Examination of the Injured Child

Examination of the Injured Child

Anthony I. Riccio

Shital N. Parikh


Although pediatric orthopedic injuries vary widely in severity, one must recall that even a seemingly innocuous musculoskeletal injury in a child can carry the potential for associated neurologic deficit, vascular compromise, or compartment syndrome or result from a nonaccidental etiology. As such associated issues cannot be detected with standard or advanced imaging, a carefully performed and skilled physical examination is essential in every child with an extremity or axial injury. In addition, higher energy extremity trauma often presents with concomitant visceral, cerebral, and thoracic injuries. While severe limb deformity and open fractures are often outwardly apparent, this may not be the case for trauma to other organ systems. One must therefore be cognizant of the potential for such life-threatening injuries and direct their initial examination of the child to detect such injuries prior to focusing on the musculoskeletal evaluation.

Assessment of the Multiply Injured Child


National data from the United States Center of Disease Control continues to demonstrate that unintentional injury remains the leading cause of death in children older than 1 year. Although most of these deaths result from intracranial, thoracic, and abdominal trauma, 63% of multiply injured children have associated extremity fractures.1 It is therefore imperative that orthopedic surgeons are able to perform a thorough and systematic assessment of the polytraumatized pediatric patient.

Primary Survey

Initial evaluation of a traumatized child is directed at identifying life-threatening injuries while beginning resuscitative measures. The primary survey begins with a rapid compilation of the mechanism of injury, known medical problems, medication allergies, and any treatments initiated prior to arrival. Following this quick history, the patient is assessed for airway patency, breathing and ventilation, circulatory issues, and neurologic disability. This primary evaluation is commonly referred to as the ABCs of trauma care:

  • Airway: Assure that the airway is patent. Talking and crying both require an open airway and usually indicate the absence of obstruction. Airway patency can be more difficult to assess in the unconscious patient. The presence of grunting, snorting, or choking may indicate a compromised airway obstruction that must be managed acutely with attempted removal of obstructing body fluids via suctioning, use of the jaw thrust maneuver, and intubation when necessary. It is critical to assume the presence of a cervical spine injury in all traumatized children. Therefore, airway management must be conducted using spinal precautions, including cervical stabilization with an appropriately sized rigid collar. Furthermore, because of the increased head size to body size ratio in younger children, flexion of the cervical spine should be avoided by placing the child on a backboard with a cutout for the head or by elevating the torso relative to the head.

  • Breathing: Ventilation is assessed by inspection (looking), auscultation (listening), and palpation (feelings). Breath sounds should be present equally in both lung fields. Unilateral absence of breath sounds or diminished breath sounds may indicate a pneumothorax, hemothorax, or malpositioned endotracheal tube. The thorax should be inspected to assess for a flail segment or penetrating injury. Deviation of the trachea should be noted as this is indicative of a tension pneumothorax on the side opposite the direction of deviation. Palpation of the chest and neck may reveal the presence of subcutaneous emphysema that can be associated with a tension pneumothorax.

  • Circulation: Elevated heart rate, diminished blood pressure, delayed capillary refill time (CRT), and coolness or mottling of the peripheral extremities may all be indicative of circulatory compromise. It is important to note that healthy pediatric patients can lose a considerable amount of blood volume prior to manifesting clinical signs of hypovolemic shock. In such instances, tachycardia usually precedes the onset of hypotension.

  • Disability: Neurologic disability is frequently assessed by calculating the Glasgow Coma Scale (GCS) score (Table 9.1).

  • Exposure: All clothing should be removed to allow for complete inspection of the patient. The patient should be kept warm with blankets, heat lamps, and/or warmed intravenous fluids following exposure.

Table 9.1 The Glasgow Coma Scale




Open spontaneously


Open to verbal stimuli


Open to painful stimuli


Do not open



Smiles, follows objects, interacts, oriented


Crying but consolable with inappropriate interaction or confusion


Inconsistently consolable or using incoherent words


Incomprehensible sounds or moans


No response



Spontaneous movement or obeys commands


Localizes to painful stimuli


Withdrawal from painful stimuli


Abnormal extremity flexion to painful stimuli


Abnormal extremity extension to painful stimuli


No movement


GCS, Glasgow Coma Scale.

