Upper and Lower Extremity Nerve Palsies

Pediatric Ortho

• Always consider non-accidental trauma in children
• Occult fractures are more common in peds
• If in doubt, splint and follow-up with ortho
• Presence of fat pads can indicate underlying fracture
  • Posterior is always pathologic.
  • A thin anterior fat pad is normal, but a “sail sign” is pathologic
• Management of common fractures
  • Monteggia fracture – urgent ortho consult for ORIF
  • Seymour fracture – physeal fracture of distal phalanx with associated nailbed injury. High risk for soft tissue entrapment. Requires Hand consult for likely ORIF
  • Tufts fracture w/ nailbed injury – antibiotics not required. Follow-up in 7-10 days with Hand
  • Common avulsion fractures (e.g. ASIS, lesser troch, iliac crest apophysis avulsion) should be NWB on affected extremity and f/u with ortho.
  • Torus fracture – splint with short arm cock-up splint
  • Greenstick fracture – unstable, requires splinting
  • Bowing deformity – treat it like a fracture and splint it
  • Mid and proximal humerus fracture – sling and swathe OR coaptation splint, sling, ortho f/u

Drug Rashes

• Common drug-induced rashes
  • Exanthematous drug eruption (EDE) – maculopapular
  • Urticaria w/o anaphylaxis
  • Vancomycin flushing syndrome (“Red man”)
• Uncommon and severe drug-induced rashes
  • Fixed drug eruptions
  • angioedema
  • acute generalized exanthematous pustulosis
  • DRESS
  • SJS and TEN
• DRESS can occur up to 8 weeks from drug exposure
• EDE (T-cell related) vs Urticaria (histamine) – draw an image on patient’s skin. If it appears red and/or raised after 10 min, it is urticaria
• Antihistamines: First gen (sedating): diphenhydramine, hydroxyzine; Second gen (less sedating): cetirizine, loratadine
• Topical corticosteroids – medium to high potency preferred for short course