(NRNP 6541) i Human: Andrew Chen latest update 2023- 2024
i Human: Andrew Chen
PRIMARY DIAGNOSIS:
S89.021A: Salter-Harris type 2
... [Show More] physeal fracture of the right distal tibia.
The Salter-Harris (SH) Classification System is a way to grade fractures that involve the growth plate (physis). Seventy-five % of lower extremity fractures in children are SH type 2. (Levine et al., 2022) When a Pt presents with ankle symptomsa detailed history and physical examination are crucial. Although a nurse practitioner may provide initial care and refer to a pediatric orthopedic specialist, obtaining details about the trauma may help narrow down the differentials and testing needed. In addition, a basic understanding of the pediatric anatomy can leadto a better understanding of the mechanism of injury. Bone growth is not completefor a male until somewhere between the ages of 14 to 17 years old. Growth plates are made of cartilage and as the child ages, the cartilage hardens into bone which isless flexible and rubbery. (Su & Larson, 2015) AC is 14 years old and because his growth plates are still primarily cartilage, the risk of SH fracture is high. AC presented with right ankle pain, swelling and bruising. On exam, his inability to walk/bear weight and the presence of right ankle bony tenderness make a fracture much more likely. (Levine et al., 2022)
The Ottawa Ankle Rules (OAR) were initially developed for adult Pts but have been shown to be useful in pediatric Pts over 5 years old. The goal of the OAR’s are to decrease the incidence of unnecessary x- rays, increase the efficiency of care(waiting time) and keep the cost of medical care down. According to OAR, imaging is necessary if there is pain in the malleolar zone and at least one of the following:
⦁ Bone tenderness along the distal 6 centimeters (cm) of the posterior edge of the medial or lateral malleolus.
⦁ Inability to bear weight for 4 steps immediately after injury and at initialmedical evaluation.
⦁ Midfoot pain with tenderness over the navicular bone or the base of the 5thmetatarsal.
The overall sensitivity of the OAR is 98.3% so it can be a useful clinical decisiontool. (Knipe & Foster, 2016)
TREATMENT:
⦁ Immobilization with short leg splint to stabilize ankle until they see ortho.
⦁ RICE: Rest, ice (10 minutes, 2 to 3 times a day), compression (ace wrap)and elevate above heart when resting.
⦁ Use crutches with ambulation.
⦁ Ibuprofen for pain.
⦁ Educate dad and AC on neurovascular assessment. Check capillary refill,make sure he can wiggle toes, check sensation (no numbness, tingling).
⦁ Educate Pt/dad about symptoms of compartment syndrome which is an increase in pressure in and around muscles that can inhibit flow of blood, Oxygen and nutrients to muscle tissue and nerves. Assess for progressivelyworsening pain, numbness and feeling of muscle bulging.
⦁ Psychological: Andrew is 14 years old boy who loves playing basketball. Hewants to play in the last game and support his team. The news that he fractured his ankle and there will be a 4-to-6-week recovery period will be devastating. When sharing information of this magnitude, we need to be empathetic, clear, and honest. Encourage AC and dad to stop the conversation if they don’t understand something or have questions. When dealing with a fracture it may help to show them the x-ray and/or pictures ofthe joint. If I am discussing a complex issue with a large amount of information, I like to include written information and a website if appropriate.
DIFFERENTIAL DIAGNOSES:
Right Ankle Muscle Sprain: Muscle sprain is a common childhood injury especially with the added risk factor of playing sports. In basketball, AC runs, jumps, stops on a dime, and changes direction quickly. Although there may be some pain and swelling, the symptoms will be less severe. AC should be able to walk (even if it is a limp) and bone tenderness will not be severe. (Solove & Benedict,2020)
Right Ankle Ligament Sprain: There are 3 sets of ligaments in the ankle: medial,lateral, and
syndesmotic. Ligaments are made of connective tissue containing collagen and elastic fibers. Ligaments attach bone to bone and stabilize the ankle joint. They are important in keeping the bones in the proper position and prevent when the twisting, rolling and collapse of the ankle. Ligament injuries occur when they move in the wrong direction, are stretched or tear. Most ligament sprains are minor. Symptoms include bruising, pain in the front or side of ankle, difficult weight bearing and a popping sound at the time of injury. (Solove & Benedict, 2020) Right Ankle Contusion: A contusion is when soft tissue is crushed. Blood leaks from damaged capillaries causing a bruise. There may be swelling and discomfort at the site. Applying ice and elevating the extremity may help reduce the swelling and pain. (Solove & Benedict, 2020) MEDICATIONS:
Ibuprofen: 200mg tablets. Take 2 tablets every 8 hours for mild to moderate pain.
Take 3 tablets every 8 hours for severe pain. This medication is a non-steroidal anti-inflammatory that can be used for pain and fever. Please contact office if Ibuprofen does not control pain adequately or associated symptoms such as nauseaand vomiting develop. The orthopedic specialist may prescribe different pain medication.
TESTS, REFERRALS, FOLLOW UP:
Testing: No further testing ordered at this time.
Referral: Pediatric orthopedic surgeon referral will be made with appointment scheduled as soon as possible. Medical record release signed. We will send medicalrecords and be sure the actual x-ray film and report are available for him.
Follow up: Next scheduled appointment will be for 15 year well visit and on asneeded basis. [Show Less]