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Pediatric OrthopedicsAlexander Rogers, MD

Associate ProfessorEmergency Medicine and Pediatrics

Michigan Medicine/University of Michigan

Disclosures

I have no conflicts of interest to disclose

I will not be talking about off label use of medications

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• In 2010, analysis of National data showed more

than 7.5 million pediatric ED visits for injuries

and poisoning – the top visit category – (Wier LM, Yu H, Owens PL, Washington R. Healthcare Cost and

Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville

(MD): Agency for Healthcare Research and Quality (US); 2006-2013

Jun)

• Immaturity of pediatric skeletal structures leads

to different fracture patterns than adults, with

different short and long term risks

Scope of the problem

• Review common pediatric specific injuries

• Recognize when we need to intervene

• Cover some non-traumatic presentations

Learning goals

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• Pediatric skeleton less densely calcified than adult

• Bones are lighter and more porous

• More porous= more pliableless strengthincrease fractures

• Actively growing structure:

– long bones contain growth plates/physes

– end of bones contain epiphysis

Pediatric Musculoskeletal System

• Bones of child surrounded by thick and active periosteum

• Ligaments and periosteum stronger than bone itself

– physis is weak link

– fractures more common than sprains in younger children

• Response to trauma age dependent

Pediatric Musculoskeletal System

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• SH I – fracture through

physis – may be displaced

• SH II- through physis and

metaphysis

• SH III – through physis and

epiphysis

• SH IV – through metaphysis,

physis and epiphysis

• SH V – crush to physis

Salter-Harris Classification

In general – higher grade Associated with

higher risk of growth abnormality

• Doctor: What brings you in today?

• Patient: I jumped off a chair and hurt my arm

• Doctor: oh, why did you jump off the chair?

• Patient: I was trying to fly

• Doctor: Did you?

• Patient: A little bit!

5 yo upper extremity injury (or ‘why I work in

Pediatrics’)

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Distal Forearm fractures

• Common fracture type

• 2 view radiographs key

• Acute reduction can avoid

the OR

• Reduce if > 15-20

degrees angulated

• If not reduced acutely –

end up needing OR for

pinning

Distal Radius and Forearm fractures

Orthop Rev (Pavia). 2014 Apr 22; 6(2): 5325.

• Multiple recommendations regarding acceptable alignment parameters

• Younger age have more remodeling potential

• Age > 9 higher risk

• after skeletal maturity tx as adult

• Distal fractures remodel better

• If initial reduction is not adequate – these are difficult to manage in the

office*

*A friendly plug from my orthopedic colleagues

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• 6 yo with fall from the

monkey bars

• Pain in mid-forearm

• Subtle

swelling/deformity

Forearm fracture variants

• Plastic deformity of long bone

(in this case the ulna)

• If > 20 degrees of deformity

can prevent remodeling of the

other bone

• Increased need to reduce if >

10 yo

• Reduce with either weights or

slow, constant traction

Bowing fracture

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• 5 yo FOOSH

• Still using affected

arm, but decreased

• Pain with supination

• No swelling or

deformity

Forearm fracture variants

• Distal Radius most

common but can be

any bone

• Can usually treat

with prefabricated

splints – and your

patients will thank

you for it!*

Buckle/Taurus fracture

*Williams KG et al. A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference. Pediatr Emerg Care. 2013 May;29(5):555-9.

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• 9 yo fall from a

giant yoga ball

that was next to a

tree at family

camp

Forearm Fracture variants

• Monteggia

fracture-

dislocations consist

of a fracture of the

ulnar shaft with

associated

dislocation of the

radial head. The

ulnar fracture is

usually obvious,

whereas the radial

head dislocation

can be overlooked

Monteggia Fracture

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• Ulnar fracture + radial head dislocation

• Uncommon (2% all elbow fx’s)– but peak age 4-10

• Can be easily missed-must have films of both elbow and forearm

• Isolated ulna fractures rare

• If unrecognized and not reduced, can lead to permanent disability

• Closed reduction possible in children, less likely with increased age

Monteggia Fracture

Monteggia Fracture

• Classic:

- Fx distal 1/3 radius

- dislocation of distal

ulna

• Disruption of radioulnar joint

• Peak age 9-12 years

• Suspect in angulated distal radius fractures

• Difficult to recognize

• Requires ortho consult in ED and reduction

Galleazzi Fracture

MUGR fractures…Monteggia has fractured UlnaGaleazzi has fractured Radius

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• 6 ossification centers around the elbow joint

• C= Capitellum ( 1 yr)

• R = Radial head ( 3-5 yrs)

• I = Internal/ medial epicondyle- (4-6 yrs) on ulnar side of elbow

• T = Trochlea (6-8 yrs)

• O = Olecranon (8- 10 yrs)

• E= External/ lateral epicondyle ( 10-12 yrs) –due to anatomical position lateral epicondyle on radial side of elbow

Pediatric Elbow

• Anterior Fat Pad

– May be normal

• Posterior far pad

– Always abnormal if visible

– Treat a posterior fat pad

as an occult fracture even

if the rest of the structures

are normal

Elbow Fractures and Anatomic Landmarks

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• Anterior humeral

line

– Follow anterior

humeral cortex

– Should pass through

the middle 1/3 of the

capitellum

– Note the visible

posterior fat pad!

