Your SlideShare is downloading. ×
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
GEMC: Pediatric Orthopedic Emergencies: Resident Training
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

GEMC: Pediatric Orthopedic Emergencies: Resident Training

879

Published on

This is a lecture by Dr. Stuart Bradin from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the …

This is a lecture by Dr. Stuart Bradin from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

Published in: Education
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
879
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
40
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Project: Ghana Emergency Medicine Collaborative Document Title: Pediatric Orthopedic Emergencies Author(s): Stuart A Bradin, DO, FAAP, FACEP License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  • 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  • 3. Pediatric Orthopedic Emergencies Stuart A Bradin, DO, FAAP, FACEP Assistant Professor of Pediatrics and Emergency Medicine University of Michigan Health System Richard Masoner, Flickr Derrick Mealiffe, Wikimedia Commons Wikimedia Commons 3
  • 4. Objectives 1.  Introduction of most common pediatric orthopedic injuries 2.  Understand physiologic differences between adult and pediatric musculoskeletal system 3.  Introduction of orthopedic injuries unique to pediatrics 4.  Discussion of initial evaluation and management of common pediatric orthopedic injuries 4
  • 5. Introduction nn Children experience diverse array of illnesses andChildren experience diverse array of illnesses and injuriesinjuries nn Many unique to pediatricsMany unique to pediatrics nn 1/3 of all ED patients annually are children1/3 of all ED patients annually are children (Annals of Emergency(Annals of Emergency Medicine, 1990)Medicine, 1990) nn PrePre--hospital setting, 10% ambulance runs are forhospital setting, 10% ambulance runs are for pediatric patientspediatric patients ((KallsenKallsen GW, inGW, in DieckermanDieckerman RA, 1991)RA, 1991) nn Trauma represents majority of pediatric transportsTrauma represents majority of pediatric transports (50(50--65%)65%) nn Age dependentAge dependent nn Injuries are most common reason pediatric patientsInjuries are most common reason pediatric patients present to the EDpresent to the ED 5
  • 6. Introduction Ø Represent 10-15% of ED visits Ø 70% related to falls in younger children Ø In the multi- trauma patient, > 50% will have at least 1 musculoskeletal injury Ø Injury patterns in pediatrics differ greatly from adults Ø Recognizing and understanding these differences critical to appropriate diagnosis and care 6
  • 7. Pediatrics nn Prehospital providers often have:Prehospital providers often have: –– Limited pediatric patient contactsLimited pediatric patient contacts –– Limited knowledge, training, andLimited knowledge, training, and experience specifically directed towardsexperience specifically directed towards pediatricspediatrics nn Many other healthcare providers areMany other healthcare providers are similarly affectedsimilarly affected nn Children are not little adults!!!Children are not little adults!!! 7
  • 8. Pediatric Trauma Ø Distinguished from that in adults by differences: 1. mechanisms of injury 2. fracture patterns 3. multiple acceptable treatment options 4. associated systems injuries 5. mortality in pediatric polytrauma 6. residual morbidity 8
  • 9. Common Pediatric Mechanisms of Injury Ø Pedestrian struck by vehicle Ø Fall from low heights Ø Non accidental injury in infant/ toddler Ø Power tools/ lawn mower injuries Ø Vehicle operator and falls from heights (teens) 9
