What is the initial management for a 6-year-old female presenting to the pediatric emergency room with a history of fall onto her right arm, complaining of pain, and tenderness on palpation, with a previous history of clavicle fracture?

Management of Pediatric Arm Injury After Fall

For a 6-year-old female with right arm pain after a fall, provide immediate pain management followed by appropriate immobilization based on x-ray findings, with special attention to neurovascular status and previous clavicle fracture history. 1

Initial Assessment

• Document the exact mechanism of injury including height of fall, landing position, and time since injury occurred 1
• Assess pain characteristics using an age-appropriate pain scale, noting location, severity, and factors that worsen or improve symptoms 1
• Evaluate the entire right arm for tenderness, with special attention to the previous clavicle fracture site 1, 2
• Perform and document a thorough neurovascular assessment, confirming the strong pulse and brisk capillary refill already noted 3, 1
• Examine joints above and below the injury site to avoid missing associated injuries 1

Pain Management

• Administer ibuprofen 10 mg/kg orally as first-line analgesic, which provides superior pain relief compared to acetaminophen or codeine for pediatric musculoskeletal trauma 4
• Consider adding acetaminophen 15 mg/kg for multimodal pain control if needed 4
• Pain management should begin immediately upon presentation and continue through discharge 3
• Ensure administration of analgesics is as painless as possible 3

Diagnostic Evaluation

• Standard radiographic evaluation should include anteroposterior and lateral projections of the entire right arm 3, 1
• Ensure radiographs are performed upright when possible, as malalignment can be underrepresented on supine imaging 3
• Pay special attention to growth plate involvement, which may require additional imaging views 1
• Consider additional imaging if initial radiographs are negative but clinical suspicion remains high 3, 1

Management Based on X-ray Findings

If Fracture Identified:

• For non-displaced or minimally displaced fractures:

  • Immobilize with appropriate splint or sling based on fracture location 1, 5
  • Schedule orthopedic follow-up within 1 week 1

• For displaced fractures:

  • Consult orthopedics for potential reduction or surgical intervention 5
  • Pediatric clavicle fractures generally have excellent outcomes with non-operative management 6
  • Adolescent patients may require treatment algorithms similar to adults 5

If No Fracture Identified:

• Provide symptomatic treatment with immobilization as needed for comfort 1
• Instruct on activity restrictions with specific timeframe 1

Discharge Instructions

• Provide clear instructions on care of the injured extremity 1
• Explain when to return to the emergency department (worsening pain, color changes, numbness, or increased swelling) 1
• Schedule appropriate follow-up based on injury severity 1
• Give detailed instructions regarding analgesic administration at home 3
• Educate on expected recovery timeline and activity limitations 1

Common Pitfalls to Avoid

• Inadequate pain management - ensure appropriate dosing of analgesics 3, 1
• Missing growth plate injuries which may not be obvious on initial radiographs 1
• Incomplete neurovascular assessment documentation 1
• Inadequate follow-up instructions for parents/caregivers 1
• Failure to consider the patient's previous clavicle fracture history when developing the treatment plan 1, 2