The Glasgow Coma Scale score is calculated by adding the scores from each of the three variables (GCS score = eyes + verbal + motor).

Secondary Survey

The secondary survey is conducted following initial resuscitation and management of any life-threatening injuries identified during the primary assessment. A complete history should be obtained along with a head-to-toe assessment of the entire patient. All extremities should be palpated including all digits, all joints without obvious deformity should be ranged, and an examination of the spine should be performed while maintaining spinal precautions. Radiographic evaluation includes a lateral cervical spine film, anteroposterior pelvis film, and an anteroposterior radiograph of the chest. Orthogonal radiographs are also obtained of any extremity that is deformed, swollen, or ecchymotic or demonstrates crepitus on examination. It is during the secondary survey that data can be gathered to classify injury severity via one of the numerous classification systems used to predict morbidity and mortality in the multiply injured patient (Tables 9.2,9.3,9.4). During the secondary survey, it is essential to continuously reassess the patient’s airway, breathing, and circulation for deterioration that might warrant emergent intervention.

Tertiary Survey

The tertiary skeletal examination is a careful and more detailed assessment performed once vital signs have stabilized and emergent and urgent pathologies have been addressed. This examination is ideally performed once the patient is awake and alert enough to participate in the examination. The tertiary
musculoskeletal examination involves palpation of all extremities, assessment of restriction, pain or crepitus with joint range of motion, a detailed neurologic examination, and a careful spinal examination. The goal of the tertiary survey is to identify missed injuries that have been reported to present in up to 12% of multiply injured patients.2,3,4,5 In the presence of an uncooperative or unconscious patient, the tertiary survey should be repeated once the patient is extubated and awake.

Table 9.2 An Example of the Injury Severity Score in Use


AIS, Abbreviated Injury Scale.

Table 9.3 The Revised Trauma Score


























Table 9.4 The Pediatric Trauma Score










Weight (kg)




Systolic blood pressure (mm Hg)






Loss of consciousness





Open or multiple




Major or penetrating

Commonly Missed Injuries

While tertiary surveys and formalized tertiary survey protocols have been shown to decrease the incidence of missed injuries in polytrauma patients, delays in the detection of musculoskeletal injuries do occur.2 Patients with lower GCS scores and more severe distracting trauma seem to be at higher risk for having a delay in diagnosis of a less obvious extremity or axial injury.6 Although no high-level study or systematic literature review has characterized the distribution of missed injuries in children with multisystem injuries, the peripheral skeleton (hands, feet, and ankles) and the shoulder girdle region seem to be areas in which delayed diagnoses of fractures are frequently encountered3 (Figure 9.1). These areas therefore deserve careful attention during the tertiary survey.

It is also important to note that the incidence of multilevel vertebral column injuries at both contiguous and noncontiguous levels has been reported to be as high as 47% in children.7 Therefore, identification of a single spinal injury should prompt a careful physical and radiographic assessment of the entire spine to rule out a concomitant injury.

FIGURE 9.1 A, Right hip radiographs of a 12-year-old female unrestrained passenger in a motor vehicle collision demonstrate a displaced intertrochanteric hip fracture. The patient presented with a Glasgow Coma Scale (GCS) score of 7 and also sustained a closed head injury, a pneumothorax, a high-grade liver laceration requiring operative hemostasis, and multiple compression fractures of the thoracolumbar spine. B, Following a 2-week ICU stay during which the patient was intubated and sedated, she noted ankle pain with attempted mobilization. Right ankle films demonstrated a displaced healing medial malleolus fracture. C, CT scan of the ankle demonstrates abundant callus and significant joint diastasis.