  • 10. Mechanisms of Pediatric Injury Waddell’s Triad William Murphy, Flickr Rhymeswithbombs, Fllickr 10
  • 11. Mechanisms of Pediatric Injury PMcM, Liftarm, Wikimedia Commons 11
  • 12. Non accidental Injury Ø  Close to 1% all children victims of abuse Ø  1/3 of these kids will be reinjured Ø  1-5% of these kids will die if returned to original environment Ø  Abuse is 2nd leading cause of death infants and children Ø  Majority < 1 year of age Ø  Must have high index of suspicion Ø  Risk factors: parental substance abuse young parent child < 3 yrs old premature disability 12
  • 13. Non accidental Trauma History - what is mechanism - is story plausible - who witnessed event - time from injury to tx - who has access to pt - inconsistent stories Physical Exam -  serious injury can exist despite no outward signs -  patterns of bruising/ unexpected areas -  burns/ scars -  May require opthy exam/ CT scan (Shaken Baby) 13
  • 14. Orthopedic injuries in Non accidental Trauma Ø  Seen 30-50% children Ø  Injuries highly specific for abuse include: - corner or bucket handle fractures - scapular fractures - posterior rib fractures - old fractures - multiple fractures of different ages - spinous process fractures Ø  Spiral fractures are not pathognomonic for abuse Melimama, Wikimedia Commons 14
  • 15. Orthopedic injuries and Abuse Source Undetermined Source: RadiologyAssistant.nl 15
  • 16. Bucket handle fracture Source Undetermined 16
  • 17. Corner Fracture Source Undetermined Source Undetermined 17
  • 18. Posterior rib fractures Source Undetermined 18
  • 19. Posterior Rib fractures Source Undetermined 19
  • 20. Healing Fracture Source Undetermined 20
  • 21. Other Injuries Associated with Pediatric Non-accidental Trauma Source Undetermined Source Undetermined Source UndeterminedSource Undetermined 21
  • 22. Physiologic Differences in Child Ø  Periosteum thicker and stronger Ø  Bone more porous Ø  Higher incidence of plastic deformities Ø  Less ligament injury/ dislocation Ø  Remodeling is extensive Ø  15% childhood fractures involve growth plate Ø  Radiographic evaluation more difficult due to growth plates Ø  Kids do stupid things! Clappstar, Flickr Edwin Dalorzo, Flickr Bread for the World, Flickr Elizabeth Buie, Flickr 22
  • 23. Pediatric Musculoskeletal System Ø  Pediatric skeleton less densely calcified than adult Ø  Composed higher percentage of cartilage Ø  Bones are lighter and more porous Ø  More porous= more pliableà less strengthà increase fractures Ø  Actively growing structure: - long bones contain growth plates/ physes - end of bones contain epiphysis Ø  Bones of child surrounded by thick and active periosteum Ø  Ligaments and periosteum stronger than bone itselfà - physis is weak link - fractures more common than sprains Ø  Response to trauma age dependent Source: Wikimedia Commons 23
  • 24. Uniquely Pediatric Fractures Ø Physeal or Salter- Harris Fractures Ø Plastic deformity fractures: 1. Buckle or torus fracture 2. Greenstick fracture 3. Bowing or bending fracture Ø Avulsion fractures Ø Toddler’s Fracture 24
  • 25. Buckle Fracture Ø  Secondary to compression Ø  Usually metaphysis Ø  Stable fracture Ø  May be very subtle Ø  Quite common Ø  Requires splint and ortho follow up Source Undetermined 25
  • 26. Buckle Fracture Source: Medscape 26
  • 27. Greenstick Fracture Ø  Most common fracture pattern in children Ø  Incomplete fracture at metaphyseal- diaphyseal junction Ø  Angulation and rotation common Ø  1 cortex remains intact Ø  Often must complete fx to achieve union Source Undetermined 27
