Paediatrics Orthopaedics

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    Paediatrics Orthopaedics

    Anatomy of Long Bone

    Epiphysis

    Epiphyseal Plat

    Metaphysi

    Diaphysis

    Fracture in Children

    Physeal Injury

    Different Patt ern of Fractur

    Healing is Better (Bone Remodelling)

    Complications in Relation to Growth Plate

    Fractures

    Diaphyseal Metaphyseal Physis (Growth Plate)

    Malleabl

    Plastic Deformity

    Cancellous Bone Weakest Point in

    Skeleton of ChildrenProne to

    Periosteum Thicker

    (compared to A dult)Usually Remain Intact in

    one side of fracture

    (Help splinting fracture)

    Green Stick Fracture

    Weaker than Ligament

    Hypertrophic Zone is

    the Weakest

    Torus Fracture

    Supracondylar Humerus

    Thin Cortex Olecranon Fossa

    (Thin Bone)

    Salter Harris Classification

    I II III IV V

    Avoid

    Damage

    Avoid

    Damage

    Anatomical

    Reduction

    Anatomical

    Reduction

    No Salvage

    Restore

    Articular

    Surface

    Prevent

    Metaphyseal-

    EpiphysealBridge

    Secondary Ossification Ce nter

    Develop After Birth

    Intraarticular Fractur

    Small Hair Line is Misleadin

    Bone Remodelling

    Better in

    Near to Growth Plate Plane of Joint Motion Young Age (2 Years Growth Remaining)

    Complications

    Growth Arrest

    Angular Deformity Shortening

    Mechanism of Injury

    Normal Bone Fracture

    Pathologic Fracture

    Child Abuse

    Pathologic Fracture Child Abuse

    Caused by Triv ial Injury History

    Causes

    Osteopetrosis Osteogenesis Imperfecta Rickets Fibrous Dysplasia Malignant Bone Tumour

    Vague, Not Consistent with Forcenecessary to cause injury

    (eg. Single V ertebra Fracture afterChild Fell from Couch)

    Delay in Seeking Treatment

    Poor Child-Parent Interaction

    (no Eye Contact)Feature

    Head Chest Limb

    Malnourished Child

    Physical Examination (Soft Tissues)

    Soft Tissue Injuries (80% of cases)

    Clustering of Injuries (Face, Trunk, Buttocks)

    Thermal Injuries (Popliteal Sparing)

    Regularly Spaced Patterns (Scratch Mark s, Radiator Burns)

    Imprinting (Wire Hanger Marks, Cigarette Burns)

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    Fractures

    Metaphyseal Corner Fractur

    Lower Extremity Fractures (in Non-Weight Bearers)

    Rib, Spine, Skull Fracture

    Bilateral Acute Fracture

    Overabundant Callus

    Improper Immobilizat ion Bone over BoneVarious Stages of Healing

    Metaphyseal Corner Fracture (Child Abuse)

    Highly supportive of diagnosi

    Secure attachment of Perichondrial F ibreNature ofTraction Injury

    Callus (Child Abuse )

    Due to Improper Immobilization

    Bone in Bone

    Lower Extremity Fractures in Nonwalkers

    Femoral Fracture in Child < 1 y/o

    Rib Fracture

    Especially Posterior (Difficult to Detect on X-Ray)(but Bone Scan helps) Due to Shaking, Hitting from Behind

    RadiologicalLocation

    Personality

    Displace

    Angulation

    Localized Bone Lesion

    Bone Quality

    Joint, Growth Plat

    Differentiate Fracture, Physis

    Growth Plate ofMedial Epichondyle

    Persist until 16 y/o

    Contralateral

    Monteggia Fracture

    Line Cross the Capitulum in both AP, Lateral

    Pelvis Radiograph

    Subtle AP, Obvious Lateral

    Subtle Feature (Supracondylar Humerus Fracture)

    Fat Pad Sign

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    Management

    Reduce

    Hold

    Rehabilitat

    Casting

    Remodelling Potential (Good)

    Recovery from Stiffness (Good)

    Fast Healing

    Very well Adjusted

    3 Point Molding

    Position of Joint

    Closed R eduction

    Adequate Anaesthesia + Muscle Relaxation

    Reverse the Mechanism

    Relax the Deforming Force

    Acceptable Reduction

    No Rotation

    Contact

    No Shortening (Except Femur 1.5 cm)Angulation

    Varus Valgus 10 Recurvatum, Procurvat um

    After Cast Care

    Loss of Correction

    Must review at 1 week

    POP Care (Plaster of Paris)

    Pressure Sore

    CompartmentMaterial Inside

    Wet

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    Paediatric Bone, Joint Infectio n

    Causative Organisms (Osteomyelit is, Septic Arthritis)

    Neonates

    ( < 1 y/o)

