Author Question: Pediatric Fall From Skateboard

Carol Asks:

A four-year-old falls off a moving skateboard onto a driveway (no helmet, or pads.) Someone was doing something he wasn’t supposed to do.

This is what I’m proposing happens to this child.

Result: Greenstick fracture in one of the bones of the forearm and possible concussion?

Treatment: Cast in ER and keep overnight for observation? Possible sedatives or stronger meds (like codeine) for pain that may make her sleepy?

Follow: Specialist?

Jordyn Says:

Thanks, Carol, for sending me your question.

I’ll answer in the same way you sent your scenario to me with my opinion.

Result: Yes, greenstick fracture is good. You can hit the link for further information. However, we don’t use this term (as least not in Colorado.) We say “buckle fracture” as in the bone buckles or squishes a little. Bones in this age group are very pliable. This is a very common fracture in kids. The fracture is not a line crack through the bone. Concussion, yes. And you’re right– this kid needs a helmet on!

Treatment:

Splint in the ER. Casting is rare in the emergency department. The difference between the two is a splint only has hardening material on one side and is secured in place by an ace wrap. This leaves space for the injury to swell and can limit the potential for developing compartment syndrome— though that would be rare for this type of fracture. Casting has circumferential hardening material— usually something like fiberglass sheeting that hardens. Also, some providers are just placing a removable type wrist splint on these fractures since they are very stable and the child will usually self limit activities until the pain goes away.

I’m going to assume your child/character has a mild concussion. No loss of consciousness. No amnesia. Maybe a headache, nausea, dizziness, etc. We would not give any sedative or narcotics to this patient— for the concussion nor for the fracture.

Ibuprofen is the preferred drug of choice for the fracture and even for the headache that might be associated with the concussion. Some providers are against ibuprofen in concussion because of a concern for increased bleeding (ibuprofen makes platelets less sticky), but that’s with multiple dosing. We give Ibuprofen often to kids with head injuries and they do fine. Acetaminophen can be given for headache and it will help with pain from the fracture, but it will do little to help the swelling of the fracture. This is why ibuprofen is preferred for broken bones because it helps with both pain and swelling.

Assuming this child has a normal neuro exam and is at their normal neurological baseline (meaning, they are acting as they normally do at home)— then they would be sent home. There is no reason to obs this kid overnight.

Follow up: With orthopedics in 7-10 days for reevaluation of the fracture with cast placement. Cast would be on for 4-6 weeks.

Hope this help and good luck with this story.

Forensic Medical Question: Forensic MRI for Child Abuse

Susan Asks:

mri-782459_1920Is there such a thing as a forensic MRI? Not to be done on a dead person, but in a child abuse case? Can one tell if a child has been beaten and see healed bruises, etc?

Jordyn Says:

Thanks for your questions.

The only indication I can think of using MRI to discern abuse would be for head trauma. MRI is the most sensitive study when it comes to differentiating old and new bleeds (as in possibly discerning two episodes of shaking), but still an exact time of the bleed could probably not be given. We just would know there were two separate instances of injury that caused bleeding.

Also, it wouldn’t be called a forensic MRI on a live child. We would just call it by the study we’re doing. In this case, a brain MRI, but the reason for doing the study would be concern for child abuse and/or intracranial (inside the brain) bleeding.

You can’t really tell healed bruises because they’re healed after all. The skin would have normal appearance. We could at least take a history of where the bruises were because we know normal versus abnormal bruising patterns in children, but pictures are always more impressive so seeing current injuries will always be better if trying to build a child abuse case.

Perhaps you’re thinking about healed fractures which you could possibly see some evidence of healed fractured on x-rays depending on how significant the fracture was. However, not all healed fractures are visible on x-ray. Healing fractures can be seen on x-ray.

Book Review of The Psychology of Dexter: Part 1/3

Frequent followers of this blog know I’m a fan of the television show Dexter– not necessarily for its medical accuracy but for its amazing plot and character development. Honestly, I wish I would have been the author to create a series about a vigilante serial murderer working for the police department.

Sheer genius. You can read some of my medical analysis of Dexter here and here.

So, of course, I was intrigued when I found the non-fiction book The Psychology of Dexter that includes a collection of essays on various topics analyzing the show from different mental aspects and, over the next few posts, I’m going to highlight some interesting tidbits I learned along the way.

The first essay I found interesting was titled Rethinking Dexter by Lisa Firestone, PhD. What follows are quotes from the actual book or are very close paraphrases. This particular essay dealt with childhood PTSD and  whether or not early treatment of psychopathic children could reduce their violent nature in the future.

1. “Research shows that a child’s cruelty toward animals almost always arises out of an abusive family environment. Humane education that focuses on developing empathy toward animals generalizes to empathy for human beings. The National District Attorney Association suggests that targeted therapy at this could save future lives.”

2. “Research suggests that psychopaths almost always are treatable if they receive intensive therapy for a proper duration of time.” which throws out the theory that there is not hope for these types of people.

3. “Studies have shown that almost 100% of children who witness parental homicide develop PTSD because of the severity of the traumatic event. Eighty percent of children that have been imprisoned, rendered immobile in some way (buried alive, tied up, or tortured) will develop PTSD as well.”

4. “Childhood trauma has an impact on actual brain development. It can cause serious structural abnormalities in the frontal lobe, known as ‘the seat of emotion.’ Brain researchers have found that these abnormalities often result in deep-seated personality deficits such as an inability to be empathetic.”

4. “When childhood events are traumatic enough to cause PTSD, children dissociate from themselves as the helpless victim and identify instead with the aggressor. They identify with the very person who is hurting them, who they see as strong and not vulnerable to the type of pain they are experiencing. This is the only survival strategy available to the child.”

5. “An additional common symptom of early childhood PTSD is post-traumatic play, in which children repeat themes or aspects of the trauma they experienced. This does not relieve anxiety.”

Are you surprised by any of this information as it relates to childhood PTSD?