  • 28. Greenstick and Bending Fracture Source: Medscape 28
  • 29. Bowing Fracture Ø  Forces on bone stops short of fracture Ø  Persistent plastic deformity can result Ø  Little remodeling Ø  Forearm, fibula common Ø  Functional and cosmetic deficits Ø  Requires ortho referral Source Undetermined Source Undetermined 29
  • 30. Physeal Fractures Ø  18-30% of pediatric fractures Ø  Common adolescence Ø  Peak 11-12 yrs Ø  Usually upper extremity injury Ø  Physis = weak area Ø  Salter- Harris Classification Ø  Salter Harris type 2 most common Source Undetermined 30
  • 31. Salter-Harris Classification • SH I - through physis • SH II - through physis & metaphysis • SH III - through physis & epiphysis • SH IV - through metaphysis, physis & epiphysis • SH V - crush injury to entire physis Source Undetermined 31
  • 32. Salter- Harris Fractures Image Removed (Salter Harris Fracture Classification) Source Undetermined 32
  • 33. Salter- Harris 1 Fracture Source Undetermined Lena Carleton, University of Michigan 33
  • 34. Salter- Harris Type 2 Fracture Source Undetermined Lena Carleton, University of Michigan 34
  • 35. Salter- Harris Type 3 Fracture Source Undetermined Lena Carleton, University of Michigan 35
  • 36. Salter Harris Type 4 Fracture Source Undetermined Lena Carleton, University of Michigan 36
  • 37. Salter-Harris Type 5 Fracture Source Undetermined Source Undetermined Lena Carleton, University of Michigan 37
  • 38. Case Ø  18 mth old brought in by mom because she won’t bear wt on R leg. No fever. No recent illnesses. No witnessed trauma. Ø  Exam: afebrile, non toxic appearing no gross deformity, swelling, redness / warmth, bruising Draws leg up when standing Cries when you try to move lower R leg No rash/ petechiae Mom and baby good rapport, eye contact What do you think is going on? What do you want to do? Jocelyndale, Flickr 38
  • 39. Toddler’s Fracture Ø  Hairline, non displaced spiral or oblique fracture tibia Ø  Typically kids < 4 yrs Ø  Minor force- usually fall Ø  Subtle findings Ø  Does not = abuse Source: Medscape 39
  • 40. Toddler’s Fractures Source Undetermined Source Undetermined Source Undetermined 40
  • 41. What’s Your Diagnosis? 15 year old baseball player Rounding 3rd base, acute pain in hip while running Pain is sharp, felt “ pop” Finished game but has pain walking Exam benign except pinpoint tenderness at AIIS, worse w/ abduction of hip 41
  • 42. Avulsion Fracture of the Pelvis Ø  Intense muscular contraction Ø  Subsequent shearing of secondary ossification center Ø  Pelvis, tibia tubercle, phalanges Ø  Require conservative care Ø  Adolescent -14-18 yrs Ø  90% Male Ø  80% sports related Source Undetermined 42
  • 43. Initial Approach to Orthopedic Trauma Ø  ABC’s Ø  Evaluate involved limb for: - neurovascular compromise - open vs closed fracture - compartment syndrome Ø  Evaluate for fx’s at increased risk for significant bleeding/ hemodynamic instability ( pelvic/ femur fractures) Ø  Search for associated injuries Ø  Pain control Ø  Immobilization Ø  Xray evaluation Ø  Miscellaneous: last meal, allergies/ meds, last period if female 43
  • 44. Fracture Treatment in Children: General Principles Ø  Children heal faster than adults Ø  Require less immobilization time Ø  Stiffness of adjacent joints less likely Ø  Vast majority- tx’d closed methods Ø  Exceptions: open fractures Salter Harris type III- IV injury multi-system trauma Ø  If any concern re: displacementà keep NPO Ø  Any swollen elbow is displaced supracondylar fx until proven otherwise Ø  Analgesia ( morphine 0.1 mg/kg IV), then Xrays 44
