Antipsychotics in Children and the Elderly: Controversies, Issues, and Ethics
Author
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Editor
Timothy E. Corden, MD
Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center
Medical College of Wisconsin
Associate Director, PICU
Children's Hospital of Wisconsin
Milwaukee, Wisconsin
Disclosure: Timothy E. Corden, MD, has disclosed no relevant financial relationships.
Pediatric patients are at risk for a specific set of fractures. The decreased bone mineral density, proportionally stronger ligaments and tendons, increased bone flexibility, and developing growth plates lead to a unique fracture pattern that requires tailored treatment options. The image shown is of an individual with a Salter-Harris II fracture of the distal femur.
The epidemiology of pediatric fractures is different from adults or seniors. The risk for fracture increases with age, and boys are much more likely to sustain a fracture than girls. Trauma from either playing events or sports injuries accounts for the majority of fractures. The most common locations of fractures for children are in the upper extremities. There is a growing body of evidence regarding the increasing incidence of obesity in children and increased fracture risk.[1]
The bones of pediatric patients are more porous than mature bone, placing them at greater risk for compression fractures, termed buckle fractures. The tendons and ligaments in pediatric patients are proportionally much stronger than the bones, leading to an increased incidence of avulsion type fractures. The increased flexibility of pediatric bones makes them more likely to bend rather than break, termed plastic deformation. Greenstick fractures occur when the bone bends and partially breaks but does not extend through the width of the bone, giving it a tented appearance (shown). Mid-shaft fractures should always raise concern for child abuse and may present as spiral fractures if rotation force is applied to a limb. Image courtesy of Wikimedia Commons.
Growth plate fractures are unique to pediatric patients. They are caused by disruption in the cartilaginous physis of the long bones, typically due to compression loads or shear forces applied to areas of provisional calcification. Overall, physeal fractures are estimated to be responsible for about 30% of all long bone fractures. The distal radius and then the distal humerus are the most common fracture areas. Fractures are most likely to occur during periods of growth spurts when the physes are weakest. The most commonly used classification system for physeal fractures is the Salter-Harris system, which divides fractures based on the presence of metaphyseal, physeal, and epiphyseal fracture patterns and helps determine treatment options. The image shown is of an individual with impressive swelling of the right knee who was found to have a Salter-Harris I fracture of the distal femur.
Salter-Harris I fractures traverse the physis, splitting it longitudinally and separating the epiphysis from the metaphysis. They may be difficult to detect on radiographs if there is no displacement, although subtle physeal widening may be appreciable (red arrow shown). The physical examination may be more obvious, though, with significant swelling around the joint. The prognosis is typically excellent with closed reduction and casting or splinting. Re-examination in 7-10 days is important to evaluate maintenance of the reduction.
Salter-Harris II fractures split through the physis and the metaphysis (shown). They are the most common type, representing approximately 75% of all physeal fractures. The periosteum on the fragment side typically remains intact, facilitating reduction. Treatment is similar to Salter-Harris I fractures, with closed reduction and casting or splinting. Any fracture that involves the physis is at risk for growth failure arrest and should be followed up with serial radiographs at 6 and 12 months. Fractures considered at greatest risk for growth arrest are the distal femur, distal tibia, distal radius and ulnar, proximal tibia, and triradiate cartilage.
Salter-Harris III fractures involve the physis and then extend through the epiphysis and into the joint (distal tibia shown). They have the potential to disrupt the joint surface. Treatment for Salter-Harris III fractures requires open reduction and internal fixation to ensure proper anatomic realignment of both the physis and the joint surface. Fortunately, these are uncommon fractures.
Salter-Harris IV fractures involve the metaphysis, physis, and epiphysis (shown). As with type III fractures, there may be disruption of the joint surface; therefore, open reduction and internal fixation are required. Fortunately, they are also very uncommon. The outcome of treatment is typically dependent on the amount of energy associated with the injury itself and the adequacy of the reduction.
Salter-Harris V fractures are compression or crush injuries to the physis itself. Unfortunately, they are extremely difficult to diagnose at the time of the injury on radiographs, thus emphasizing the importance of the clinical history in establishing the details of the mechanism of injury. The image on the left is the initial radiograph in a child who experienced significant compressive and inversion forces. Only minimally displaced fractures of the tibia and fibula are appreciated with apparent maintenance of the distal tibial physeal architecture. The image on the right is a follow-up image showing growth arrest secondary to failure of the medial growth plate due to an undetected Salter-Harris V fracture. Growth failure arrest is an unfortunate complication of type V fractures, which are rarely diagnosed acutely.
A slipped capital femoral epiphysis, or SCFE, is a separation of the femoral epiphysis from the metaphysis, most commonly in a varus relationship. The name itself is a misnomer because the epiphysis is held in place in the acetabulum, while it is the metaphysis that moves proximally and anteriorly. It occurs most commonly in obese males and often presents as occult knee pain or limp. Diagnosis is made by plain film radiographs. Treatment is focused on stabilization of the hip joint, but surgery itself is not emergent. Surgical options include pinning, epiphysiodesis, and osteotomy. If not addressed promptly, remodeling of the hip joint may occur, leading to significant long-term morbidity. The hip radiograph shown demonstrates an acute SCFE without remodeling and a chronic SCFE with significant remodeling.
A toddler's fracture is a spiral fracture of the distal tibia (shown). It most commonly occurs from low energy trauma typically with a rotational component, such as athletic injuries or ground level falls. Children will typically refuse to bear weight on the affected leg, and there may be localized tenderness, swelling, or warmth. It must be on the differential for children who present with complaints of a limp. Treatment is typically long leg casting for 5-6 weeks to ensure proper alignment while healing.
