Green 39's Skeletal Trauma in Children

GREEN’S SKELETAL TRAUMA IN CHILDREN
Copyright
Dedication
Contributors
Preface
Acknowledgments
1 - Skeletal Growth, Development, and Healing as Related to Pediatric Trauma
	Introduction
	Formation of Bone
		Membranous Bone Formation
		Endochondral Ossification
	Biology of Fracture Healing
		Inflammatory Phase
		Reparative Phase
		Remodeling Phase
	Physeal Fracture Healing
		Remodeling after a Fracture in Childhood
		Anatomic Differences of Pediatric Bones
			Epiphysis
			Physis
			Metaphysis
			Diaphysis
		Plastic Deformation
		Buckle Fractures
		Greenstick Fractures
		Complete Fractures
			Spiral Fractures
			Oblique Fractures
			Transverse Fractures
		Physeal Fractures
	Summary
	References
2 - Physeal Injuries
	Introduction
	Relevant Basic Science
	Epidemiology
	Mechanism of Injury
		Consequences of Injury
		Associated Injuries
	Classification
	Diagnosis
	Treatment
		General Principles
		Salter–Harris Fractures
	Issues Based on Specific Anatomic Location
		Distal Humerus
		Distal Radius and Ulna
		Proximal Femur
		Distal Femur
		Proximal Tibia
		Distal Tibia
	Other Mechanisms of Physeal Injury
		Iatrogenic Injuries
		Infections
		Neoplasms
		Thermal Injuries
		Metabolic Abnormalities
		Repetitive Stress Injuries
	Complications
		Growth Arrest
			Epidemiology
		Partial Growth Arrest
		Complete Growth Arrest
	Clinical and Radiographic Assessment
	Treatment
		Complete Growth Arrest
	Apophyseal Injuries
	References
3 - Casting Techniques
	Introduction
	General Cast Principles
	Body Casts
	Spica Casting
	Upper Extremity Splinting and Casting
	Lower Extremity Splinting
	Short Leg Cast
	Long Leg Cast
	Cast Wedging
	Complications of Casting
	Cast Saw Burns and Cast Removal
	References
4 - Pathologic Fractures in Children
	Introduction
	Bone Physiology
		Pathologic Fracture
	Outcome Triangle
		Outcome, Part I—Bone Biology
		Outcome, Part II—Pathology
			Nonoperative Management
			Intralesional Curettage
			Wide Tumor Resection
		Outcome, Part III—Function
	Conclusion
	References
5 - The Multiply Injured Child
	Introduction
	Pathology
		Anatomic Differences
		Biomechanical Differences
		Physiologic Differences
	Incidence
	Mechanism of Injury
		Falls
		Motor Vehicle Accidents
	Associated Injuries
		Spinal Injuries
		Rib Fractures
		Pelvic Fractures
		Other Injury Patterns
			Obesity and the Pediatric Trauma Patient
	Trauma Scoring Systems
		Modified Injury Severity Scale
		Pediatric Trauma Score
	Consequences of Injury
		Morbidity
	Trauma Evaluation and Management
		Pediatric Trauma Centers
		Trauma Team
		Primary Survey and Resuscitation
			Airway and Breathing
			Endotracheal Intubation
			Cricothyroidotomy
			Life-Threatening Ventilation Abnormalities
			Gastric Distention
			Tension Pneumothorax
			Circulation and Resuscitation
			Shock
			Cardiac Tamponade
			Hemorrhage
			Resuscitation
			Acid-Base Balance
			Urinary Output
			Hypothermia
		Secondary Survey
			Trauma Radiographic Series
			Lateral Cervical Spine Radiograph
			Anteroposterior Chest Radiograph
			Anteroposterior Pelvic Radiograph
			Other Radiographs
			Head Injuries
			Spine and Spinal Cord Injuries
			Chest Injuries
			Abdominal Injuries
			Extremity Injuries
			Vascular Injuries
			Compartment Syndromes
	Fracture Management in the Multiply Injured Child
		Indications for Surgical Management
		Timing of Fracture Management
		Physeal Fractures
		Principles of Surgical Management
		Surgical Techniques
			Open Reduction and Internal Fixation
			Closed Reduction and Internal Fixation
			Intramedullary Nailing
			External Fixation
		Open Fractures
	Rehabilitation
		Physical Therapy
		Psychologic Rehabilitation
	References
6 - Fractures with Soft Tissue Injuries
	Characteristics
	Classification
		Specific Mechanisms of Injury
	The Mangled Extremity
	Closed Fractures with Severe Soft Tissue Injuries
	Treatment Plan