  • 45. Radiographic Evaluation Ø  Point tenderness Ø  Large amount of swelling Ø  Severe pain Ø  Persistent symptoms after 3-5 days Ø  High risk mechanism Ø  Must include joint above and below Ø  Comparison views? Ø  All unstable and deformed fractures must be immobilized prior to transfer to radiology 45
  • 46. What Does Ortho Need to Know? Ø  Age and sex of patient Ø  Mechanism of injury Ø  Bone or bones involved in injury Ø  Type of fracture Ø  Neurovascular status of the extremity Ø  Presence and amount of displacement Ø  Presence and estimate of angulation Ø  Open or closed fracture Mike Blyth, Flickr 46
  • 47. Description of Injury-Location Source Undetermined Humerus Radius Femur Tibia Gray’s Anatomy, Wikimedia Commons Gray’s Anatomy Wikimedia Commons Gray’s Anatomy Wikimedia Commons Gray’s Anatomy Wikimedia Commons 47
  • 48. Fracture Description Ø  Fracture pattern: spiral ( twisting) oblique (bending) transverse (direct) Ø  Displacement Ø  Angulation Ø  Communition Source: http://askabiologist.asu.edu/how-bone-breaks 48
  • 49. Fracture Types Source Undetermined Lena Carleton, University of Michigan 49
  • 50. Fracture Types and Description Source Undetermined Source Undetermined 50
  • 51. Open Fractures Xy01, Wikimedia Commons Saltanat enli, Wikimedia Commons 51
  • 52. Open Fractures • IV antibiotics, tetanus prophylaxis – Cefazolin & Gentamicin – TdaP • Emergent irrigation & debridement – 6-8 hrs • NPO Bobjgalindo, Wikimedia Commons Saltanat, Wikimedia Commons 52
  • 53. Pediatric Extremity Injuries Requiring Emergent Orthopedic Evaluation Ø  Femur Fractures Ø  Pelvic fractures Ø  Open fractures Ø  Spinal fractures Ø  Complete fracture of long bones of lower extremities Ø  Neurovascular compromise Ø  Dislocation of large joint Ø  Fractures with significant displacement Ø  Fractures involving large joint 53
  • 54. Injuries to the Upper Extremity Ø Clavicle Ø Shoulder Ø Humerus Ø Elbow Ø Forearm Ø Wrist and hand 54
  • 55. Clavicle Fracture Ø  Most common childhood fracture Ø  Direct trauma and indirect forces Ø  > 50% kids less than 10 yrs of age Ø  Symptoms: - point tenderness/ pain - decreased mobility - unnoticed until “lump” noted as callus forms Ø  Sling or sling and swathe Ø  Pain control Ø  Ortho follow up 2-3 weeks Source Undetermined Source Undetermined Wikimedia Commons 55
  • 56. Shoulder dislocation Source Undetermined Source Undetermined Source Undetermined 56
  • 57. Humerus Fracture Ø  Proximal - 80% growth - Adolescent - non union unlikely - consult ortho: > 50 degrees angulation NV compromise - sling & swathe Ø  Shaft - less common - spiral fx < 3 yrs consider abuse - look for radial nerve injury - sling & swathe Source Undetermined Source Undetermined 57
  • 58. Elbow Anatomy Source Undetermined 58
  • 59. Elbow Fractures and Anatomic Landmarks • Anterior Fat Pad – May be normal if “adherent” to bone • Posterior Fat Pad – Always abnormal if visible Source Undetermined 59
  • 60. Radiograph Anatomy and Landmarks • Anterior Humeral Line – drawn along the anterior humeral cortex – should pass through the middle 1/3 of the capitellum Source Undetermined 60
  • 61. Anatomy and Landmarks • Radiocapitellar line – should intersect the middle 1/3 of the capitellum – Radial head dislocation • Make it a habit to evaluate this line on every pediatric elbow film Source Undetermined 61
  • 62. Radiocapitellar Line What kind of fracture is this? • Monteggia Fracture • Ulnar fracture w/ Radial Head Dislocation Source Undetermined 62
  • 63. Supracondylar Fracture Ø  Fall on outstretched arm Ø  Hyperextension Ø  Common elbow fracture Ø  Complications: - NV compromise - compartment syndrome Ø  Graded 1- 3 Ø  Management dependent upon type of injury ( splint or OR for repair) Ø  Ortho needs to see all elbow fractures Source Undetermined Source Undetermined 63
