1. The document discusses pediatric orthopedic emergencies, focusing on the unique aspects of pediatric musculoskeletal injuries compared to adults.
2. Key differences include the pediatric skeleton being less dense, more porous, and still growing, making children more prone to certain injury patterns like plastic deformity fractures.
3. The document reviews mechanisms of injury, uniquely pediatric fractures, and the initial approach to pediatric orthopedic trauma, emphasizing immobilization and careful evaluation for other injuries.
conventional plates including different functions of screws, modes of plate application, Compression Mode.
Neutralization Mode.
Buttress plate.
Antiglide plate.
Bridge plating or span plating.
Tension band.
prebending precountouring
working length
lag screw
AO principles
biological fixation
MIPO
conventional plates including different functions of screws, modes of plate application, Compression Mode.
Neutralization Mode.
Buttress plate.
Antiglide plate.
Bridge plating or span plating.
Tension band.
prebending precountouring
working length
lag screw
AO principles
biological fixation
MIPO
This slide is a brief overview of Femoral shaft fractures for undergraduate medical students (MBBS) . Video lecture of the content is available on
https://www.youtube.com/watch?v=4rHXKtG36HA
Feel free to drop in any comments or questions
describing the decision making process in deciding which implant to use for trochanteric fractures and its complications - done for Basic AO course in Bengbu, China
This slide is a brief overview of Femoral shaft fractures for undergraduate medical students (MBBS) . Video lecture of the content is available on
https://www.youtube.com/watch?v=4rHXKtG36HA
Feel free to drop in any comments or questions
describing the decision making process in deciding which implant to use for trochanteric fractures and its complications - done for Basic AO course in Bengbu, China
Accrington Stanley FC Youth Team Injury Audit and Pre season planning power p...Tony Tompos
Accrington Stanley FC Youth Team Injury Audit and Pre season planning power point courtesy of data collected from www.benchmark54.com and 'Fitness in Soccer (Van Winckel,2014).
A course Review from James Moore's Sporting Hip and Groin Course - February 2016 (Highly Recommend!). Following my attendance of the course, i performed my own research on 'The Sporting Hip and Groin' and incorporated this into the course review which I presented to the Sports Science and Medicine staff at Wigan Athletic FC. Further references available upon request.
classification of soft tissue injuries. gustilo anderson classification, tscheren classification, hanover fracture scale and ao soft tissue grading system, types of wounds. orthopedic open fracture classification for management of soft tissue injuries
GEMC- Pediatric Trauma: Special Considerations- Resident TrainingOpen.Michigan
This is a lecture by Ruth S. Hwu, MD 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/.
GEMC - Medical Student - Trauma - Initial Assessment and Management of Trauma...Open.Michigan
This is a lecture by Dr. Patrick Carter 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/.
GEMC: “Taming the Wild Child” - Pearls, Pitfalls and Controversies in Pediatr...Open.Michigan
This is a lecture by Dr. Jeff Holmes 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/.
CASE STUDY DELL INC. IMPROVING THE FLEXIBILITY OF THE DESKTOP PCMaximaSheffield592
CASE STUDY: DELL INC.: IMPROVING THE FLEXIBILITY OF THE DESKTOP PC
SUPPLY CHAIN ASSIGNMENT INSTRUCTIONS
INSTRUCTIONS
Read the Dell Inc.: Improving the Flexibility of the Desktop PC Supply Chain Case Study in the
Simchi-Levi et al. text.
Submit a response to each of the end-of-case discussion questions. Each
question must be answered thoroughly, and responses must be supported by the concepts
introduced in the Learn materials. Each question/answer must be delineated under a heading in
current APA format. Include a title page and reference page also in current APA format.
Incorporate a
minimum of 5 peer-reviewed sources with
at least 1 source per question.
Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.
End of case Discussion Questions:
What is a push strategy? A pull strategy? A push–pull strategy? How would you characterize Dell’s supply chain strategy?
When should the firm use push? pull? or push–pull? What are the key drivers when selecting the appropriate strategy?
What does it take to implement a push–pull strategy? What is the impact? What would it cost?
What is the impact of the Internet on the supply chain strategy employed by the traditional retailers and the online stores? In particular, what is the impact on distribution and fulfillment strategies?
Instructions:
Respond to your colleagues by sharing cultural considerations that may impact the legal or ethical issues present in their articles.