		Initial Care
		Wound Contamination
			Gas Gangrene
			Wound Care
			Wound Coverage
	Compartment Syndrome
	Vascular Injury
	Traumatic Amputations and Related Injuries
	Achieving Bone Union
	Fracture Fixation
		Operative Methods
			Plates
			Intramedullary Nails
			External Fixation
		Diaphyseal Fractures
	Psychosocial Factors
	References
7 - Complications of Fractures in Children
	Vascular Injuries
	Nerve Injuries
	Compartment Syndromes
	Malunion
	Synostosis (Cross Union)
	Nonunion
	Refracture
	Growth Disturbances
		Distal Femur
		Distal Tibia/Ankle
		Proximal Tibia
		Pelvis
	The Overgrowth Phenomenon
	Ligamentous Instability
	Spontaneous Deep Vein Thrombosis
	Fat Embolism
	Hypercalcemia of Immobilization
	Ectopic Bone Formation
	Superior Mesenteric Artery Syndrome (Cast Syndrome)
	Traction-Induced Hypertension
	Reflex Sympathetic Dystrophy
	References
8 - Nerve Injury and Repair in Children
	Introduction
		Children Are Not Small Adults
	Types of Nerve Injury/What Happens after Nerve Injury
	Diagnostic Studies
	Demystifying Treatment of Nerve Injuries
	Treatment Options
	Nerve Injuries after a Fracture
		Diaphyseal Humeral Fractures
		Elbow Fractures
		Forearm Fractures
	Nerve Injuries after a Dislocation
	Nerve Injury after a Laceration or Penetrating Trauma
	Iatrogenic Nerve Injuries
	Nerve Injury Secondary to Compartment Syndrome
	Conclusion
	References
9 - Outcomes Assessment of Fractures in Children
	Introduction
	What are Outcomes
		Technical Versus Functional Outcomes16
	Outcome Measures: General Considerations
		Generic Versus Condition-Specific Measures
		Mortality, Health, and Quality of Life
		Capacity and Performance
		Properties of a Good Outcome Measure
	Outcome Measures for Pediatric Fractures
		Clinical Measurements
			Pediatric Outcomes Data Collection Instrument51
			Activities Scale for Kids41
			Child Health Questionnaire60
			Pediatric Quality of Life Inventory64
			Disabilities of the Arm, Shoulder and Hand66
			PROMIS: Item Response Theory and Computer Adaptive Testing
		Patient Satisfaction
		Nonclinical Measures
			Costs: Health Economic Evaluations
	Development of Goal-Based Outcome Measures for Pediatric Fractures
	Other Considerations
	References
10 - Fractures of the Spine
	Developmental Anatomy
		Relevant Anatomy
	Characteristics of Spinal Injury in Children and Adolescents
		Mechanism of Injury
	Diagnosis
		Cervical Spine Considerations
		Thoracolumbar Spine Considerations
		Neurological Examination
		Plain Radiography, Cervical
		Normal Radiographic Alignment
		Normal Developmental Anomalies
		Dynamic Radiographs
			Plain Radiographs, Thoracolumbar Spine
			Computed Tomography, Cervical
		Computed Tomography, Thoracolumbar
			Magnetic Resonance Imaging
			Thoracolumbar
	Spinal Cord Injury in Children
		Classification of Spinal Cord Injury
			Management of Spinal Cord Injury
	Specific Cervical Spine Injuries
		Atlanto-Occipital Dislocation
		Fractures of the Atlas
			Atlanto-Axial Subluxation
			Atlantoaxial Rotary Fixation
		Odontoid Fractures
		Hangman Fractures
		Lower Cervical Spine Injuries
	Pediatric Halo
	Thoracolumbar Fractures
	References
11 - Fractures and Dislocations about the Hip and Pelvis
	Introduction/Pathology
		Relevant Anatomy
			Mechanism of Injury/Biomechanics
			Associated Injuries
		Evaluation
			History
			Physical Exam
			Imaging
			Special Studies
			Classification
	Treatment
		Pelvic Fractures
			Technique
			Technique
		Operative Treatment
			Anesthesia and Positioning
			Technique
			Timing
			Preoperative Planning
			Anesthesia and Positioning
			Technique
			Physical Therapy
			Implant Removal
		Skeletal Traction
			Triradiate Cartilage Injuries
			Physical Therapy
			Implant Removal
		Complications
		Outcomes
	Conclusion
	Proximal Femur Fractures
		Relevant Anatomy
	Mechanism of Injury/Biomechanics
		Associated Injuries
		Evaluation
			History