  • 64. Elbow Fractures in Children Ø  Very common Ø  Radiographic assessment difficult Ø  Requires thorough exam and reassessment Ø  Neurovascular injuries can occur before and after reduction Ø  Kids will not move elbow if fracture present Ø  Swelling about the elbow is constant feature - may be minimal if non displaced fx - may not develop for 12-24 hrs after injury Ø  60% are supracondylar fractures Ø  May be accompanied by distal radius or forearm fx 64
  • 65. Supracondylar Fractures • Type 1: Non-displaced • Type 2: Angulated/displaced fracture with intact posterior cortex – Hinged • Type 3: Complete displacement, with no contact between fragments Source Undetermined Image Removed, Supracondylar Fracture 65
  • 66. Type 1- Nondisplaced • Note the non- displaced fracture (Red Arrow) • Note the Posterior Fat Pad (Yellow Arrows) Source Undetermined 66
  • 67. Type 2: Angulated and Displaced Source Undetermined Source Undetermined 67
  • 68. Type 3 Supracondylar Fracture Ø  High risk for NV compromise Ø  Significant associated swelling Ø  Ortho consult Ø  OR for percutaneous pin fixation Ø  Open reduction may be necessary Source Undetermined Source Undetermined Source Undetermined 68
  • 69. Type 3: Complete Displacement Source Undetermined Image Removed, Bone Displacement 69
  • 70. Case Ø  9 yr old falls off slide, landing on outstretched L arm Ø  Presents to ED due to pain in forearm and elbow Ø  No hx LOC/ CHI Ø  Benign medical hx Ø  Tender over proximal L forearm Ø  Decreased ROM forearm and elbow due to pain, swelling, guarding Ø  NV intact, good radial pulse, can wiggle fingers Ø  Cap refill < 2 sec Ø  What do films show? What do you want to do? Source Undetermined Source Undetermined 70
  • 71. Monteggia Fracture Ø  Ulnar fracture + radial head dislocation Ø  Uncommon in kids (2% all elbow fx’s) Ø  Can be easily missed- must have films of both elbow and forearm Ø  Isolated ulna fractures rare Ø  If unrecognized and not reduced, can lead to permanent disability Ø  Pain control, ortho consult, OR for repair Source Undetermined Source Undetermined 71
  • 72. Galleazzi Fracture Ø  Classic: - Fx distal 1/3 radius - dislocation of distal ulna Ø  Disruption of radioulnar joint Ø  More common teenagers and adults Ø  Rare fracture Ø  Suspect in angulated distal radius fractures Ø  Difficult to recognize Ø  Requires ortho consult in ED and reduction Source Undetermined 72
  • 73. Radial Head Subluxation: Nursemaid’s Elbow • Nursemaid’s Elbow • Tractional mechanism • Unusual > 5 yo • Holds arm pronated, slightly flexed at elbow and at side • No swelling or ecchymosis • X-rays not necessary Kevin Harber, Flickr 73
  • 74. Nursemaid’s Elbow Ø  Radial head subluxation due to annular ligament tear Ø  Typically “ pull” on pronated forearm Ø  Typical presentation: -do not appear in pain -refuse to use arm -held in pronation and slightly flexed -no swelling/ bruising -may hold wrist to support extremity Ø  Reduction techniques: - pressure over radial head - supination w/ flexion - pronation w/ flexion - extension/ hyperpronation Ø  Films only if hx / exam not consistent Wikimedia Commons Sean Dreilinger, Flickr 74
  • 75. Pediatric Forearm Fractures Ø  Approximately 4% children’s fractures Ø  Most due from fall onto outstretched hand Ø  ¾ fractures distal Ø  Rare to see isolated ulna fracture Ø  Neurovascular compromise rare Ø  Remodels well Ø  Ortho consult : angulation > 10’ midshaft > 15’ distal will require procedural sedation for reduction Ø  Treatment- sugartong or volar splint Source Undetermined Source Undetermined Source Undetermined 75
