Pain, Minor Injuries & Painful Limbs

“Approximately 50% of paediatric ED attendances are for trauma and skeletal injuries. Hands are the most commonly injured body part.”

EM Curriculum: (click to view)

Background

Pain in children is a distressing symptom for all involved in the care of a child, it can affect parents and healthcare workers as much (sometimes more so!) as the child themselves.

Adequate assessment and treatment of pain is a very important consideration in all children. It can be impossible to examine a child without pain relief and the response to analgesia can be very helpful in the assessment of an injured child.

We've all met the children with minor injuries who seem very distressed initially but are then tearing round the waiting room 40 minutes later after a bit of Calpol or Ibuprofen!

Pain relief is not just important for the relief of symptoms due to an injury or organic disease process.

There are a number of procedures we need to perform on a regular basis when dealing with unwell children that can be painful and the administration of appropriate pain relief strategies are key in the smooth performance of these investigations.

Approximately 50% of paediatric ED attendances are for trauma and skeletal injuries. Hands are the most commonly injured body part and the most hand injury is a fingertip injury.

Accounting for 5-10% of ED attendances research has found that as many as 20-30% of hand injuries are improperly diagnosed and managed initially.

It is important to fully understand the anatomy of both the bones and soft tissues in the hand to ensure injuries are picked up and treated expediently to avoid any adverse consequences.

Paediatric x-rays can be difficult to interpret as many abnormalities can be subtle and the situation is complicated further by the appearance of secondary ossification centres.

Doctors working in the Emergency Department should have a sound knowledge of the normal x-ray appearances across all age groups.

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Assess pain in children.

  • Be aware of the pharmacological and non-pharmacological options for analgesia.

  • Know the principles of safe sedation in children.

  • Understand the differential diagnoses for the limping child.

  • Assess children presenting with hand injuries including nail bed injuries.

  • Recognise the common fractures and soft tissue injuries seen in children and be aware of associated injuries to look for.

LEARNING OUTCOMES FROM FACE-TO-FACE TEACHING

  • Prescribe and administer entonox, oral analgesia, IV opiates and intranasal diamorphine to paediatric patients.

  • Examine a child systematically to localise an injury and check for neurovascular compromise.

  • Examine a child's joints and assess gait.

  • Reduce a pulled elbow and common dislocations presenting to the ED.

TASKS

Complete the following before the face to face session:

TASK 1: Pain management and sedation in Children

Duration: 60 mins

Listen to this podcast and then read these two documents from RCEM.

Task 2: e-LFH Injuries in Children

Duration: 40 mins

This e-LfH module gives an good basic overview of common paediatric soft tissue and bony injuries.
Click on the picture or link below to be directed to the e-LfH site.

 

Task 3: Hand Injuries

Duration: 60 mins

This RCEM learning module on hand injuries is very comprehensive regarding all soft tissue injuries of the hand, it's pretty much all you'll ever need to know!

Task 4: BMJ Review – The Limping Child

Duration: 20 mins

This article gives a good summary of the differential diagnoses and clinical assessment of a child presenting with a limp.

#EM3 Content

Lightning Learning:

Simblog:

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“An 8 year old girl presents with a painful swollen elbow following a FOOSH which occurred as she was jumping off a trampoline.”
“A 9 year old boy presents having fallen from a climbing frame, he has a painful and deformed left thigh which is an isolated injury.”
“A 14 year old boy sustained an injury to his right hip whilst playing rugby. Since the injury he has complained of a very painful hip and an inability to weight bear.”

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

BMJ:

Easily missed? Septic arthritis in children [article]

  • A brief overview of septic arthritis in children.

Easily missed? Septic arthritis in children [module]

  • An interactive short module based on the above article. This is not one of the free modules but can be accessed for free via Athens if you do not have a BMJ learning account.

Patterns of skeletal fractures in child abuse: systematic review

  • An interesting article and box 2 on page 7 highlights the probability of abuse from several fracture types.

e-LFH:

Interpretation of Radiological Images (e-IRI) programme

  • This x-ray interpretation module is written primarily for radiographers as an introduction to becoming a reporting radiographer, however it is an excellent resource for anyone who looks at x-rays! There are lots of x-rays to look at covering common injury patterns and each section has a 'hot reporting' series at the end to help you spot the common abnormalities seen in children.

Traumatic injuries of the elbow

  • A very informative module covering clinical assessment of a painful elbow in both adult and paediatric patients, x-ray interpretation and the diagnosis and management of common injuries. There is particular focus on the appearance of the secondary ossification centres in children, supracondylar fractures and forearm fracture-dislocations.

Radiopedia.org:

Royal Children's Hospital Melbourne:

Fracture Education Module

  • A great introduction to paediatric fractures, with good revision of the basic sciences as well as lots of clinical information. There are lots of really informative little animation in this which are really useful for visualising what happens at the time of injury and therefore helps in the understanding of the clinical and radiological findings.

Paediatric Fracture Guidelines

  • This section of the RCH site provides a fantastic summary of the pathophysiology, classification, presentation, investigation and treatment of all the common fractures of each limb bone. It's a brilliant resource and if you ever find yourself with a fracture you're not sure how to treat, here's where you'll probably find your answer!

Doctors.net:

Paediatric fractures: upper limb

  • A short but informative module that covers all the common upper limb fractures through six interactive case studies. This provides a good overview of the evidence base surrounding management of these injuries.

Nice Guidance:

Sedation in Children and Young People

  • The above link is to the Quick Reference Guide as the full guideline is 385 pages long!

Paediatric anaesthesia: Good practice in Postoperative and Procedural Pain Management

  • This article provides a review of the evidence regarding analgesia for painful procedures, many of which are commonly performed in the ED.

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: