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ORTHO PUZZLERSSTICKS AND STONES SUCK
CHRISTOPHER S. AMATO, MD, FACEP, FAAP
MORRISTOWN MEDICAL / GORYEB CHILDREN’S HOSP.
EMERGENCY MEDICAL ASSOCIATES
MORRISTOWN, NJ
ENVISION PHYSICIANS GROUP
DISCLOSURE
Financial Interests
Sponsorship
NONE
NONE
Disneyland releases ~300 feral cats at night to deal with some cousins
The Evil Queen intermittently appears in the window above Snow
White’s Scary Adventure
OBJECTIVES
Describe how the anatomic and physiologic differences that exist in pediatric patients affect the management of pediatric orthopedic injury.
Discuss growth plate-related injuries and the typical ages that they close.
Review specific types of orthopedic injuries that are fraught with medical-legal issues and how to spot them in the first place.
Discuss the level of urgency, emergency, and non-urgency of these conditions.
Review the complications of these conditions.
THEORTHOPEDIC EMERGENCIES
Open Fractures Acute Compartment Synd. Neurovascular injuries Dislocations Septic Joints Cauda Equina Syndrome
PEDIATRIC FRACTURES
• Salter-Harris Classification
• Greenstick – incomplete angulated long bone fracture
• Torus – incomplete fracture with cortical buckling/wrinkling
PEDIATRIC GROWTH PLATES
SITE AGE of Closure
Proximal Tibia 16-20
Distal Tibia 17-18
Distal radius 17-19
Proximal Femur 16-18
Distal Femur 16-19
Proximal Humerus 18-21
https://www.slideshare.net/harjotsgurudatta/orthopaedic-fractures-in-children
C-R-I-T-O-E= 1-3-5-7-9-11 yrs.Capitulum-Radius-Internal (Med) Epicondyle-Trochlea-Olecranon-External Epicondyle
CASE #1
HISTORY
2 year old female brought by father (PEM doc) due to fall down stairs.
Holding L wrist and crying in pain
PMHx: her father has dropped her beforeOlder sibling has hx of Femoral fx…hmmm
PHYSICAL EXAM
VS: WNL
Gen: Awake and alert
Ext: Left arm: (+) minimal swelling of L upper extremity at distal wrist
WHAT DO WE DO IN THE ED????????CSF
Do we even need to call Ortho?
CPS?
His wife?
Masked to protect the identity of this moron
WHICH BONE IS BROKEN THE MOST?
Clavicle? only takes 8 lbs. of pressure to break the collar bone
Radial fractures are by far the most common pediatric fractures (40% to 50%)
TORUS AKA BUCKLE FX
Multiple studies challenge routine casting {acceptable angle <15°}
Splints: may remove after 3 weeks without orthopedic follow-up. An interval visit with a primary care provider at 10-14 days after injury to reassess
the child and provide anticipatory guidance about splint use may be reassuring to the caregiver.
Fracture without displacement during healing
Thus, additional radiographs are unnecessary1. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. Pediatrics. 2006;117(3):691–72. Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial. Boutis K, Willan A, Babyn P, Goeree R, Howard ACMAJ. 2010 Oct 5; 182(14):1507-12.3. Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures. Randsborg PH, Sivertsen EA. Acta Orthop. 2009;80(5):5854. The role of serial radiographs in the management of pediatric torus fractures. Farbman KS, Vinci RJ, Cranley WR, et al. Arch Pediatr Adolesc Med 1999; 153:923
SPLINT VS. CAST
Degree of initial pain
Degree of anticipated activity of the child
Parental preference.
can be removed for showering and minor activities
cast offers more protection of the fracture site in active children
Small trial (84 children from single Children’s hospital)
↑duration of pain fiberglass molded splint vs. cast (med. 6 vs. 3d, p <0.01)
A 4 y/o male is brought to the ED with limp noted on the right legNo reported trauma or signs/symptoms of illness No PMHx or comorbid diseasePE: (+) limp with gait, Otherwise (-) findingsRadiographs: Normal
LIMPChoban S, Killian JT. Evaluation of acute gait abnormalities in preschool children. J Pediatr Orthop. 1990 Jan-Feb;10(1):74-8.
