Pediatric Trauma Life Support Course – Chapter 13 – Pediatric Extremity Trauma

I’m taking the upcoming the Pediatric Trauma Life Support Course at IU Health’s Emergency Response Training Institute. And these are excerpts

The Course uses the textbook, Pediatric Trauma Life Support For Prehospital Care Providers, 3rd Edition, 2009. There is a free 2017 online update PDF.

This post is on notes from the Chapter 13 of textbook along with additional resources.

Here are excerpts (my study notes) from the chapter:


  1. Priority of care in any trauma setting is to treat life-threatening injuries first, then manage all injuries, including musculoskeletal that the child is sustained.
  2. During the ITLS secondary survey, assess TIC* and PMS* of the extremities. Document fees before and after splint application.
  3. If there is uncertainty as to whether a fracture exists, treat the injury as a fracture.
  4.  Your correct immobilization techniques can help prevent loss of function in the extremity and serious long-term problems for the child.
  5. In the multisystem trauma patient splitting may be the best accomplished by using the body and backward as the only splint until after you are en route.

*TIC – Tenderness, instability, and crepitation (TIC)

**PMS – Pulse, motor function (i.e., is the patient able to move the extremity on command?), and sensory function (pulse, motor function, and sensory function [PMS]


Assessment is of primary importance in the management of any patient. Just as in the adult patient, assessment of the pediatric patient should proceed following systematic manner

1. ITLS primary survey

A. Scene size up
B. Initial assessment
C. Rapid trauma survey or focus exam
D. Clinical interventions and transport decisions
E. Contact medical direction as needed.

2. ITLS secondary survey and/or ongoing exam

ITLS Primary Survey

A. Scene Size-Up

The mechanism of injury provides important information. Significant force is required to cause certain fractures in children and such force may cause multisystem injury in children.

B. Initial Assessment

Airway and Cervical spine

Because pediatric patients with extremity injuries may have multisystem injury, carefully determine the need to perform spinal motion restriction. Assess and manage the airway as discussed in chapter 4.


Assessment and management of breathing is discussed in chapters 4 through six. In addition, consider that when children are in pain, they might become tachypnea. Administer supplemental oxygen and monitor the child very closely.


As indicated in chapter 7, even small amounts of blood loss (e.g., and extremity injury) may result in hypo bulimic shock and a child. Tachycardia and poor perfusion may indicate possible shock. Promptly stop all active bleeding. If the child has an amputation focus care on the stone. Stump care is aimed at controlling bleeding by applying pressure dressing. If the injury involves a major extremity or if the amputation is incomplete, the bleeding may be significant and result in shock. Early application of the dressing, and sometimes a tourniquet is the pressure dressing is not sufficient, will reduce blood loss. Rarely, you may need hemostatic agents if they are available.

C. Rapid Trauma Survey or Focused Exam

When dealing with extremity trauma, the need for a Rapid Trauma Survey versus a Focused Exam depends entirely on the findings in the scene size up and the initial assessment. If there is a dangerous generalized mechanism of injury (such as an MVC or significant fall) or if the child is unconscious, perform a Rapid Trauma Survey. If there is a dangerous focused mechanism of injury suggesting an isolated injury (such as a stab wound to the groin), perform focused exam of only the injury. Extremity trauma is frequently localized and may not require a head to toe exam. However, a fall in which the child has an obvious broken arm but also an altered level of consciousness requires a rapid trauma survey to rule out other injuries such as head trauma.

D. Critical Interventions And Transport Decisions



Signs and Symptoms 




Specific Extremity Treatments

Shoulder: sling and swathe. Elbow should be flexed at a 90° angle with some support between the elbow and the abdomen.

Elbow: splint in the position found. Do not manipulate, as severe neurovascular complications may occur. Sling and swathe when possible

Humorous: if the fracture is in the upper part of the humerus, a sling and swathe is sufficient. Treat deformities in the lower part of the humerus as if they were elbow fractures.

Forearm: utilize a rigid type split to immobilize the fracture site.

Wrist: utilize a board split with gauze place between fingers, and support the hand on a board with roller gauze in the palm of the hand.

Hand: support the hand on a cushion or pillow. An alternative method is to insert a role of gauze in the poem, place gauze pads between the fingers, and wrap the entire hand in a very bulky dressing.

Pelvis: you may consider pelvic wrap devices/splints in an adolescent child, based on the size of the child and the equipment available. You may use a sheet or commercial device specifically sized for the pediatric patient to stabilize an unstable pelvic fracture. It is best to immobilize the full body to a backboard (and pad for comfort when appropriate).

Hip: splint in the position found. Secure to the backboard. Do not use traction splints on hip fractures.

Femur: if a femur fracture is present (typically indicated by pain, deformity, instability, and angulation of the thigh), apply an appropriate splint and secured to the backboard. This is the only fracture in which attraction splint may be used.

Tibia/fibula: utilize a rigid type splint and secure the backboard.

Knee: Immobilize in the position found. If distal pulses absent apply gentle longitudinal (in-line) traction the limb. Secure to the backboard. A knee fracture or dislocation is frequently associated with vascular injury. This is a true orthopedic emergency. Patella dislocations are frequently mistaken for knee dislocations.

Ankle/foot: splint using a compression dressing (pillow–type splint).

Do not take splinting of extremity likely even though it is a basic skill. Severe complications, including changing a closed fracture to an open fracture, causing neurovascular compromise, and creating a greater displacement of a joint, may occur if done improperly.

Not all pediatric trauma patient will – – or should – – be splinted as previously described. In the multisystem trauma patient, splitting may be best accomplished by using the body and backboard as the only splint until after you are in route. Remember, ABCs should always take priority over the extremities.


Sprains are ligamentous injuries that occur around the joint. Strains are tears of the muscle tendon junction and usually occur away from the joint.

Signs and symptoms

In the field, these injuries are not easily differentiated from fractures with most children presenting with pain and swelling. Children have a greater tendency to fracture than do adults, so managing any injured extremity as a fracture.


The initial treatment of a sprain or strain follows fracture management principles.





1. While not typically life-threatening, extremity injuries are often disabling. These injuries are often more obvious than more serious internal injuries and can distract caregivers to defer the usual steps of the ITLS primary survey and attend to the non-life-threatening extremity trauma.
2. Pelvic and femur fractures can be associated with life-threatening internal bleeding, so patients with these injuries are in the loading go category.
3. Proper splitting is important to protect the injured extremity from further injury as well as to minimize pain.
4. Dislocations of elbows, hips, and knees, while rare, require careful splitting and rapid transport to prevent severe disability affected extremity.

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