  • 76. Carpal Bone Fractures-Scaphoid Fracture Ø  Rare fx Ø  Teenager or adolescent Ø  Hard to diagnose- not easily seen on film Ø  Heals poorly Ø  Concern avascular necrosis Ø  Typical mechanism: fall hyperextended wrist Ø  Snuffbox pain Ø  Treat: thumb spica splint Source Undetermined Amada44, Wikimedia Commons 76
  • 77. Metacarpal Fracture-Boxer’s Fracture Source Undetermined Hellerhoff, Wikimedia Commons 77
  • 78. Boxer’s Fracture Ø  Uncommon injury Ø  Adolescent boy Ø  Mechanism of injury= direct blow/ strike object w/ closed fist Ø  Fracture 4th or 5th metacarpal Ø  Be wary of infection Ø  Look for rotational defects Ø  Never acceptable in fx of mcp or phalanges Ø  Reduce if angulation > 30’ Ø  Ulnar gutter splint Bobjgalindo, Wikimedia Commons 78
  • 79. Injuries to Lower Extremities Ø  Hip dislocations and femoral neck fx’s due to high energy impact Ø  Major trauma Ø  Care and resuscitate child before addressing orthopedic injury Ø  Single ring fx of pelvic ring = STABLE superior and inferior rami fx symphysis pubis fx Ø  Double breaks in pelvic ring = UNSTABLE high incidence GU, abdominal, vascular injuries life threatening hemorrhage 79
  • 80. Hip Anatomy Source Undetermined 80
  • 81. Bad or Really Bad? Ø  4 yr old, previously healthy Ø  Febrile, R leg pain x 1 night Ø  Slipped and fell earlier but able to walk immediately Ø  Temp 40.7, HR 160 Ø  Uncomfortable, non toxic Ø  Refuses to wt bear at all Ø  R leg held externally rotated and abducted Ø  ROM severely limited due to pain Ø  What is going on ? Ø  What do you want to do? The U.S. Army, Flickr 81
  • 82. What Now? Ø WBC 21.7, 85 seg, 4 bands Ø CRP 8.2 Ø ESR 48 Ø What do films show? Source Undetermined 82
  • 83. Septic Arthritis Ø  Peak age < 3 yrs Ø  Usually single joint Ø  Most common: hip, knee, shoulder, elbow Ø  Hematogenous seeding bacteria to joint Ø  Direct spread from adjacent osteomyelitis or trauma Ø  Staph Aureus most common pathogen Ø  Neonate: Staph aureus Group B Strep Gram negative bacilli Ø  Toddler: Staph aureus Group A streptococcus S. pneumoniae Ø  Sexually active teen: Neisseria gonorrhoeae 83
  • 84. Septic Arthritis Ø  Non specific findings neonate Ø  Older kids more localized pain, fever, decreased ROM Ø  Septic hip- classically- leg held: Externally rotated ,flexed, abducted Ø  Delay in diagnosis/ tx results rapid cartilage destruction, ischemia, avascular necrosis Ø  Film frequently normal w/ acute septic arthritis Ø  U/S- highly sensitive for detection effusion Ø  Lack of effusion does not exclude infection Source Undetermined 84
  • 85. Hip Effusion Source Undetermined Source Undetermined 85
  • 86. Septic Arthritis Ø  Labs include : elevated ESR and CRP Ø  WBC may be normal or elevated Ø  Blood cx + < 50% cases Ø  Caird, et al ( J Bone Joint Surg, 2006) – Fever, elevated ESR and CRP best predictor septic joint Ø  True orthopedic emergency Ø  Arthrocentesis for diagnosis, OR, antibiotics 4-6 wks 86
  • 87. Case Ø  14 yr old male with 3 mth hx limp and R knee pain Ø  Wt 100 kg Ø  Limps, has pain with ROM R hip Ø  Internal rotation and flexion of hip most limited Ø  No warmth, redness, afebrile Ø  What is going on? What do you want to do? Source Undetermined Source Undetermined 87
  • 88. Slipped Capital Femoral Epiphysis Ø  Etiology unknown Ø  Male > Female ( 2:1) Ø  Obese Ø  African American, 8-15 yrs of age ( time of growth spurt) Ø  Almost all cases present w/ chronic hip or knee pain Ø  Limitation of hip: internal rotation abduction flexion Ø  Must consider in any preadolescent or adolescent with knee pain Ø  Must get AP, frog leg views pelvis, both hips need comparison – slip may be subtle 10-25 % cases bilateral 88
