ED Pathway for Evaluation/Treatment of Child with a Suspected Extremity Fractures

H&P/Examination of the Injured Extremity

Details of Injury
  • Mechanism
  • Time
  • Symptoms
  • Interventions
PMH
  • Significant health problems, medications
PE
  • Evidence of other injuries, VS
  • Extremity
    • Visual inspection
    • Skin integrity (open vs closed)
    • Swelling, deformity, ecchymosis
    • Point tenderness
    • Joint above and below the injury
    • Neurovascular distal to the injury
      • Pulses, capillary refill (Nml < 2 seconds)
      • Sensation
      • Motor

Neurovascular Assessment

Patients with the following injuries are at risk for Acute Limb Compartment Syndrome (ALCS):

Neurovascular Exam

Reassess and document:

  • After splinting, casting and reduction
  • Increasing pain in spite of adequate analgesia
  • Patient complaint of paresthesias
  • For patients at risk for ACS
    • RN: Assess NV status hourly
    • MD: Assess every 2-4 hours

Perfusion

Skin color Well-perfused, pink, pallor, dusky
Capillary refill < 2 seconds
Pulses
  • 0 = no pulse
  • 1 = weak, easily obliterated with pressure
  • 2 = difficult to palpate, easy to feel when located
  • 3 = easily palpated, normal
  • 4 = strong
  • 5 = bounding
Upper Extremity Radial, Ulnar
Lower Extremity Dorsalis Pedis, Posterior Tibial