Anxiety and Fractures
The little boy was sat cuddled on the lap of a young woman. I presumed she was his mother. She wasn’t.
He was about 2 and a half, a toddler. He looked about the right size for a toddler, not undernourished and small like so many of his peers.
He seemed comfortable enough, sat sideways across her lap, she was cuddling him but didn’t make a fuss, he was equally calm, eyes half closed as I approached.
The triage sheet simply stated: “PVA” - this is “pedestrian vehicle accident”, i.e. pedestrian hit by vehicle. He had been carried on his mother’s back when she was struck by a vehicle, I presume a car. There was no witness from the scene, and the mother was apparently elsewhere in the emergency department being treated for her injuries – though when I searched later I could not find any sign of her.
The child had apparently been flung some distance from the mother and landed on tarmac, this was all I could glean from the lady caring for him, she shrugged when I asked whether she was a friend or relative, “friend” she smiled, but she knew nothing more of the accident details, and did not mention any concerns about the toddler. Given how peaceful and calm he looked, my first concerns for the little guy were that he may have sustained a head injury; quiet children in hospitals worry me.
I took my opportunity to listen to his chest and feel his tummy while he was looking so quietly curious – they seemed fine, and there was no obvious head injury, his pupils reacted normally and were equal.
“Let’s get him onto the bed” I suggest to the carer, so we could do a thorough examination. As she shifted him onto her shoulder and carried him across the room, he started to cry. When we undressed him, I found out why.
His left thigh was swollen and bruised, he lay on the bed with his left leg crossed over his right, hip externally rotated. Gently palpating and straightening the leg I felt a sickening crunch of bony crepitus, it was certainly broken.
His now very surprised and alarmed carer held gentle traction on the leg while I quickly performed a thorough exam of everything else. It seemed like an isolated injury, with a couple of scratches over his left hip and ankle, but no other obvious serious injuries.
He was really kicking off now his leg was being immobilised, so as I prescribed oral painkillers, his carer gently released the leg, and he immediately calmed down, consoled quickly with some tickling and cooing on her part.
X rays showed a partially displaced left mid shaft femoral fracture, with no other injury.
By the time he returned from xray he had been joined by 2 “aunts” who took over from the other woman as main carer, I explained he had a broken leg and would need the bone doctors to review what should be done. This required a referral to another hospital.
In the mean time I wondered how best to manage the leg. He was neurovascularly intact, and settled very quickly if simply left alone on the bed.
I searched the department for any sensible splint-making equipment, finding a sort of “SAM” splint (foam wrapped on bendable metal wires, all covered in red plastic sheet) in resus. This was stained with dried blood, I generously cleaned it with clorhexidine solution, and found some tape and crepe bandage. Looking at him, now playing on an iphone and totally happy, I felt that imposing my splint was going to make matters worse rather than better.
I asked the orthopaedic on call registrar at the tertiary hospital, who agreed we should arrange a transfer, (the fracture would be reduced and placed in a spica cast*) and was happy for him to remain on a bed self-immobilising if he was comfortable in that position, which he was.
It was 2100, I made sure he was given the maximum analgesia for his weight, and arranged the transfer.
One hour later I popped back into the paeds room. He was still there, (now asleep). I called the medical transfer ambulance number, no answer. The same company had been transferring other patients from our hospital, but for some reason not my little boy.
Between other patients and duties I kept calling the transfer company, and nervously looking in on my little guy. He would wake up, and I was relieved that he now cried and babbled to his aunty when I approached. “He doesn’t like you” she chuckled, “he says you hurt his leg.” This was fine, I would happily be the bogeyman all night if that meant he was alert, appropriately noisy and generally putting my mind at rest about any occult head injury.
My night was spent calling the transfer company repeatedly, until one of my colleagues informed me there would be no answer now until the morning. Frustrated, I spent the rest of the night in a state of anxiety, continually checking on the little boy, as if my intent staring would somehow protect him any further harm.
The morning ward round couldn’t come fast enough. My consultant, a tall, physically imposing, but friendly man, started with the paediatric patients. As we all approached, the boy started crying vigorously. I explained the fracture and the things that had and had not been done overnight, while the consultant looked with increasing concern at the child. “We didn’t immobilise him because he was so comfortable...” I found myself justifying what now seemed a gross negligence in his care – as the child was looking up in fear at the collection of doctors staring down at him. My registrar backed me up, agreeing that the child had not been lying screaming all night with a broken leg, which is how things were now starting to look.
The consultant accepted this, but understandably felt uncomfortable about transferring the child with no immobilisation at all, so instructed the day team to improvise some leg traction under sedation, while chasing the transfer to find out why they hadn’t arrived.
As we headed home from the shift, I saw the transfer team arrive for the little boy. “Did anyone call them again?” I asked, no nobody had. They just arrived, 12 hours late for reasons I will never know, waving the same reference number I had been given the previous night.
* A spica cast immobilises the injured leg in a full POP cast, which is braced against a short cast over the good leg, allowing total immobilisation of the injured limb. The excellent site https://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures--pediatric
has good examples of this.
Reflections:
I thought about this a lot. My initial reaction on finding the fracture was that we should get IV access, immobilise the limb, and have facility to give IV analgesia / sedation if needed. Ultimately I think I should have followed through on this. The reasons this didn’t happen was the child being so comfortable rapidly once left to self immobilise his leg. I felt that bed traction would be futile if he wriggled and moved himself, and he would be more distressed with a plastic splint strapped to his leg.
In retrospect, some form of immobilisation would probably have been a more guaranteed way to ensure no further neuro vascular injury (although he had no intention of moving that leg).
He was certainly going to need IV access to give sedation / analgesia for manipulation at the tertiary hospital, so I should have pro-actively put this in place early. This would also allow me easy incremental increase in analgesia if oral options were insufficient.
I did not carry these decisions alone, it was discussed with my senior colleagues in both this and the tertiary hospital, but although the outcome in this situation was good, I would do things differently next time.
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