Radiography and Anatomic Landmarks

• Radiocapitellar line

(need a good lateral

film!)

– Should intersect the

middle 1/3 of the

capitellum

– If not – think radial head

dislocation/Monteggia

fracture

Radiography and Anatomic Landmarks

Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 41196

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• Fall on outstretched arm with hyperextension

• Neuropraxia

• Absent pulse in 7-12%

• Volkmann contraction with brachial artery

compression after repair

Supracondylar fractures

Supracondylar types

Type 1 Type 2 Type 3

• Abnormal fat pad

• Posterior splint

• Pain control

• Outpatient ortho

for casting

• Posterior cortex

intact

• Posterior splint

• Pain control

• Operative repair –

in vs outpatient

• Both cortices

disrupted

• Check pulse and

nerve function!

• Posterior splint

• Pain control

• Urgent/emergent OR

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Supracondylar Reduction

• If pulseless extremity and delay

in transport to definite care,

consider closed reduction

• Traction

• ‘Milking’ of displaced portion

• Hyperflexion of elbow

• Follow by documentation of

pulses and splinting

• Do not delay transport for

reduction if pulses are

thready but capillary refill is

adequate – closed reduction

is a last resort as often slips!

Heading down…

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Lower Extremity Injuries/Kids who won’t walk

• 14 yo male with 1

month hx of limp and

progressive knee

pain

• No known trauma

• 100 kg male

• Pain with internal

rotation of hip

Limping Teenager

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• 14 yo male with 1

month hx of limp and

progressive knee

pain

• No known trauma

• 100 kg male

• Pain with internal

rotation of hip

Slipped Capital Femoral Epiphesis

• Slipped Capital Femoral Epiphysis

(SCFE)

• Male>Female, African American,

obese

• Often present as knee pain

• AP, Frog leg view of both hips

• Urgent operative repair

• Worsening slip can lead to AVN

• 18 month old male being swung in circle by father

(me) and swings free

• Fall approximately 8 inches with rotational torque

• Won’t bear weight

• No deformity noted

• Mother of child (my wife) not happy

Family Case Study

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• Nondisplaced spiral fracture of tibial

shaft

• Ambulatory children < 3 yo

• Can occur with low energy

mechanism

• Up to 40% of initial films are

negative (? US dx)

• Pain control and casting –

sometimes empiric – for 3 weeks

• Casting preferable to splinting (kids

escape splints)

Toddler’s Fracture

• 3 year old male with recent fall off bike

• URI one week ago

• Now with fever, unwilling to bear weight

• Complains of pain with movement of the right

hip

Hip pain and fever

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• Both can cause patients to be unwilling to bear weight and

have pain with hip movement

• Risk factors in order of importance

– Fever (38.5) > CRP (>2.0) > ESR(>40) > refusal to bear

weight > WBC (>12)

Hip Septic Arthritis vs. Transient Synovitis

Caird et al. The Journal of Bone & Joint Surgery. 88(6):1251–1257, JUN 2006

• Close to 1% all children victims of abuse

• 1/3 of these kids will be reinjured

• 1-5% of these kids will die if returned to original environment

• Abuse is 2nd leading cause of death infants and children

• Risk factors*:

– child < 4 years of age (majority are < 2)

– parental substance abuse

– young parents, single parents, large # children

– Nonbiological, transient caregivers in the home

– disability

Non-accidental trauma

*https://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html

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Orthopedic injuries and abuse

• Bucket handle and corner fractures are

considered Classic Metaphyseal Lesions

• Torsional force applied to immature bone

• Highly suspicious and should prompt a skeletal

survey if < 2 (NOT a babygram), 3200 and NAT

workup or transfer to appropriate facility

Fractures associated with NAT

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Fractures associated with NAT

• Posterior rib fractures – often found in contiguous ribs and different

stages of healing if repetitive trauma

• Compressive force applied to sternum and costovertebral junction

during violent shaking

• Highly suspicious and should prompt a skeletal survey if < 2 (NOT a

babygram), 3200 and NAT workup or transfer to appropriate facility

• Thanks to…

• Stuart Bradin, MD – Pediatric Emergency

• Ramon Sanchez, MD – Pediatric Radiology

• Matthew Abbott, MD – Pediatric Orthopedics

• Michelle Caird, MD – Pediatric Orthopedics

• Marco Rogers – my son who had the Toddler’s

fracture

Acknowledgements

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Thank you to MCEP!!!!

Questions?

Fractures that only need a sling…

• Humerus fractures with < 50

degree angulation in younger

kids

• Clavicle fractures – even with

significant displacement in kids

< 10 years old

• Kids approaching skeletal

maturity can consider

outpatient surgery