LIMP CHARACTERISTICS
LIMP: Differential based on 1) AGE 2) Examination3) Pain characteristics:
a. Constant pain→ infection or malignancy
b. Morning pain → inflammatory disorder
c. Pain after activity → overuse injury
d. Nighttime pain → ? malignancy
EVALUATION OF LIMP
• History and Physical
• Pain control – lead with NSAIDs (unless obvious fracture and NPO)
• Radiography
• LABS: CBC/d, CRP, ESR (LYME if endemic)
• Serial examinations
TRANSIENT (TOXIC) SYNOVITIS
• Transient Synovial inflammation
• Males>Females
• Age 4- 10 years
• Usually unilateral
• EXAM: • (+) pain radiates to thigh / knee
• Held in flexion, adducted, w/ internal or external rotation
• Radiography / Ultrasound
TRANSIENT (TOXIC) SYNOVITIS
• Radiography:• X-ray may reveal effusion
• Ultrasound: Effusion noted in 95% cases
• Laboratory:• CBC: NML or slight ↑
• ESR: NML or slight ↑
• CRP: NML or slight ↑
• MANAGEMENT: • Rest, NSAIDs, close follow up
A 4 y/o male with limp noted on the right leg(+) T 39.5, P130, RR24, Bp 100/70, PulsOx RA 99%Fell 2 days prior but without apparent issues sincePE: (+) will not move Right leg Radiographs……………
SEPTIC ARTHRITIS• Radiography:• X-ray may reveal effusion
• Ultrasound: Effusion noted in 95% cases
• Laboratory: Kocher: • CBC -- elevated >12K/ml
• ESR -- elevated >40 mm/hr
• CRP -- elevated >2mg/dL
• FEVER >38.5
• Weight Bearing No
0/4 = 0.2% chance of having septic arthritis1/4 = 3% chance. 2/4 = 40%. 3/4 = 93% chance of septic arthritis4/4 = 99.6% probability of septic arthritis J. Bone Joint Surg. Am. 1999;81:1662-70
Blood Cx (+) in 40% of casesLog roll test (passive supine rotation; Freiberg test)
Pathophysiology: Hematogenous SpreadBacteremia from Soft-tissue or other infectionSpread from Osteomyelitis (10%)
Trauma (minor or major) or Surgery
•MANAGEMENT: •Admit & consult Pediatric Orthopedics•Aspiration / wash out•Empiric Antibiotic Therapy:
May be altered based on age
SEPTIC ARTHRITIS
A 6 y/o boy with limp for months is brought to ED •Patient complains of groin and thigh pain, otherwise well. •Exam reveals a well appearing male who walks with a slight limp on the left; limited in abduction on the left
LEGG-CALVES-PERTHES
• Aseptic necrosis of femoral head • Flattening of femoral head
• Males>Females
• Age 4- 12 years
• Unilateral 85%; bilateral 15%
• Onset possibly over years• Medial thigh, groin, or knee pain
• (+) spasm of musculature
EXAM: limited range of motion•especially abduction•Length discrepancy ?
A 16 y/o boy with acute pain•Patient complains of groin and thigh pain, otherwise well
http://gifrific.com/psy-kicks-soccer-ball-away-and-dances/
Klein’s line - a line from superior cortex of femoral neck parallel to greater trochanter
SLIPPED CAPITAL FEMORAL EPIPHYSIS
• Typically obese male (weight >90%)
• Males 12-15 yrs., Females 10-13 yrs.
• Males>>Females
• Gradual hip/thigh/knee pain• Can present acutely following minimal trauma
• Hip externally rotated
• 10-25% bilateral
• X-rays – widen physis, Klein line• Include frog-leg view
SCFE VS. LCP
SCFE Insidious onset common May have inciting event
Male > female
Peak 12-14 years
Bilateral in up to 25%
Limp/hip pain
Tx: Admit for ORIF
LCP Insidious onset common
Male > female
Peak 5-7 years
Bilateral in up to 20%
Limp/hip pain
• Tx: NSAIDs, decreased activity
• Non-weight bearing – casting/ braces
WHAT IF?????