    Child

    (1-4 y/o)> 4 y/o Adults

    Staphylococcus

    aureus

    Staphylococcus

    aureus

    Staphylococcus

    aureus

    Staphylococcus

    aureus

    Group B

    Streptococcus

    Haemophilus Streptococcus

    Pyogenes

    Streptococci

    (A, B, C, G,

    pneumoniae)

    HiB Vaccine Introduction

    (Incidence of Haemophilus Infections has dropped dramatically )

    Route of SpreadOsteomyelitis (OM) Septic Arthritis (SA)

    Haematogenous Haematogenous

    Spread from Contiguous Soft Tissue

    Infection

    Spread from Contiguous Soft Tissue

    Infection

    Direct Inoculation (Penetrating Injury) Direct Inoculation (Penetrating Injury)

    Spread from

    Metaphyseal Osteomyelitis(where Metaphysis is Intra-Articular)

    Pathophysiology

    Acute Haemat ogenous Osteomyelitis

    Spread to

    Metaphysis

    Lifts PeriosteumInvolucrum

    Formed Against

    Sequestrum

    Local Spread toJoint, Soft

    Tissues

    Casual Relationship OM, SA

    Clinical Features (OM, SA)Neonates Younger Child, Toddler Adult

    Irritibility Limp with Weight

    Bearing

    Symptoms ofInfe ction

    Lethargy

    Refuse Feeding Refuse to Walk

    Fever Irritabl

    Pseudoparalysis Fever

    Clinical Exam ination

    Osteomyelitis (OM) Septic Arthritis (SA)

    All findings ofInflammation, Infe ction All findings ofInflammation, Infe ction

    Pus Discharge Severe Range of Motion (ROM)

    Painful Septic Joint

    Types of Osteomyelitis

    Acute

    (Acute Haematogenous Osteomyelitis)

    Pathology

    Inflammation Suppuration Necrosis New Bone Formation Resolution Subacute (Brodies Abscess)

    Painful Limp, Systemically, No Signs of Local Infection, Insidious

    X-Rays Well-Established Lesion in MetaphysisCommon Sites Femur, Tibia

    Blood Tests Normal

    Chronic

    Etiology

    Inadequate Treated Acute Osteomyelitis Delay in Treatment Haematogenous Spread Penetrating Trauma Open Fractures Contiguous Focus InfectionCausative Organisms

    Staphylococcus aureus (if 2 to Acute Osteomyelitis) Staphylococcus aureus (Following Trauma)(but may be Polymicrobial) Sinus Tracts become Colonized by many Organisms

    (Superficial Swabs are Unhelpful)Classification (Cierny)

    I II III IV

    Medullary Superficial Localized Diffuse

    Risk F actors

    Moderate

    Normal Immune

    System

    Local, Mild Systemic

    Deficiency

    Major Nutritional or

    Systemic Disorders

    Non-Smoker Smoker

    Septic Arthritis

    Pus, Cartilage are IncompatibleCartilage Destruction

    EpidemiologyChildren (can occur at any age)

    < 2 y/o < 5 y/o

    50% cases 30% cases

    Common Sites

    Infants Older Children

    Hip Knee

    > 1 Joint affected (10% cases)

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    Investigations

    Blood

    ESR, CRP

    FBC

    Blood Culture

    Radiological Study

    Plain Radiograph

    Aspiration (SA)

    Other Special Radiological Imaging

    US

    MRIBone Scans

    T-99 Indium, GaliumManagement

    Principle

    Supportive

    Analgesics Hydration Splint, TractionAntibiotics

    Anti-Staphylococcal AntibioticsAnti-Streptococcal Antibiotics

    1st

    Line 2n

    Line

    Cloxacillin Vancomycin Benzylpenicillin

    Fucidic Acid

    Drainage

    Surgical Indication

    Osteomyelitis Septic Arthritis

    Not Responding to MedicalTreatment 24 48h

    Drainage (Treatment)

    Eradicate, Dilute Bacteria InoculumDestructive Enzymes from

    Immune Response

    DecompressExcision Nonviable TissuesMinimizing Destructive Changes

    Evidence ofSubperiosteal Abscess

    Chronic Osteomyelitis (Treatment Principles)

    Antibiotics (Prolonged)

    Surgical Debridement, Bony Stabilisation

    (Remove All Dead, Infected Tissue, Bone)Control of Dead Space

    Soft Tissue Cover

    Complications

    Pathologic Fracture

    Osteonecrosis of Proximal Femur

    Growth Deformity

    Physeal Arrest Physeal StimulationSystemic Sepsi

    Distant Seeding

    Chronic Osteomyelitis

    Hip Dislocation

    Differential (Diverse, Limping Child)Celluliti

    Inflammatory Arthriti

    Toddler Fractur

    Neoplasms (Ewings Sarcoma, Leukaemia)

    Bone Infarction (Sickle)

    Diskiti

    Acute Rheumatic Fever

    Transient Synoviti

    X-Rays

    Pathologic Fracture

    Hip Dislocation Hip Dislocation

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