–505 Schunk JE, Schutzman SA Pediatric head injury Pediatr Rev 2012;33(9):398– 411 Zonfrillo M, Nadel F, Corwin D Children’s