**minimum of three (3) scholarly references are required for each reply cited within the body of the reply & at the end**
Ali Rehman
Initial Discussion Post
Top of Form
Restraints in Mental Health Setting
The topic I selected that has both legal and ethical implications for PMHNP practices is restraints. Restraints come in three forms: chemical, physical, and seclusion. Restraints are used on both adults and children for one reason, which is to decrease the chase of the patient causing harm to themselves or to people around them. The use of restraints is always used as a last option, and strict guidelines must be followed when a healthcare worker decides to restrain a patient. According to Ye (2017), since physical restraints have caused adverse effects to both patients and nurses, this topic has various clinical and ethical controversies in mental health services. For years the use of any form of restraint has had major backlash due to the ethical concerns regarding safety, injury, justice and autonomy. This article goes into further detail to explain how patients should be addressed as “human” rather than be labeled “insane” under any circumstances. There have been even more ethical considerations when it comes to the restraint of children, rather than adults. According to Nielson (2021), there are ethical, moral, and legal considerations associated with the implementation of restraints in the mental health setting, including dispro ...
GEMC - Bone and Joint Infections - Resident TrainingOpen.Michigan
This is a lecture by Dr. Keith Kocher 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/.
This is a lecture by Dr. Keith Kocher 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/.
11.20.09: Hearing Loss from a Family Doc's StandpointOpen.Michigan
Slideshow is from the University of Michigan Medical
School's M2 Neurosciences sequence
View additional course materials on Open.Michigan: openmi.ch/med-M2Neuro
11.30.09(a): Introduction to the M2 Musculoskeletal SequenceOpen.Michigan
Slideshow is from the University of Michigan Medical School's M2 Musculoskeletal sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M2Muscu
This is a lecture by Dr. Mark Rosner 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/.
Similar to GEMC: Pediatric Orthopedic Emergencies: Resident Training (20)
This is a lecture by Joe Lex, MD 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/.
This is a lecture by Jim Holliman, MD 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/.
This is a lecture by Joe Lex, MD 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/.
GEMC- Alterations in Body Temperature: The Adult Patient with a Fever- Reside...Open.Michigan
This is a lecture by Joe Lex, MD 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/.
GEMC- Rapid Sequence Intubation & Emergency Airway Support in the Pediatric E...Open.Michigan
This is a lecture by Michele Nypaver, MD 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/.
This is a lecture by Joe Lex, MD 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/.
GEMC- Disorders of the Pleura, Mediastinum, and Chest Wall- Resident TrainingOpen.Michigan
This is a lecture by Andrew Barnosky, DO 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/.
GEMC- Dental Emergencies and Common Dental Blocks- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD 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/.
This is a lecture by Joe Lex, MD 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/.
GEMC- Arthritis and Arthrocentesis- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD 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/.
GEMC- Bursitis, Tendonitis, Fibromyalgia, and RSD- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD 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/.
GEMC- Right Upper Quadrant Ultrasound- Resident TrainingOpen.Michigan
This is a lecture by Jeff Holmes 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/.
This is a lecture by Joe Lex, MD 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/.
This is a lecture by Joe Lex, MD 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/.
GEMC: Nursing Process and Linkage between Theory and PracticeOpen.Michigan
This is a lecture by Jeremy Lapham 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/.
2014 gemc-nursing-lapham-general survey and patient care managementOpen.Michigan
This is a lecture by Dr. Jeremy Lapham 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/.
This is a lecture by Dr. Jessica Holly 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/.
GEMC: The Role of Radiography in the Initial Evaluation of C-Spine TraumaOpen.Michigan
This is a lecture by Dr. Stephen Hartsell 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/.
This is a lecture by Dr. Jim Holliman 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/.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
GEMC: Pediatric Orthopedic Emergencies: Resident Training
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
nn Children experience diverse array of illnesses andChildren experience diverse array of illnesses and
injuriesinjuries
nn Many unique to pediatricsMany unique to pediatrics
nn 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)
nn 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)
nn Trauma represents majority of pediatric transportsTrauma represents majority of pediatric transports
(50(50--65%)65%)
nn Age dependentAge dependent
nn 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
nn 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
nn Many other healthcare providers areMany other healthcare providers are
similarly affectedsimilarly affected
nn 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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