Cervical Spine Injuries
Among children in the United States, there are approximately 1300 new cases of spinal cord injury each year, with most occurring at the cervical level. Cervical spine injuries may accompany serious head trauma, such as severe deceleration injuries caused by high-speed motor vehicle crashes or falls from extreme heights. Sports injuries are another common mechanism. Less often, they may result from injuries to the top of the head or the back of the neck.
Clinical Presentation
Cervical spine injuries are most common in patients with severe head injuries. Therefore, cervical spine injury is always a possibility in a child who is unconscious or has an altered mental status after head trauma. This is especially true in younger children, whose horizontally aligned facet joints and more elastic intervertebral ligaments can predispose to subluxation without bony injury. This occurs when the angular momentum resulting from forceful impact levers the proportionately larger head on the fulcrum of the upper cervical spine. The result is a condition known as spinal cord injury without radiographic (including CT and MRI) abnormality (SCIWORA), which predisposes the victim to paraplegia and neurogenic shock or respiratory arrest. Approximately 20% of all pediatric spinal injuries are SCIWORA.
In the alert patient the most common finding is midline cervical tenderness. Less often, there is weakness, pain, or paresthesias along the affected nerve roots. In the unconscious patient with high-grade partial or complete cord transection, common findings include spinal shock (flaccidity and areflexia instead of spasticity, hyperreflexia, and Babinski’s sign) and neurogenic (“warm”) shock (hypotension that is poorly responsive to volume resuscitation but is paradoxically associated with bradycardia, “normal” urine output, and warm extremities).
Diagnosis
Assume that a cervical spine injury may have occurred in a patient who is unconscious or has an altered mental status after head trauma. Spinal cord injury is sometimes overlooked during the initial evaluation of a comatose patient with severe traumatic brain injury.
See pp. 749–758 for the general approach to the patient with multiple trauma and pp. 521–527 for the general approach to the patient with head trauma.
Often, an awake, alert patient arrives in the ED immobilized on a backboard, in a semirigid extrication collar. Ask about the presence of pain at the top of the head (C2–3) or back of the neck, and about paresthesias of the hands, arms, or legs. If none of these are present, without moving the patient, carefully remove the cervical restraint while maintaining in-line stabilization of the neck. Palpate the spinous processes for local tenderness-associated interspinous muscle spasm, or obvious deformity. The first spinous process that can be palpated is C2; C6 and C7 are the largest. Ask the patient to move the fingers and hands, feet and toes, and to raise the arms and legs. If there is no tenderness, hyperesthesia or paresthesias in the extremities, or evidence of trauma, and the patient moves all extremities easily, ask him or her to move the neck gently from side to side, then up and down. Do not attempt to move the patient’s neck yourself; insist that the patient stop immediately if any movement causes pain.
Suspect a cervical spine injury in a patient with any of the following: unresponsiveness after head trauma; paresthesias or weakness; hyperesthesia; limitation of neck motion; inability to cooperate with the examination; pain on top of the head; neck trauma; or injury above the clavicles. Assume that there is a cervical spine injury until proven otherwise in a patient who is intoxicated or has a distracting injury that interferes with response to pain.
ED Management
Begin by performing an assessment of the ABCs, the initial component of the primary survey (see Resuscitation, pp. 1–4). Immediately stabilize the head and neck of every patient suspected of having a cervical spine injury, if temporary immobilization was not accomplished earlier in the field. The preferred method is with an appropriate-size semirigid extrication collar and head immobilizer. A thin layer of padding placed beneath the torso from shoulders to hips is required for a young child to assure maintenance of a neutral position, as the prominent occiput predisposes the neck to slight flexion unless this precaution is taken. A soft collar, sandbags, or large IV bags placed on both sides of the patient’s head (despite being well-secured with tape across the forehead) do not provide adequate immobilization of the head and neck. Finally, because ventilation may be impaired by the very techniques required to achieve adequate immobilization, monitor the patient carefully for signs of respiratory compromise.
If intubation is necessary, apply bimanual in-line stabilization to the sides of the head and remove the extrication collar, if one is present. Have an assistant apply slight downward pressure over the larynx (the Sellick maneuver), if necessary, to bring the vocal cords into view. Avoid hyperextending or flexing the neck during the procedure. Never delay intubation when indicated, because a cross-table lateral cervical spine x-ray has not been obtained or interpreted.