Nonorthopedic System Evaluation

Modern level 1 trauma care delivery systems in the United States must adhere to strict criteria imposed by the American College of Surgeons to maintain accreditation, including the coordination of care for a multiply injured child by a trauma-trained pediatric surgeon. Nonetheless, it is important for the orthopedic specialist to be familiar with the basic assessment of nonorthopedic systems as the presence of visceral or thoracic trauma may raise awareness of orthopedic injuries and alter the timing or method of musculoskeletal care:

  • Head injury: High rates of concomitant head trauma have been reported in the presence of pediatric cervical spine injuries.7,8 Inspection and palpation of the skull for abrasions, depressions, and lacerations may heighten suspicion for intracranial trauma, especially in the setting of a known spinal injury.

  • Thorax: The thorax should be carefully inspected. Paradoxical motion of a segment of the chest wall is defined as inward motion of the segment with inspiration while the remainder of the chest wall expands and outward movement of the segment with expiration as the remainder of the chest wall contracts. This is seen in the presence of a flail chest and usually indicates an associated pulmonary contusion as well. Palpation of the chest may reveal subcutaneous emphysema consistent with a tension pneumothorax. Absent or diminished breath sounds on auscultation of a hemithorax may result from a pneumothorax or hemothorax.

  • Abdominal/genitourinary injury: An abdominal examination consists of palpation, percussion, and inspection of all our quadrants of the abdomen. Guarding, abdominal distention, and tympanic percussion are indicators of free air within the peritoneal cavity and possible bowel injury. An inspection of the abdomen may alert the examiner to possible axial trauma. Visual inspection of the abdomen of children involved in a motor vehicle collision may reveal transverse liner ecchymosis or abrasions across the abdomen commonly referred to as seatbelt sign (Figure 9.2). This finding has been associated with an underlying intra-abdominal injury, may be a predictor of the need for intra-abdominal surgery, and is frequently seen in the presence of a flexion-distraction injury of the thoracolumbar spine9 (Figure 9.2). The presence of blood at the urethral meatus may indicate bladder rupture or urethral disruption, the latter of which can be secondary to an associated pelvic ring injury.

FIGURE 9.2 A, Clinical photograph of a 13-year-old female backseat passenger in a motor vehicle collision. The patient was restrained with a lap belt. Note the liner abrasions across the lower abdomen characteristic of a “seatbelt sign.” B, The patient had a mesenteric hematoma and an L1-L2 flexion-distraction injury of the spine, both of which required surgical intervention.

Orthopedic Emergencies

Open Fractures

The accurate and prompt diagnosis of an open fracture is essential as the timely administration of antibiotics has been associated with diminished infection rates particularly in higher grade injuries.10 The importance of the physical examination is underscored by the fact that antibiotic selection is usually guided by open injury classification, which is classically based on examination findings. While more severe open injuries are easily identified, the determination of whether smaller poke hole-type injuries are truly representative of an open fracture can be difficult. A careful examination is critical as identification that a pediatric fracture is open often times alters the treatment plan dramatically, frequently mandating operative intervention for an injury that might otherwise be managed closed in a splint or cast.

One tenet of open fracture management is that any unnecessary soft tissue and bony manipulation should be avoided during the initial physical examination. Repetitive and vigorous examinations may result in further dissemination of contamination within the wound, further injury, and devitalization to surrounding soft tissues from underlying fracture fragments as well as patient discomfort. Any wound over a fracture should therefore be visually inspected for size, integrity of the overlying skin, and the presence of gross contamination. Classification of open injuries is based on the size of the dermal laceration and the extent of underlying soft tissue injury (Figure 9.3). The former can be ascertained during initial examination, whereas the latter is often determined during intraoperative assessment. One should, however, note the presence of any obvious tendon or muscle disruption as well as exposure of any vascular or nervous structures when larger wounds are present.

As noted, small puncture wounds may be difficult to distinguish from abrasions. The presence of dark sanguineous drainage from a wound (representative of fracture hematoma) often indicates an open fracture. If sanguineous staining is present on a dressing that was applied prior to assessment and the wound is no longer draining, gentle manipulation of the extremity that yields such drainage should raise suspicion of an open fracture (Figure 9.4). Similarly, the presence of fatty tissue within any fluid extravagating from a wound is also concerning for an open injury.