  • 89. Slipped Capital Femoral Epiphysis Source Undetermined Source Undetermined 89
  • 90. Treatment of SCFE Ø  Strict non wt bearing Ø  Goal: prevent further slippage Ø  Ortho evaluation urgently Ø  Screw placement/ pinning Ø  Complications: opposite side SCFE avascular necrosis degenerative changes Source Undetermined Source Undetermined 90
  • 91. Femur Fractures Source Undetermined Source Undetermined Source Undetermined 91
  • 92. Patellar dislocations Hellerhoff, Wikimedia Commons The Marines 92
  • 93. Anatomy of the Knee Mysid, Wikimedia Commons 93
  • 94. Fractures of the Knee Image Removed © Christy Krames Classification of Knee Fractures Source Undetermined Source Undetermined Source Undetermined 94
  • 95. This can’t be good… Ø  16 yr old female soccer player Ø  Planted leg, felt “pop” Ø  Immediate pain Ø  Quite swollen Ø  Hard to weight bear Ø  What does film show? Source Undetermined 95
  • 96. Segond Fracture Ø Lateral capsule sign Ø Avulsion fx lateral aspect proximal tibia Ø Pathognominic for intra-articular injury Ø >70% ACL tear Source Undetermined 96
  • 97. Knee Sprain Ø  ACL- basketball, soccer, football, volleyball Ø  > 70% occur w/o contact Ø  Rare < 11 yrs age Ø  1/ 100 high school aged kids Ø  Girls higher incidence (2-8 x boy similar sports) Ø  Typical hx: twisting injury painful pop immediate swelling feeling instability inability to weightbear Ø  Physical exam: hemarthrosis limited ROM Lachman Test sportEx journals, Flickr Lam, et al., Wikimedia Commons 97
  • 98. Mechanism and Anatomy of Ankle Injuries Gray’s Anatomy, Wikimedia Commons Image Removed- Mechanism of Ankle Injury 98
  • 99. Who Gets Films? Image Removed Gray’s Anatomy, Wikimedia Commons 99
  • 100. Triplanar Fracture Ø  Unusual fracture Ø  Combination SH 2 and SH 3 fx of distal tibia Ø  Associated fibular fx common Ø  Most common 12-15 yrs of age Ø  Unstable fracture Ø  Require Ortho consult Ø  Growth plate damage potentially significant Ø  Anatomic reduction essential Source Undetermined Source Undetermined Source Undetermined 100
  • 101. Splinting Pointers: -  Use the appropriate size and shape -  Pad all bony prominences, especially elbow, ankle, and heels -  Wrap somewhat loosely -  Splint in position of Kinds of Splints: 1.  Volar Splint 2.  Thumb Spica Splint 3.  Ulnar Gutter Splint 4.  Sugar Tong Splint 5.  Posterior Short-Leg Splint 6.  Stirrup Splint 7.  Medial-Lateral Long-Leg Splint 8.  Posterior Long Leg Splint Splinting 101
  • 102. Distal Forearm Splints Ø  Buckle fx Ø  Forearm fracture Sugar Tong Splint handarmdoc, flickr Volar Splint Matanya, Wikimedia Commons 102
  • 103. Thumb Spica Splint Ø  1st metacarpal fx Ø  Thumb fx Ø  Scaphoid fx Ø  Lunate fx handarmdoc, flickr 103
  • 104. Ulnar Gutter Splint Ø  Fx involving 4th and 5th MCP joint Ø  Boxer’s Fracture handarmdoc, flickr 104
  • 105. Posterior Long Arm Splint Ø  Proximal Forearm Fx Ø  Elbow Fx Ø  Distal Humerus Fx Matanya, Wikimedia Commons 105
  • 106. Posterior Short Leg Splint Ø  Ankle fx Ø  Ankle sprain Ø  Foot Fx Posterior Short-Leg Splint Stirrup Splint Gray’s Anatomy, Wikimedia Commons 106
  • 107. Posterior Long Leg Splint Ø  Tibial Fx Ø  Fibular Fx Ø  Distal Femur Fx Gray’s Anatomy, Wikimedia Commons107
