Saturday, 16 April 2016

If it isn't broken

Minor injuries in children are common.  Quite often, parents will present their children to General Practice, a Minor Injury Unit or an Emergency Department seeking reassurance.  This is often possible without the need for any investigations.  This post will explore some of the general principles of assessing and treating minor injuries in children.  I hope that by understanding some of the subtleties of how children's injuries work you will feel a bit more confident about managing these injuries when appropriate.  Over the next few weeks, there will be a smattering of posts that give specifics about injured body parts.  First, as my science teachers told me, we must return to first principles.

1.  Children injure themselves in different ways to adults

In fact, each part of childhood has a different pattern of injuries.  The main reason for this is engineering.  Children's bones are less brittle, especially when they are very young.  They are also very flexible creatures.  The combination of these mean that sprains are far less common in the under five year olds.  It also means that small children can fracture bones with seemingly innocuous injuries.  The best example of this is the toddler's fracture, which can occur with a simple tumble from running.

2.  Small children may not localise injuries well

There are several reasons for this and nobody really knows what they are.  I suspect that it is a combination of not being aware of specific body parts (have you ever seen a 3 year old draw a person?) and basic stupidity inherent to being a small child.  Whatever the reason, it is wise to look at least one joint above and below the reportedly injured part before deciding what to do.

3.  It is particularly desirable to avoid radiation in children

Because children are more susceptible to the dangers of X-rays, unnecessary radiation should be avoided.  X-rays should be done if there is a good chance that they will change management.  They should not be done for reassurance or as part of defensive medicine.

4.  If a child has normal use of the limb after analgesia then they are very unlikely to have a significant injury.

The ability to move a joint well is a good rule out (for the exception to this, see below), but persistent pain after analgesia does not always mean a treatable injury.

5.  Some children perceive and respond to pain differently.

Children with neurological or developmental problems including ADHD and ASD are more capable of having significant fractures despite seemingly normal limb function.  These children require a higher index of suspicion and a more interventional approach.

6.  Sometimes, the injury is not an injury (as such)

Amazingly, young people often ignore niggling pains.  They do so until whatever is a problem is suddenly made worse through exertion or an injury.  For this reason, some things that present as injuries are more significant and long term problems.  That doesn't mean that you have to disbelieve every injury.  However if something is slow to resolve or doesn't fit then it is wise to look again.  There are certain presentations, (e.g. as adolescents with hip pain after an injury) that should always be investigated carefully.

7.  The injury should fit the mechanism

This applies for several reasons.  The one that most will think of is the issue of safeguarding.  However it is equally true that when the mechanism does not really explain the injury, there may be a medical reason for this.  For that reason, keep an open mind. (Ref Shrodinger's Safeguarding)

Assessing and treating minor injuries in children is relatively straightforward and rewarding.  If you know what to look for and what the pitfalls are, it is often possible to be pragmatic.  Investigations are not always necessary and children heal quickly, given the chance.

GPpaedsTips is written for clinicians.  We all have to work within our own competencies.  However I don't think that minor injuries are more complicated than minor illness in children.

If it isn't broken give them analgesia and a sticker.  But how do I know????   That's easy.  Sometimes you just know because the child shows you how uninjured they are, sometimes it doesn't necessarily matter (that will be covered in the specific injury posts coming soon) and sometimes I doubt myself and do an X-ray.  And that's fine too.

Edward Snelson

Disclaimer: On no account is anyone to ask my children about my ability to recognise a significant injury.

This post is the first in a series of posts about injury.  Click these links to read about specific injuries and when to treat, refer etc. -

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