FIGURE 9.3 The Gustilo Anderson classification: A, A grade 1 open supracondylar humerus fracture. Grade 1 injuries have a wound less than 1 cm, minimal soft tissue injury, and intact periosteum. B, A grade 2 open tibia fracture. Grade 2 injuries have a wound that is greater than 1 cm, moderate soft tissue injury, and intact periosteum. C, A grade 3A open proximal humerus fracture. Grade 3A injuries have extensive soft tissue damage to the skin and underlying soft tissues with adequate tissue remaining for coverage of the wound. D, A grade 3B open tibia fracture. Grade 3B injuries have extensive soft tissue damage to the skin and underlying soft tissues, extensive periosteal striping, and do not have adequate tissue remaining for coverage of the wound.

FIGURE 9.4 Innocuous-looking wound on the leg of an 8-year-old girl following tibia-fibula fracture. Gentle manipulation of the fracture led to a sanguineous discharge, suggesting an open fracture.

Compartment Syndrome

It is critical to understand that compartment syndrome is a clinical diagnosis, often based more on observation of a patient’s pain level and analgesic needs than on objective physical examination findings. Consensus does exist as to the definition of compartment syndrome (elevated interstitial pressure within a closed fascial compartment resulting in microvascular compromise and tissue ischemia), the importance of making a timely diagnosis (preservation of limb function), and treatment (decompressive fasciotomies). On the other hand, no consensus exists with regard to diagnostic criteria. Moreover, as younger children are often incapable of understanding and verbalizing discomfort, the diagnosis in a child can be more difficult than in an alert adult. Consequently, few clinical entities pose as much consternation as a suspected compartment syndrome in a pediatric patient.

Physical Examination

The examination for compartment syndrome often begins with palpation of the involved extremity to assess for fullness of the fascial compartments. Soft compressible compartments are often reassuring, while tight, firm, unyielding compartments should raise concern of a possible compartment syndrome in the setting of a characteristic fracture and the symptoms described previously. It should be understood, however, that the ability of orthopedic surgeons to manually detect elevated compartment pressures is far from perfect. A cadaveric study revealed a positive predictive value of only 19% and a negative predictive value of 24% for detection of leg compartment pressures above the commonly accepted threshold for a compartment syndrome. In addition, only 60% of examiners recommended fasciotomies when pressures of 80 mm Hg (greater than twice the commonly accepted threshold) were present.12 Obviously, one cannot diagnose or exclude compartment syndrome by palpation alone.

The presence and symmetry of distal pulse strength should be noted as pressure elevation can result in diminished pulses. A complete neurologic examination is also essential to identify altered sensation and motor weakness resulting from nerve compression and/or muscle ischemia. Pain with passive stretch of the musculotendinous units within affected compartment by gentle flexion/extension of the digits has been classically associated with compartment syndrome of the leg and forearm. While part of an adequate examination for compartment syndrome, such pain with passive stretch may be present in the setting of normal compartment pressures in the presence of a displaced forearm or tibia fracture because of muscle contusion or motion across fracture spikes.

Compartment Measurements

Although not routinely performed in pediatric patients, compartment pressure measurements can be helpful when suspicion of a compartment syndrome exists in an obtunded patient or when the clinical scenario is suspicious. In children who are not obtunded, these measures are made under sedation or
general anesthesia with a commercially available pressure monitor (image Video 9.1) or by using a needle attached to an arterial line pressure transducer. If using an arterial line, it is critical that the pressure transducer is placed level with the extremity being examined. In the leg, the needle should be introduced through the skin, subcutaneous tissue, and the fascia in the anterior, posterior, lateral, and deep posterior compartments. In the forearm, the volar, dorsal, and mobile wad compartments may be testing, although the volar compartment alone usually suffices.