Once the airway has been secured and the head and neck have been properly immobilized, order a cross-table lateral x-ray of the cervical spine. The base of the skull, all seven cervical vertebrae, and the top of the first thoracic vertebra must be visualized. Continuity of the normal lordotic curves of the cervical spine and important anatomic measurements (Table 25.1) must be confirmed by a physician experienced in interpretation of pediatric cervical spine radiographs. Be aware of certain anatomic features of young children that mimic vertebral injuries, including unfused epiphyses (particularly at the base of the dens), widening of the prevertebral soft tissue spaces on forced expiration (crying), and hypermobility of the upper cervical spine (resulting in the slight forward shifting of C2 on C3 and C3 on C4, known as pseudosubluxation). Suspect that the cervical spine is unstable in a child under eight years of age if >4.5 mm of subluxation is present at C2–3 or C3–4, or in an older patient if >3.5 mm of subluxation is noted at any level.
A lateral cervical spine radiograph alone can miss certain vertebral fractures. Thus, once this film is obtained and interpreted as normal, transport a patient with stable vital signs to the x-ray suite for AP and open-mouth views. An open-mouth view permits visualization of the odontoid process (dens) of the axis (C2) and the ring of the atlas (C1). Obtain a CT of the cervical spine when it is impossible to obtain a full radiographic series, there is a suggestion of fracture on radiograph without the actual fracture being seen (e.g., increased prevertebral soft tissue), or to look for additional fractures despite a fracture already having been identified on x-ray. Given that cervical injuries to children under eight years of age are more likely to be ligamentous than bony, do not use a CT scan as a screening tool in this population.
There is no immediate need to ascertain the integrity of the cervical spine in the comatose patient. Normal x-rays cannot definitely exclude spinal cord injury because of SCIWORA, while the patient’s inability to relate symptoms compromises the reliability of the physical exam. Thus, it is safest to presume that spinal cord injury may be present, maintain full spinal immobilization, and defer comprehensive evaluation of the cervical spine to a later time. SCIWORA can be evaluated with an MRI. Findings include spinal cord transection or hemorrhage, or ligamentous or disk injury, although some MRIs may be normal.
When a cervical spine injury is diagnosed clinically or radiographically, immediately call the appropriate surgical specialist (neurosurgeon, orthopedist) to assist in further management (e.g., application of Gardner-Wells tongs). Admit any patient in whom cervical spine injury cannot be definitively ruled out in the ED.
Indications for Admission
Bibliography
Hand Injuries
The injured hand requires a thorough evaluation, as improper management may lead to permanent disability. A systematic approach is essential to avoid overlooking subtle injuries.
Clinical Presentation
Lacerations
Hand lacerations may affect the skin only or may be deep and involve underlying structures. Active extension of a digit is possible despite partial laceration of the extensor tendon. A dorsal hand laceration associated with pain on extension of the digit against resistance suggests a partial tendon injury.
Bites
Bites (pp. 763–766) are actually lacerations combined with crush injuries. Suspect that an irregular laceration over the metacarpophalangeal (MCP) joint is a human bite sustained by punching another person in the mouth. This is a serious injury, as oral flora can be inoculated into the MCP joint.
Fractures and Dislocations
Phalangeal Fractures
These fractures are common but not serious unless they are malrotated or the joint, volar plate, or collateral ligament is affected.
Wrist Fractures
Wrist fractures are less common in children than in adults. The most commonly fractured carpal bone is the scaphoid. Key findings include tenderness on deep palpation in the anatomic snuffbox area (between the extensor pollicis longus, extensor pollicis brevis, the prominent edge of the base of the first metacarpal and the styloid process of the radius); pain with longitudinal pressure placed on thumb; pain on pronation followed by ulnar deviation of the wrist; pain in the snuff box with resisted pronation or supination (ask the patient to “shake hands” with you while resisting your efforts to twist the wrist); and tenderness to palpation of the scaphoid tubercle (extend the child’s wrist with one hand and apply pressure to the tuberosity at the proximal wrist crease with the opposite hand).
Metacarpophalangeal Joint Dislocations
MCP dislocations are rare. They usually involve the thumb and index and fifth fingers. Most of these dislocations can only be detected on lateral radiographs.