			Physical Exam
			Imaging
		Treatment
			Operative
		Skeletal Traction
		CLOSED REDUCTION AND INTERNAL FIXATION
		Anesthesia and Positioning
		Technique
		Open Reduction Internal Fixation
		Anesthesia and Positioning
			Technique
			Postoperative Management
			Physical Therapy
			Implant Removal
			Operative
			Technique
			Wagner Technique
		Postoperative management
		Complications
			Infection
			Loss of Reduction/Fixation
			Chondrolysis
			Avascular Necrosis
			Nonunion
			Premature Physeal Closure
			Missed Associated Injuries
			Iatrogenic Subtrochanteric Femur Fracture
			Femoroacetabular Impingement
	Outcomes
	Hip Dislocations
		Introduction/Pathology
			Incidence
			Mechanism of Injury/Biomechanics
			Associated Injuries
			Physical Examination
			Imaging
			Special Studies
		Classification
		Treatment
		Emergent Treatment
		Nonoperative Treatment
			Closed Reduction
				Timing
				Preoperative Planning
				Anesthesia and Positioning
				Technique
				Timing
				Preoperative Planning
				Anesthesia and Positioning
				Technique
			Physical Therapy
			Implant Removal
			Complications
			Avascular Necrosis
			Sciatic Nerve Injury
			Osteoarthritis
			Recurrent Dislocation
		Outcomes
	Conclusion
	References
12 - Fractures of the Femoral Shaft
	Introduction: Scope and Purpose
	Anatomy and Development
	Demographics and Mechanism of Injury
	Evaluation
		Imaging
		Classification
	Management
		Emergent Treatment
		Indications for Definitive Care
			Pavlik Harness
				Technique
			Hip Spica Casting
				Technique
			Skeletal Traction
				Technique
				Technique
			Flexible Intramedullary Nailing
				Technique
			Plate Fixation
			Rigid Intramedullary Nailing
				Technique
	Complications
		Limb Length Discrepancy
			Skeletal Traction
			External Fixation
			Flexible Intramedullary Nailing
			Plating
			Rigid Intramedullary Nailing
	Guidelines
	Conclusion
	References
13 - Fractures Around the Knee in Children
	Introduction
	Fractures of the Distal Femoral Metaphysis
		Pertinent Anatomy
		Mechanism of Injury
			Imaging
		Classification
		Emergent Treatment
		Nonoperative Treatment
			Traction and Cast Application
		Surgical Treatment
			External Fixation
			Closed Reduction and Percutaneous Pin Fixation
			Open Reduction and Internal Fixation
			Submuscular Bridge Plating
		Outcome
		Complications
	Fractures of the Distal Femoral Physis
		Pertinent Anatomy
		Mechanism of Injury
			Imaging
		Classification
		Emergent Treatment
		Nonoperative Treatment
		Surgical Treatment
			Closed Reduction and Percutaneous Fixation
			Open Reduction and Internal Fixation
		Outcome
			Neurovascular Injury
			Ligament and Meniscal Injury
			Growth Disturbance
			Nonunion
	Osteochondral Fractures
		Pertinent Anatomy
		Mechanism of Injury
			Imaging
		Classification
		Emergent Treatment
		Nonoperative Treatment
		Surgical Treatment
		Outcome
		Complications
	Fractures of the Patella
		Pertinent Anatomy
		Mechanism of Injury
			Imaging
		Classification
		Emergent Treatment
		Nonoperative Treatment
		Surgical Treatment
		Outcome
		Complications
	Tibial Eminence Fracture
		Pertinent Anatomy
		Mechanism of Injury
			Imaging
		Classification
		Emergent Treatment
		Nonoperative Treatment
		Surgical Treatment
		Outcome
			Residual Knee Laxity
			Stiffness
	Tibial Tubercle Fracture
		Pertinent Anatomy
		Mechanism of Injury
			Imaging
		Classification
		Emergent Treatment
		Nonoperative Treatment
		Surgical Treatment
		Outcome
			Compartment Syndrome
			Prominent Hardware
	Fractures of the Proximal Tibial Physis
		Pertinent Anatomy
		Mechanism of Injury
			Imaging
		Classification
		Emergent Treatment
		Nonoperative Treatment
		Surgical Treatment
			Closed Reduction and Percutaneous Fixation
			Open Reduction and Internal Fixation
			Neurovascular Injury
			Growth Disturbance
	Proximal Tibial Metaphyseal Fractures
		Evaluation
			Emergent Treatment