Table 9.5 Suggested Compartment Pressures Diagnostic for Compartment Syndrome

Absolute pressure > 30 mm Hg

(Diastolic blood pressure) − (compartment pressure) ≤ 20 mm Hg

(Mean arterial pressure) – (compartment pressure) ≤ 30 mm Hg

Controversy exists as to the pressure that constitutes a compartment syndrome and whether an absolute pressure measurement alone is sufficient to make the diagnosis (Table 9.5). For instance, in an assessment of adult tibial shaft fractures in patients without clinical signs of compartment syndrome, one-time compartment pressure measurements were above these accepted thresholds in a high percentage of patients with a false-positive rate of 35%.13 The use of catheter placement for continuous pressure monitoring has therefore been suggested as being more accurate.

In summary, pediatric compartment syndromes are a devastating complication that usually occurs in the leg or forearm after significant trauma or periods of avascularity greater than 6 hours (Figure 9.5). Most
importantly, compartment syndrome is a clinical diagnosis that should be suspected based on symptoms (the three “A’s”) and a swollen tense compartment that is extremely painful; although excessive compartment pressure measures are helpful to confirm diagnosis, they are not required to perform fasciotomy (Figure 9.6).

FIGURE 9.5 A 3-year-old boy with a supracondylar humerus fracture undergoes treatment. After 3 weeks, his cast is removed and he has stiff fingers that do not extend (yellow arrow) and full-thickness skin lesions in the forearm are noted (red arrow). These skin lesions have been termed “sentinel lesions” and suggest an established compartment syndrome. Despite free muscles transfer, 15 years later, he has a scarred stiff and functionless arm.

FIGURE 9.6 This boy has a very swollen and tense forearm after closed elbow injury, and there is clinical concern for a compartment syndrome (A). In the operating room, the pressure measures 40 mm Hg of mercury and a decision to release the forearm is made. After incision of the skin and subcutaneous tissue, the volar fascia is seen and is very tight (B). The superficial and deep fascia is cut and the muscles bulge out through the defect relieving the pressure (C).

Vascular Injury

The importance of early detection of vascular compromise in the presence of an extremity injury cannot be understated. A prolonged tissue perfusion deficit can lead to irreversible ischemia, myonecrosis, fibrosis, severe functional loss, and nonviability of the involved extremity (Figure 9.5). Furthermore, the metabolic results (myoglobinuria and metabolic acidosis) of prolonged ischemia can be life threatening
(renal failure). For these reasons, any vascular abnormality in the setting of extremity trauma should be considered an emergency and dealt with promptly and with the appropriate support of vascular surgeons or those trained in microvascular techniques when needed. One must also be aware of those fractures in children that are commonly associated with vascular disruption, occlusion, or spasm and be vigilant for any vascular differences on examination. Such fractures include displaced extension supracondylar humerus fractures (brachial artery injury) (Figure 9.7), fractures through the distal femur and proximal tibia (popliteal artery injury), and knee dislocations (popliteal artery injury) (Figure 9.8).

Physical Examination

Examination begins with inspection of the extremity for pallor and temperature. In the presence of arterial insufficiency, the skin is often cool, pale, and occasionally has a bluish hue or patchy areas of purple overlying otherwise white pale skin (mottling). In the setting of vascular congestion due to disruption of venous outflow, the extremity may appear swollen and dark purple in color, which may improve somewhat with elevation. In the setting of penetrating trauma, the presence of an expanding or pulsatile hematoma should raise concern about an active arterial bleed.

Capillary refill time (CRT) is easily assessed by manually compressing a distal phalanx to effectively exsanguinate the tip of the digit than observing for the duration of time before the end of the digit becomes pink and reperfused (image Video 9.2). This is oftentimes best observed through the nail plate. CRT of 2 seconds or less is commonly considered normal, although results should always be compared with the uninvolved extremity to identify differences.

The presence and quality of distal pulses must be documented and compared with the uninjured extremity. In the upper extremity, the radial pulse is usually easiest to assess. In the lower extremity, the posterior tibial artery (posterior to the medial malleolus) and the dorsalis pedis pulse (dorsum of the foot
in the region of the medial midfoot) should be examined. A palpable pulse that is diminished in comparison with the contralateral extremity can be indicative of vascular compromise and merits concern. In the absence of a palpable pulse or in the setting of a barely palpable pulse, Doppler examination of the pulses is useful (image Video 9.3A and B). Dopplerable pulses are described as monophasic, biphasic, or triphasic (Table 9.6). Triphasic flow is normal (image Video 9.4), while a monophasic flow often represents partial occlusion of flow or even complete arterial occlusion with the signal resulting from retrograde flow.