14 year old playing soccer – went to kick ball and then had immediate pain????
RUNNER / JUMPER
http://www.radiologyassistant.nl/data/bin/a5518160776b4f_17-avulsion.jpg
A 4 y/o male is brought to the ER with left arm pain. Child was playing at the monkey bars when he fell and stopped the fall with his left arm. PE: (+) left distal forearm pain. Your order left forearm X-Ray.
COMMON DISTAL FOREARM FRACTURES
Torus Fracture Greenstick FractureBOWING / PLASTIC DEFORMITY
http://eu-csite-storage-prod.s3.amazonaws.com/www-eurorad-org/mediafiles/0000002791/000002_text.jpg
A 4 y/o male is brought to the ER with left arm pain. Child was playing at the monkey bars when he fell and stopped the fall with his left arm. PE: (+) left distal forearm pain. Your order left forearm X-Ray.
MONTAGGEIA FRACTURE
Fracture of the proximal 1/3rd of ulna combined with dislocation of the radial head
https://www.google.com/search?q=galeazzi+fracture&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwjaiNPCr7zTAhVlxlQKHY1tCYoQ_AUIBigB&biw=1507&bih=852#tbm=isch&q=montaggeia+fracture&imgrc=a-RCOim-CZwI_M:
GALEAZZI FRACTURE
radial shaft fracturecommonly at the junction of the middle and distal third
dorsal angulation
Dislocation of the distal radioulnar joint
ELBOW FRACTURES
40
Radiocapitellar line should intersect the capitellum in all views
Make it a habit to evaluate this line on every pediatric elbow film
ELBOW FRACTURESRADIOGRAPH ANATOMY/LANDMARKS
Anterior Humeral Line Drawn along the
anterior humeral cortex
Should pass through the middle of the capitellum
Variable in very young children
TYPE 1NON-DISPLACED
Note the non- displaced fracture (Red Arrow)
Note the posterior fat pad (Yellow Arrows)
-Skaggs. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81:1429. -Bohrer. The fat pad sign following elbow trauma. Its usefulness and reliability in suspecting “invisible” fractures. Clin Radiol. 1970;21:90.
TYPE 2ANGULATED/DISPLACED FRACTURE WITH INTACT POSTERIOR CORTEX
In many cases, the type 2 fractures will be impacted medially Leads to varus angulation
The varus malposition must be considered when reducing these fractures Apply a valgus force for
realignment
TYPE 2ANGULATED/DISPLACED FRACTURE WITH INTACT POSTERIOR CORTEX
TYPE 3COMPLETE DISPLACEMENT
Mother presents and states there is “something wrong with her Right leg” (6 wk. old) daughterNo history of trauma, previously healthyChild alert, held by motherPE: (+) Not moving Right leg (+) mid thigh hematoma
HR 132, RR 42, BP 80/67, T 37.3°C, O2 sat 96%
NON-ACCIDENTAL TRAUMA
For each case of child maltreatment reported, 2 go unrecognized
Follow the guidelines of:
Listen, Look, Explain, Evaluate, Record, Report
Follow a multidisciplinary approach:
Clinicians, social services, law enforcement
NON-ACCIDENTAL TRAUMA
Differential Dx: Osteogenesis imperfecta
Hypophosphatasia
Rickets
Leukemia
Primary and metastatic bone tumor
Management Give proper analgesia.
Splint inured limb.
Notify child protection services.
Consult appropriate services:
Child abuse
Orthopedics
Genetics
STRANGEST ORTHO CASE TO DATE:
Strangest Ortho case to date:
THANK YOU!
ACKNOWLEDGEMENTS
Ariel Vera, MD
Dhwani Patel, DO
Marianne Gausche-Hill, MD
Univ. of Hawaii.edu, pediatric radiology case studies
LSU Medical Student Clerkship, New Orleans, LA
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