			Nonoperative Treatment
			Surgical Treatment
			Complications
			Mechanism of Injury
			Evaluation
			Nonoperative Treatment
			Operative Treatment
	Proximal Fibular Metaphyseal and Physeal Fractures
	Open Injuries in the Knee Region
	References
14 - Fractures of the Tibia and Fibula
	Introduction
	Pathology
		Fracture Patterns
		Prevalence
		Mechanisms of Injury
		Consequences of Injury
		Associated Injuries
		Classification
	Diagnosis
		Physical Examination
		Radiographic Evaluation
		Special Diagnostic Studies
	Management
		Evolution of Treatment
			Current Algorithm
			Special Considerations for Multiple Traumatic Injuries
				Surgical Management
				Valgus Deformities
			Follow-Up Care and Rehabilitation
			Results
			Authors’ Preferred Method of Treatment
		Fractures of the Tibial and Fibular Shafts
			Evolution of Treatment
			Current Algorithm
			Special Considerations for Multiple Traumatic Injuries
			Treatment Options
				Nonoperative Management
				Surgical Management
			Follow-Up Care and Rehabilitation
			Results
			Authors’ Preferred Method of Treatment
		Isolated Fractures of the Tibial Diaphysis
			Battered Child Syndrome
			Bicycle Spoke Injuries
			Slide Injuries
			Trampoline Fractures
			Stress Fractures
			Ipsilateral Tibial and Femoral Fractures
			Tibial Fractures in Children with Neuromuscular Disorders
			Pathologic Fractures
		Isolated Fractures of the Fibular Diaphysis
		Fractures of the Distal Tibial Metaphysis
		Open Tibial and Fibular Fractures
			Assessment and Injury Classification
			Treatment
				Splints and Casts
				External Fixation
				Internal Fixation
			Follow-Up Care and Rehabilitation
			Results
				Summary of Recent Studies
			Authors’ Preferred Method of Treatment
	Complications
		Nonunion
		Angular Deformity
		Malrotation
		Asymmetric Proximal Tibial Physeal Closure
		Lower Extremity Length Inequality
		Vascular Injury
		Neurologic Injury
		Compartment Syndrome
		Osteopenia
	References
15 - Fractures and Dislocations of the Foot and Ankle
	Introduction
	The Ankle
		Incidence and Mechanism of Injury
		Consequences of Injury
		Radiologic Evaluation
		Classification
		Indications for Surgical Treatment
		Surgical Technique
			Supination-Inversion
			Supination-External Rotation
			Pronation-Eversion-External Rotation
			Supination-Plantar Flexion
			Type VI Fracture
			Type VII Fracture
			Transitional Fractures
		Dislocation of the Ankle Joint
		Leg-Length Discrepancy
		Osteoarthritis
		Rotational Deformities
		Nonunion or Delayed Union
	The Foot
		Types of Injuries
			Talus
			Complications
			Os Trigonum
			Osteochondral Fractures
			Subtalar Dislocations
		Calcaneus
			Classification
			Management of Calcaneus Fractures
			Complications
		Navicular Bone
		Cuboid Fractures
		Tarsometatarsal (Lisfranc) Injuries
			Mechanism of Injury
			Management
		Metatarsal Fractures
			Treatment
		Phalangeal Fractures
		Forefoot Dislocations
		Compartment Syndrome
		Lawn Mower Injuries
		Wound Coverage
		Amputation
		Laceration Injuries of the Foot
		Puncture Wounds
		Foreign Body
		Miscellaneous Causes of Foot Pain
			Stress Fractures
			Pathologic or Fragility Fractures
			Complex Regional Pain Syndrome
			Childhood Obesity and Fractures
	References
16 - Fractures and Dislocations about the Shoulder
	Clavicle
		Developmental Anatomy
			Mechanism
			Diagnosis
				Operative
			Mechanism and Diagnosis
			Treatment
			Mechanism and Associated Injuries
			Diagnosis
				Operative
			Incidence
			Mechanism of Injury
			Classification
			Treatment
	Acromioclavicular Joint Injury
	Scapula
		Anatomy
		Incidence and Classification
			Body Fractures
			Glenoid Fractures
			Acromion Fractures
			Coracoid Fractures
	Glenohumeral Joint Dislocation
		Anatomy
		Incidence
		Classification
		Mechanism of Injury
		Diagnosis
		Treatment
	Proximal Humeral Fractures
		Anatomy
		Incidence
		Mechanism of Injury