FIGURE 9.7 Clinical (A) and radiographic (B) presentation of an open supracondylar humerus fracture with brachial artery laceration. C, Arterial bypass grafting using saphenous vein (white arrows) was performed once the supracondylar humerus fracture was reduced. (Courtesy: Kevin Little, MD.)

FIGURE 9.8 The popliteal artery is in close relationship to the posterior aspect of distal femur and proximal tibia. Displaced fractures of distal femur or proximal tibia can cause popliteal artery injury.

In the setting of a side-to-side difference in the peripheral pulse examination, a more objective assessment can be obtained by determining the ankle brachial index (ABI) or arterial pressure index (API) (Figure 9.9). The ABI is obtained using a blood pressure cuff and stethoscope or Doppler to record the systolic pulse at the ankle and brachial artery (image Video 9.5). A patient’s ABI is calculated by dividing the systolic blood pressure at the ankle by the pressure obtained at the arm. An ABI of less than 0.9 is considered abnormal and is commonly used as the threshold to perform more advanced diagnostics to assess for a vascular injury. The API is calculated by comparing the systolic pressure in the injured extremity with the systolic pressure in the contralateral uninjured extremity. As with the ABI, an API less than 0.9 should raise concern for a vascular insult and consideration of more advanced vascular assessment.

Table 9.6 Arterial Waveforms on Peripheral Pulse Doppler Examination




Forward flow (systole); reverse flow (early diastole); forward flow (late diastole)


Forward flow (systole); reverse flow (diastole)


Single phase with muted/absent acceleration or deceleration of flow

FIGURE 9.9 Determination the ankle brachial index (ABI).

Peripheral Neurologic Injury

A detailed peripheral nerve examination is essential in any assessment of an injured extremity. In children, neurologic deficits are commonly associated with supracondylar humerus fractures (Figure 9.10) and to a lesser degree physeal injuries about the knee.14 Although many nerve injuries in children are neuropraxias that can be managed expectantly, the identification of a neurologic deficit prior to reduction or operative management of a fracture is critical to obviate concerns that intraoperative manipulation or implants might be the inciting cause if identified following treatment.

Upper Extremity Neurologic Examination

Motor Examination

Motor function of the anterior interosseous nerve is tested via active flexion at the interphalangeal (IP) joint of the thumb (indicating an innervated flexor pollicis longus) as well as active flexion of the distal interphalangeal (DIP) joint of the index finger (indicating an innervated flexor digitorum profundus) while manually maintaining extension at the proximal interphalangeal (PIP) joint and metacarpophalangeal (MP) joint. Asking younger children to make “an OK” sign allows for assessment of both the FDP and FPL simultaneously (Figure 9.11). Integrity of the posterior interosseous nerve is assessed via active extension of the MP joints of the fingers and the IP joint of the thumb, whereas DIP and PIP extension is an ulnar nerve function (Figure 9.12). A common pitfall, therefore, is trying to confirm posterior interosseous function by watching the child extend his or her fingers (Figure 9.13). The ability to abduct and adduct the fingers indicates innervated interosseous muscles and thus a functioning ulnar nerve. Asking a child to cross their fingers is an easy method to check ulnar nerve function (Figure 9.14). Active wrist extension indicates an intact radial nerve and motor function. The median nerve can be isolated by asking a child to touch their thumb to their little finger, thereby testing function of the opponens pollucis (image Video 9.6).

FIGURE 9.10 A 9-year-old girl with severe extension-type supracondylar humerus fracture. A, The child has ecchymosis (red arrow) over the brachialis, and this implies significant trauma and displacement. B and C, The distal humerus is displaced posteriorly, and one could imagine that the median nerve (yellow line) would be at risk for stretch and compromise over the spike of bone.

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Aug 12, 2021 | Posted by in ORTHOPEDIC | Comments Off on Examination of the Injured Child

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