GEMC: Pediatric Orthopedic Emergencies: Resident Training

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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

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

Introduction nn Children experience diverse array of illnesses and Children experience diverse array of illnesses and

injuriesinjuriesnn Many unique to pediatricsMany unique to pediatricsnn 1/3 of all ED patients annually are children 1/3 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 for hospital setting, 10% ambulance runs are for pediatric patientspediatric patients ((KallsenKallsen GW, in GW, in DieckermanDieckerman RA, 1991)RA, 1991)

nn Trauma represents majority of pediatric transports Trauma represents majority of pediatric transports (50(50--65%)65%)

nn Age dependentAge dependentnn Injuries are most common reason pediatric patients Injuries are most common reason pediatric patients

present to the EDpresent to the ED

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

Pediatrics nn Prehospital providers often have:Prehospital providers often have:

–– Limited pediatric patient contactsLimited pediatric patient contacts–– Limited knowledge, training, and Limited knowledge, training, and

experience specifically directed towards experience specifically directed towards pediatricspediatrics

nn Many other healthcare providers are Many other healthcare providers are similarly affectedsimilarly affected

nn Children are not little adults!!!Children are not little adults!!!7

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

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)

Mechanisms of Pediatric Injury

Waddell’s Triad

William Murphy, Flickr

Rhymeswithbombs, Fllickr

Mechanisms of Pediatric Injury

PMcM, Liftarm, Wikimedia Commons 11

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

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)

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

Orthopedic injuries and Abuse

Source Undetermined

Source: RadiologyAssistant.nl

Bucket handle fracture

Source Undetermined 16

Corner Fracture

Source Undetermined

Posterior rib fractures

Posterior Rib fractures

Healing Fracture

Source Undetermined

Other Injuries Associated with Pediatric Non-accidental Trauma

Source Undetermined Source Undetermined

Source Undetermined Source Undetermined 21

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

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

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

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

Buckle Fracture

Source: Medscape

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

Greenstick and Bending Fracture

Source: Medscape

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

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

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

Salter- Harris Fractures

Image Removed (Salter Harris Fracture Classification)

Source Undetermined

Salter- Harris 1 Fracture

Source Undetermined

Lena Carleton, University of Michigan

Salter- Harris Type 2 Fracture

Source Undetermined

Salter- Harris Type 3 Fracture

Source Undetermined

Salter Harris Type 4 Fracture

Source Undetermined

Salter-Harris Type 5 Fracture

Source Undetermined

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

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

Toddler’s Fractures

Source Undetermined Source Undetermined Source Undetermined 40

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

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

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

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

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

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

Description of Injury-Location

Source Undetermined

Humerus Radius Femur Tibia

Gray’s Anatomy, Wikimedia Commons

Gray’s Anatomy Wikimedia Commons

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

Fracture Types

Source Undetermined

Fracture Types and Description

Source Undetermined

Open Fractures

Xy01, Wikimedia Commons

Saltanat enli, Wikimedia Commons 51

Open Fractures

• IV antibiotics, tetanus prophylaxis– Cefazolin &

Gentamicin– TdaP

• Emergent irrigation & debridement– 6-8 hrs

• NPO

Bobjgalindo, Wikimedia Commons

Saltanat, Wikimedia Commons 52

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

Injuries to the Upper Extremity

Ø Clavicle Ø Shoulder Ø Humerus Ø Elbow Ø Forearm Ø Wrist and hand

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

Wikimedia Commons

Shoulder dislocation

Source Undetermined

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

Elbow Anatomy

Elbow Fractures and Anatomic Landmarks

• Anterior Fat Pad– May be normal if

“adherent” to bone

• Posterior Fat Pad– Always abnormal if

visible

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

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

Radiocapitellar Line

What kind of fracture is this?

• Monteggia Fracture• Ulnar fracture w/

Radial Head Dislocation

Source Undetermined

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

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

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

Type 1- Nondisplaced

• Note the non-displaced fracture (Red Arrow)

• Note the Posterior Fat Pad (Yellow Arrows)

Type 2: Angulated and Displaced

Source Undetermined Source Undetermined 67

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

Type 3: Complete Displacement

Source Undetermined

Image Removed, Bone Displacement

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

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

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

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

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

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

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

Metacarpal Fracture-Boxer’s Fracture

Source Undetermined Hellerhoff, Wikimedia Commons

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

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

Hip Anatomy

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

What Now?

Ø WBC 21.7, 85 seg, 4 bands

Ø CRP 8.2 Ø ESR 48 Ø What do films

Source Undetermined

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

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

Hip Effusion

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

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

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

Slipped Capital Femoral Epiphysis

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

Femur Fractures

Source Undetermined

Patellar dislocations

Hellerhoff, Wikimedia Commons The Marines 92

Anatomy of the Knee

Mysid, Wikimedia Commons

Fractures of the Knee

Source Undetermined

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

Segond Fracture

Ø Lateral capsule sign

Ø Avulsion fx lateral aspect proximal tibia

Ø Pathognominic for intra-articular injury

Ø >70% ACL tear

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

Mechanism and Anatomy of Ankle Injuries

Image Removed- Mechanism of Ankle

Injury

Who Gets Films?

Image Removed

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

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

Distal Forearm Splints

Ø  Buckle fx Ø  Forearm

fracture

Sugar Tong Splint

handarmdoc, flickr

Volar Splint

Matanya, Wikimedia Commons

Thumb Spica Splint

Ø  1st metacarpal fx Ø  Thumb fx Ø  Scaphoid fx Ø  Lunate fx

handarmdoc, flickr

Ulnar Gutter Splint

Ø  Fx involving 4th and 5th MCP joint

Ø  Boxer’s Fracture

handarmdoc, flickr

Posterior Long Arm Splint

Ø  Proximal Forearm Fx Ø  Elbow Fx Ø  Distal Humerus Fx

Matanya, Wikimedia Commons

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

Posterior Long Leg Splint

Ø  Tibial Fx Ø  Fibular Fx Ø  Distal Femur Fx

Gray’s Anatomy, Wikimedia Commons 107

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

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 )

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

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

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

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

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

Question 5

What nerve is most commonly injured in a child with a supracondylar fracture?

a.  Median b.  Ulnar c.  Radial d.  Brachial

Questions?

Ben PollardWikimedia Commons

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Orthopedic Emergencies: Compartment Syndrome/Acute Joint Dislocation Ahmad Bin Nasser MBBS, FRCSC Assistant Professor Course 451 KSU

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