		Diagnosis
		Classification
		Treatment
		Incidence
		Mechanism of Injury
		Diagnosis
		Treatment
	Humeral Shaft Fractures
		Incidence
		Mechanism of Injury
		Diagnosis
			Operative
	References
17 - Fractures and Dislocations about the Elbow
	Introduction
	Distal Humeral Anatomy
		Vascular Anatomy
		Joint Anatomy
		Radiographic Anatomy
		Carrying Angle of the Elbow
	Supracondylar Fractures of the Humerus
		Anatomy
		Mechanisms of Injury
		Injury Biomechanics
		Associated Injuries
			Nerve Injuries
			Vascular Injuries
		Classification
			Radiographic Evaluation
			Management
				Type I Fracture
				Type II Fracture
				Type III Fracture
				Type IV Fracture
			Specific Treatment
				Closed Reduction and Cast Treatment
				Closed Reduction and Percutaneous Pinning (Author’s Preferred Treatment)
				Open Reduction and Internal Fixation
			Timing of Surgical Intervention
		Complications
			Vascular Compromise
			Neurologic Injury
			Cubitus Varus
		Flexion-Type Supracondylar Fracture
			Mechanisms of Injury
			Classification
			Diagnosis
			Treatment
				Author’s Preferred Method of Treatment
			Treatment
		Floating Elbow
	Physeal Fractures and Dislocations About the Elbow
		Fracture of the Lateral Condyle of the Humerus
			Mechanisms of Injury
			Classification
			Diagnosis
			Treatment
				Closed Treatment
				Closed Reduction and Percutaneous Pinning
				Open Reduction and Pinning
				Delayed Open Reduction
			Complications
				Malunion
				Tardy Ulnar Nerve Palsy
		Fracture of the Capitellum
			Classification
			Diagnosis
			Treatment
			Incidence
			Mechanism of Injury
			Classification
			Diagnosis
			Imaging
			Treatment
				Author’s Preferred Method of Treatment
		Fracture of the Lateral Epicondyle
			Anatomy
			Mechanism of Injury
			Classification
			Diagnosis
			Management
				Nonoperative Treatment
				Operative Treatment
				Postoperative Care
			Complications
			Mechanism of Injury
			Classification
			Treatment
		Dislocations of the Elbow Joint
			Posterior Dislocation of the Elbow Joint
				Mechanism of Injury
				Treatment
				Complications
			Transverse Divergent Elbow Dislocation
			Radial Head Dislocation
				Mechanism of Injury
				Differentiation from Congenital Dislocation of the Radius
				Management
			Mechanism of Injury
			Management
	References
18 - Fractures and Dislocations of the Forearm, Wrist, and Hand
	Introduction
	Mechanism of Injury/Biomechanics
		Mechanism of Carpal Fractures
		Mechanism of Hand Fractures
	Evaluation
		Examination
		Imaging
	Classification
		Plastic Deformation
		Partial (Greenstick) Fractures
		Complete Fractures
	Management
		Diaphyseal Forearm Fractures
			Indications for Definitive Care
			Nonoperative Treatment
			Surgical Treatment
				Surgical Anatomy
					. A thorough understanding of the development of the radius and ulna and their articulation is essential for treating injuries t...
				Surgical Approach
					. The anterior approach to the forearm, also commonly referred to as the Henry approach (Table 18.2), is a workhorse for the upp...
				Reduction Techniques
				Fixation Techniques
					. In unstable fracture patterns, an acceptable reduction may be achieved via closed manipulation but may be difficult or impossi...
			Pitfalls/Avoidance of Complications
			Postoperative Care and Rehabilitation
			Malunion
			Refracture
			Radioulnar Synostosis
		Fractures of the Distal Radius
			Emergent Treatment
			Indications for Definitive Care
			Nonoperative Treatment
			Surgical Treatment
				Surgical Anatomy
				Positioning Techniques
			Surgical Approach
				Reduction Techniques
				Fixation Techniques
				Pitfalls/Avoidance of Complications
				Postoperative Care and Rehabilitation
				Special Circumstances
					. Pediatric Galeazzi injuries are rare. Radiographically, they are recognized as displaced distal radial fractures associated wi...