The supracondylar fracture is the most common pediatric elbow fracture, representing 60% of elbow fractures, and is rarely seen after age 15 years. Extension-type fracture with posterior displacement is the most common mechanism of injury (shown). The principle complications related to supracondylar fractures are boney deformity and injury to the nerves or blood vessels. The most common complication is a cubitus varus, or gunstock deformity, which is a loss of the carrying angle. This is predominately a cosmetic rather than functional disability. Injury to the median, radial, or anterior interosseus nerves may occur. Deficits typically resolve with conservative management. Motor function usually returns within 7-12 weeks and sensory function over a period of up to 6 months. Vascular injury should always be suspected, but 10% of children will have temporary loss of the radial pulse secondary to swelling and not direct arterial injury.
A rare but serious complication is a Volkmann ischemic contracture due to postfracture swelling causing a compartment syndrome, in which the perfusion pressure falls below the tissue pressure in a closed anatomic space. This leads to muscle and nerve necrosis with eventual replacement by fibrotic tissue. Treatment for epicondyl fractures is dependent on fracture displacement and angulation. Nondisplaced, nonangulated fractures can be splinted with the elbow in 90 degrees of flexion. Angulated or displaced (shown) fractures warrant an orthopedic consultation. Angulated fractures require reduction and splinting, while displaced fractures require reduction and percutaneous pinning. If neurovascular structures are compromised, then traction to the limb may need to be applied to re-establish distal pulses. Open reduction is reserved for vascular insufficiency with a probable entrapped brachial artery in the fracture site or for irreducible fractures.
Lateral condyle fractures are the second most common elbow fracture in pediatrics, accounting for approximately 15% of elbow fractures. They are most commonly seen in children 4-10 years of age. The 2 major mechanisms of injury are a fall on an outstretched arm with the elbow extended and the forearm abducted or more commonly from traction forces as the lateral condyle is the origin of the forearm extensor muscles. Acute varus stress applied to an extended elbow with the forearm supinated may avulse the lateral epicondyle. The fracture line typically begins in the lateral aspect of the metaphysis and extends medially through the physis and into the epiphysis (shown). The major complications are instability, malunion, and nonunion. Minimally displaced fractures are usually casted, while displaced fractures usually require open or closed reduction with pin fixation.
Medial epicondyle fractures account for 10% of elbow fractures in children, most commonly in children 7-15 years of age. About half of medial epicondyle fractures are associated with elbow dislocation or subluxation. The major mechanisms of injury include acute valgus stress during a fall on an outstretched arm, posterior stress with acute elbow dislocation, and chronic muscular traction from the flexor and pronator muscles, such as with throwing. Due to traction from the forearm flexors, the medial epicondyle is displaced distally (shown). The major complication is entrapment of the fractured medial epicondyle within the elbow joint. Treatment is typically immobilization of the forearm in flexion and pronation with the wrist in flexion. Significant fracture displacement requires internal fixation.
Facial bone and mandible fractures are fortunately very uncommon in pediatric patients due to a number of factors. There is decreased inertial generation secondary to the light weight and small size of the head. Pediatric facial bones are also more resistant to fractures due to their higher elasticity, poor pneumatization by the sinus, thick surrounding adipose tissue, and stabilization of the mandible and maxilla by the unerupted teeth. Motor vehicle crashes and then sports injuries are the most common etiologies. After the nasal bones, the mandible is the most commonly fractured facial element. Pediatric facial bone fractures may be difficult to assess on plain films and may require computed tomography (CT) for best visualization. Treatment options vary depending on the location and type of fracture as shown.[2]
The ribs of children are very flexible and difficult to break. For comparison, the force applied during cardiopulmonary resuscitation is typically not enough to break a child's ribs. The most common site of traumatic rib fracture is in the lateral or posterior ribs. Fractures may be difficult to detect on standard posterior-anterior and lateral views of the chest, and additional oblique views may be necessary. Given the difficulty in causing a rib fracture in children, child abuse must be suspected. The image shown demonstrates multiple healing fractures with significant callus formation. Treatment is typically conservative.
Skull fractures in pediatric patients are the result of a powerful mechanism of injury. They are associated with a relative risk of 6.1 for concomitant traumatic brain injury. Typically plain skull radiographs are the first evaluation method, with a follow-up CT scan useful to help detect underlying brain injury if positive. Isolated, nondepressed skull fractures without neurologic deficits can be managed conservatively, but all other fractures should be evaluated by a neurosurgeon. The CT scan shown demonstrates a left parieto-occipital contusion, subdural hygroma, and skull fracture.
Bucket-handle fractures are caused by a subacute metaphyseal fracture that forms an arc along the proximal margin of the metaphysis. New bone formation leads to a thickened appearance and simulates a handle (arrow shown). Bucket-handle fractures are caused by excessive torsional forces and are a red flag for potential child abuse. Patients are typically asymptomatic, and treatment is conservative.
Author
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Editor
Timothy E. Corden, MD
Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center
Medical College of Wisconsin
Associate Director, PICU
Children's Hospital of Wisconsin
Milwaukee, Wisconsin
Disclosure: Timothy E. Corden, MD, has disclosed no relevant financial relationships.
Common Rashes Not to Miss
Diseases of the Nails
Earthquake in Haiti and the Medical Aftermath of Natural Disasters
Occupational Lung Diseases