Tendon Injuries
Gamekeeper’s (Skier’s) Thumb
Gamekeeper’s thumb is caused by acute radial deviation of the thumb at the MCP joint that tears the ulnar collateral ligament. Typically the injury occurs when a patient falls with the thumb abducted. On examination, there is tenderness along the ulnar aspect of the first MCP joint, associated with >15 degrees of joint laxity on passive radial abduction (performed under local anesthesia) when compared to the unaffected thumb.
Mallet (Baseball) Finger
A mallet finger results from a direct blow to the tip of an extended digit, rupturing the DIP extensor tendon or avulsing it from the base of the distal phalanx (a Salter I, II, III or IV fracture). The finger is flexed at the DIP joint. Radiographs, which must contain a view of the PIP joint, may reveal an avulsed bone chip remaining attached to the extensor tendon.
Boutonnière (Buttonhole) Deformity
A boutonnière deformity follows violent flexion of the PIP joint. It presents with PIP flexion and DIP hyperextension. The lateral bands of the intrinsic muscles are pulled volar to the PIP axis, such that the lateral bands become PIP flexors while hyperextending the DIP. As a result, the PIP “buttonholes” through the torn extensor hood.
Nail Bed Injuries
Blunt trauma to the nail can cause a subungual hematoma, bleeding between the nail and the nailbed. A very tender nail with blue-black subungual discoloration is seen.
Infections
Paronychia
A paronychia is an infection of the soft tissues around the fingernail. It usually begins as a hangnail and is more common in patients with a history of finger sucking or nail biting. There is exquisite tenderness to palpation of the nail as well as erythematous swelling along the nail margin. There may also be a purulent collection or discharge and/or an associated felon (see below).
Felon
A felon is a serious distal pulp space infection. Tense, tender, erythematous swelling of the volar surface of the distal phalanx is seen.
Purulent Tenosynovitis
This infection of the flexor tendon sheath is a true surgical emergency. There is usually a history of penetrating trauma. Kanavel’s four cardinal signs of tenosynovitis are: (1) symmetric swelling; (2) slight flexion of the finger; (3) tenderness over the flexor tendon sheath; and (4) increased pain on passive finger extension (most likely to be present early in the disease). Tenosynovitis may progress to a palmer space infection.
Palmar Space Infection
A palmar space infection presents with tense, tender, erythematous swelling of the palmar surface with pain and decreased mobility of the third and fourth fingers (midpalmar space) or thumb (thenar space). In certain circumstances, the dorsum of the hand may be more swollen than the palmar surface. These infections can spread to the flexor tendon sheaths. Associated signs may include fever, lymphangitis, and lymphadenitis.
Ganglion
A ganglion is a benign, well-defined, smooth, cystic lesion of synovial origin. It is fixed to the deep tissues, typically tendon sheaths, or. less commonly, herniated joint lining. Usually less than 3 cm in diameter, it is most often found on the volar or dorsal surface of the wrist or on the palmar surface at the base of a digit.
Diagnosis
The evaluation begins with a careful history, including hand dominance, tetanus immunization status, and description of any previous hand injuries. Inquire about the mechanism of injury, including the hand position at the time of injury, the time elapsed since injury, and whether the trauma occurred in a clean or dirty environment.
Expose and inspect the entire upper extremity. Note any discrepancy between active and passive mobility of upper-extremity joints. Inspect the hand and evaluate the vascular status. Look for an alteration in the usual resting cascade of the digits, suggestive of a tendon or nerve injury. Check the color and temperature of the injured digit, and assess capillary refill.
Before anesthetizing the hand in preparation for a surgical procedure, assess sensory function by evaluating two-point discrimination with two points of a paper clip. Apply both points to the radial side of each digit. Then move the points closer together until the patient can no longer distinguish between them. Use an uninjured digit as a control. Repeat the exam on the ulnar side. Then, evaluate the median (volar index fingertip), radial (dorsal web space between the thumb and index finger), and ulnar (volar fifth fingertip) sensory nerves. The “immersion test” can substitute when an adequate two-point discrimination test cannot be obtained. Failure of the skin to wrinkle after 5–10 minutes in water suggests sensory nerve injury.
Motor (nerve, muscle, and tendon) function must be evaluated in a systematic manner. First, test the extrinsic flexors: the IP joint of the thumb (flexor pollicis longus), the DIP joints of the fingers while the PIP joints are held in extension (flexor digitorum profundus), and then the PIP joints of each finger while the other fingers are held completely extended (flexor digitorum superficialis). Next, have the patient flex the wrist against resistance, and palpate the three tendons (flexor carpi ulnaris, palmaris longus, and flexor carpi radialis, from medial to lateral) at the base of the wrist. The palmaris longus is best seen by flexing the wrist against resistance with the thumb and fifth finger opposed; however, it is absent in approximately 15–20% of children.