			Physeal Arrest
			Indications for Definitive Care
			Nonoperative Treatment
			Positioning Techniques
				Dorsal Approach to the Scaphoid
		Reduction Techniques
			Fixation Techniques
			Pitfalls/Avoidance of Complications
				Postoperative Care and Rehabilitation
			Malunion
			Emergent Treatment
			Indications for Definitive Care
				Distal Phalangeal Injuries
					. Crush injuries to the distal aspect of the finger are the most common injury in a toddler. Partial or complete distal tip ampu...
				Phalangeal Neck Fractures
				Malrotated Fractures
				Intraarticular Fractures
				Dislocations
	References
19 - Skeletal Trauma in Young Athletes
	Introduction
	Epidemiology of Youth Sports
		Influence of Gender
		Diagnostic Imaging
	Sport Injuries to the Upper Extremity
		Shoulder Dislocation and Instability
			Overuse Injuries
			Treatment
		Elbow Injuries
			Treatment
			Overuse Elbow Injures
				Treatment
	Wrist Injuries
		Gymnast Wrist
			Treatment
			Treatment
	Pelvic and Hip Injuries
	Knee Injuries
		Ligamentous Injuries of the Knee
		Anterior Cruciate Ligament Injury
		Tibial Eminence Avulsion
			Evaluation and Treatment of a Medial Collateral Ligament Injury
			Incidence and Mechanism of Lateral Collateral Ligament and Posterolateral Corner Injuries
			Clinical Examination of the Patient with Suspected Lateral Collateral Ligament or Posterolateral Corner Injuries
			Treatment of Lateral Collateral Ligament and Posterolateral Corner Injuries
			Incidence and Natural History of Posterior Cruciate Ligament Injuries
			Evaluation and Management of Posterior Cruciate Ligament Injuries
			Treatment of Posterior Cruciate Ligament Injuries in Children
			Anatomy
			Anatomic Risk Factors
			Mechanism of Injury
			Medial Patellofemoral Ligament
			Osteochondral Injuries
			Natural History
				Clinical Evaluation
				Imaging Evaluation
				Treatment
				Physeal Considerations in Skeletally Immature Patients
				Nonoperative Treatment Protocol
				Operative Treatment Protocol
		Osteochondritis Dissecans
			Diagnostic Imaging
				Treatment
		Ankle Injuries
		Tillaux Fractures
			Treatment
		Triplane Fractures
			Treatment
		Osteochondral Lesions of the Talus
			Treatment
	References
20 - Nonaccidental Trauma: Inflicted Skeletal Injuries or Child Physical Abuse
	Introduction
		Legal Aspects
		Historical Perspective
	Forms of Abuse and Neglect
	Physical Abuse
		Age Demographics
		History of Injury
		Physical Examination
			Radiographic Evaluation
			Radiographic Dating of Injuries
	Fracture Patterns
		Diaphyseal Fractures
	Treatment
		Epiphyseal-Metaphyseal Fractures
			Type I Proximal Femoral Fractures
			Rib Fractures
			Fractures of the Shoulder Girdle
			Spinal Fractures
			Skull Fractures
	Differential Diagnosis
		Normal Variants
		Birth Trauma
		Osteogenesis Imperfecta
		Osteopenia of Prematurity
		Temporary Brittle Bone Disease
		Osteomyelitis
		Rickets
		Copper Deficiency
		Congenital Syphilis
		Congenital Insensitivity to Pain
		Caffey Disease
		Vitamin A Intoxication
		Leukemia
		Scurvy
		Drug-Induced Bone Changes
	Management
	Conclusion
	References
21 - Anesthesia and Analgesia for the Ambulatory Management of Children’s Fractures
	Introduction
	Principles of Pain Management in Children
	Anesthetic Techniques
		Techniques to be Avoided
		Local and Regional Anesthesia
		Hematoma Block
		Intravenous Regional Anesthesia
		Axillary Block
		Wrist and Digital Blocks
		Femoral Nerve Block
		Sedation
		Nitrous Oxide
		Parenteral Sedation
		Propofol
		Ketamine
		Etomidate
	Dexmedetomidine
		Comparative Studies
	Summary
	References
22 - Rehabilitation of the Child with Multiple Injuries
	Introduction
	Inpatient Rehabilitation
	Rehabilitation of Fractures
		Orthoses and Adaptive Equipment
		Pain Control
		Prevention of Reinjury
	Spinal Cord Injury
		Complications of Spinal Cord Injury
	Traumatic Brain Injury
		Complications of Traumatic Brain Injury
	Spasticity Management
		Physical Interventions for Spasticity
		Oral Medications for Spasticity
		Injections for Spasticity
			Surgery for Spasticity
	Psychosocial Factors
	References