  • 108. Splinting Controversies Ø  Cast vs Splint Plint AC, Perry JJ, et al (Pediatrics, March 2006) Children’s Hospital Ottawa, Canada Kids w/ removable splint for buckle fx wrist : 1. better physical function 2. less difficulties ADL Ø  Cast vs Brace Boutis K, Willan AR, et al ( Pediatrics, June 2007) Hospital For Sick Children, Toronto, Canada Removable ankle brace better than casting for some ankle injuries: 1. isolated low risk ankle fractures 2. Greater proportion in aircast/ braced group returned to baseline activities at 4 weeks 3. Greater parental and child satisfaction 108
  • 109. NSAIDS and Bone Healing Ø  Controversial in orthopedic world Ø  Delayed healing long bones retrospective animal studies Ø  Prospective human studies ( only 2) inconclusive Ø  No pediatric studies Ø  Ibuprofen much better analgesia than Tylenol or Codeine for fractures ( Clark EC, et al, Pediatrics March 2007) Ø  Ibuprofen provides analgesia equivalent to acetaminophen- codeine in the treatment of acute pain in children with extremity injuries: a randomized clinical trial. (Friday JH, Kanegaye JT, McCaslin I, Zheng A, Harley JR, Acad Emerg Med. 2009 Aug;16(8):711-6 ). Ø  A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain. (Drendel AL, Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK. Ann Emerg Med. 2009 Aug 18. Epub ) 109
  • 110. Conclusions Ø  Kids are not little adults Ø  Think about mechanisms of injury Ø  Injuries must correspond to history, exam, developmental level of the child Ø  Non accidental trauma may be manifested by orthopedic/ extremity injury Ø  Don’t be distracted by the obvious- look and treat life threatening injuries Ø  Be kind and control a child’s pain Ø  Fractures may not always be seen on initial films and can be very subtle Ø  Think “ fracture” before sprain Ø  When in doubt, SPLINT!! Ø  Early diagnosis and treatment septic arthritis essential 110
  • 111. Question 1 10 yr old boy presents to ED after hurting R index finger playing basketball. Exam remarkable for swelling and tenderness of the proximal interphalangeal joint (PIP) Film shows fx line through the growth plate extending into the metaphysis This is what type of fracture: a. Salter Harris- 1 b. Salter-Harris -2 c. Salter –Harris -3 d. Salter- Harris- 4 e. Salter-Harris-5 Source Undetermined 111
  • 112. Question 2 13 yr old boy presents to ED for R thigh pain that began after falling playing soccer. After further questioning, he admits he has had similar pain intermittently past 3 weeks Exam : R hip externally rotated pain increase when you attempt to flex or internally rotate hip The most likely X ray finding is : a.  Displaced fx of femoral shaft b.  Intertrochanteric fx of femur c.  Avulsion fx of anterior superior iliac spine (ASIS) d.  Step off between metaphysis and epiphysis of the femur (SCFE) Source Undetermined 112
  • 113. Question 3 A 9 yr old girl fell playing soccer and twisted her ankle She has swelling at the lateral malleolus and is tender over the distal fibula Films show soft tissue swelling but no fracture What is the most appropriate treatment: a.  rest, ice, compression, elevation x 2 days and ambulate as tolerated b.  Short leg cast or splint, repeat films in 1 week c.  Ace wrap and crutches d.  Ankle CT 113
  • 114. Question 4 14 yr old boy complains of R wrist pain after falling while skateboarding. He thinks he landed on his R hand when he tried to brace himself Exam: mild swelling in wrist snuff box pain and pain when pressure applied to thumb pain with supination forearm/ hand Film negative What do you want to do: a.  Velcro wrist splint b.  Sugar tong splint c.  Thumb spica d.  Ace wrap e.  Volar splint 114
  • 115. Question 5 What nerve is most commonly injured in a child with a supracondylar fracture? a.  Median b.  Ulnar c.  Radial d.  Brachial 115
  • 116. Questions? Ben Pollard Wikimedia Commons 116

×