Evaluate the thenar muscles and median motor function by opposing the pulp of the thumb with that of the other four fingers. Test thumb adduction (adductor pollicis) and ulnar nerve function by having the patient grasp a piece of paper between the thumb and radial surface of the proximal index finger. Weakness is indicated by Froment’s paper sign, contraction of the flexor pollicis longus with flexion of the IP thumb joint. To check the hypothenar muscles, ask the patient to abduct the small finger. Evaluate the interosseous muscles (ulnar nerve) by having the patient spread the fingers apart. Test the lumbricals (median and ulnar nerves) by asking the patient to flex the digits at the MCP joints while keeping the PIP and DIP joints extended. Assess motor function of the radial nerve by having the patient extend the wrist against resistance.
ED Management
Manage profuse bleeding with elevation and pressure. Never use clamps for hemostasis, as the nerves traveling with the blood vessels can be damaged.
Palpate for localized bony tenderness or soft tissue swelling, and examine for obvious deformities, ecchymoses, and functional deficits. Obtain x-rays if any of these findings are present over the wrist or hand. Radiographs of the fingers are indicated for gross deformities, lacerations in association with crush injuries, or loss of IP joint mobility.
Instill local anesthesia for surgical procedures only after a satisfactory sensory examination has been completed. If a digital block is required, allow the skin to dry after preparing it with povidone-iodine. Use a 25 or 27 gauge needle to inject 2–4 mL of 2% lidocaine without epinephrine into both medial and lateral sides of the digit at the level of the metacarpal head. The maximum allowable dose of lidocaine is 4–5 mg/kg (without epinephrine). Before administration, be sure to inquire about personal or family history of previous reactions to local anesthetics.
Lacerations and Bites
Carefully debride and irrigate these wounds after administration of local anesthesia (see pp. 722–724). Close with 5-0 or 6-0 nylon, using simple sutures that are left in place for seven days. Avoid the use of deep sutures due to the risk of infection. A drain may be needed if the laceration is large. Carefully evaluate human bite wounds adjacent to MCP joints for evidence that the joint capsule has been violated. Open irrigation in the operating room is necessary if the wound has penetrated the capsule.
All deep lacerations and bite injuries of the hand require prophylactic antibiotics for seven days. Treat human and animal bite wounds with an IV dose of ampicillin/sulbactam (45 mg/kg). Follow this with amoxicillin/clavulanate alone (875/125 formulation, 45 mg/kg/day of amoxicillin div bid). Alternatively, give penicillin VK (50 mg/kg/day div qid) plus 40 mg/kg/day of either cephalexin (div qid) or cefadroxil (div bid) for five days. For other deep or potentially contaminated lacerations, discharge the patient with cephalexin or cefadroxil, as above. Administer tetanus toxoid for all tetanus-prone wounds unless it is certain that the patient received a booster within the last five years. Administer tetanus immune globulin if the patient’s tetanus immunization status is incomplete or is unknown.
Fractures and Dislocations
Refer patients with fractures (except distal tuft), MCP dislocations, or non-radiographic suspicion of a scaphoid fracture to an appropriate surgical specialist (orthopedic, plastic, or hand surgeon). Treat distal tuft phalangeal fractures with a hairpin splint or bulky dressing.
A PIP dislocation can be reduced with traction and splinted after x-rays rule-out an associated avulsion fracture. To reduce a dorsal (most common) PIP joint dislocation, first anesthetize the finger with a digital block. Hold the finger proximal to the injury, then use a distracting force to hyperextend at the PIP joint to bring it back to its normal anatomic position. If successful, repeat the examination of active and passive range of motion and immobilize the joint for three weeks. If abnormal, or reduction was unsuccessful, consult with a hand specialist. A dorsal DIP joint dislocation can also be reduced using distracting force at the involved joint.
Tendon Injuries
Refer a patient with a gamekeeper’s thumb, boutonnière deformity, or jersey finger to an appropriate surgical specialist. Treat a mallet finger with a short dorsal splint, ensuring mild DIP joint hyperextension with free PIP joint mobility, for 6–8 weeks. A paper clip or tongue blade wrapped in tape can serve as a temporary splint for a mallet finger.
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