San Antonio School of Medicine June 10-12, 2011

Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center

San Antonio School of Medicine –June 10-12, 2011

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Orthopaedic SectionTravis Murray MD

Assistant Professor Pediatric Orthopaedic Surgery

UTHSCSA

Disclosure I have no financial conflicts of interest

Disclaimer:

Information taken from 2008 AAOS Academy ICL





Case #111 yo male

EMS brought in for inability to ambulate for 3 days

No history of trauma

Acute Slipped Capital Femoral Epiphysis

Case #1: SCFE Issue:

AVN Medial femoral circumflex

artery

Classification

Clinical Stable: can walk

with/without crutches

Unstable: cannot walk

50% risk of AVN

Clinical Presentation

Groin pain

Hip/leg in ER

Knee pain in 1/3

#1 SCFERadiographs:Klein’s lineMetaphyseal blanch sign

MRI may be sensitive if radiographs equivocal





#1 SCFE Workup Hypothyroidism

Panhypopituitarism

Growth Hormone abnormality

Hyopgonadism

Radiation Therapy

Renal osteodystrophy (hyperparathroidism)

Down’s Syndrome

Consider workup <10th percentile height

<10 yrs old or >15/16 yrs

<50% percentile weight

BUN/crt, TSH,

Absolute

-image other hip

-

#1 SCFE OR table

Fracture table

Radioleucent vascular table/diving board

6.5 or 7.2 cannulated screws

Urgent vs Delayed?

#1 SCFE Screw Starting point

Screw threads

Placement in head

Capsular decompression

? Reduction

Post op Unstable: crutches up to

3 mo

Stable: 6 weeks

Complications: Intraarticular screw

Impingement

Fracture

AVN

Chondrolysis





Case #2Oct 08

12 yo maleHip pain afterbeing tackeled infootball

c/o L hip pain

Hip fractures and dislocations

Case #2 (Hip dislocation/fractures) Blood supply (see

unstable SCFE)

Dec 08

Classification (Delbet) Transepiphyseal

Transcervical

Basicervical

Intertrochanteric

Fracture vs. SCFE Variable age

Vertical fracture through normal physis

60% complication rate





Case #2 Delbet type I

Rarest

Birth injury/?child abuse

50% occur with dislocation

90% AVN with dislocation

Delbet type II/III

Transcervical

Most common

AVN 50%

Basicervical

AVN 30%

Nonunion/malunion 30%

Case #2 Type IV

Rare (15%)

AVN 5%

Treatment principles

Reduction

Joint decompression

Stable fixation

Surgical emergency

Gentle traction

Anteriolateral approach

Stability more important than physis

2 yo male

Playing with sister

Fell 3 stories to ground with sister

AR





AR

AR

#2 (Dislocations) Dislocations more common than

fractures

Posterior most common High energy (75%) > low engergy

Emergent reduction Adequate relaxation Consider imaging with floro with

traction Post reduction CT

Open reduction Non-concentric Fracture In direction of dislocation

Management Protected weight bearing Hip precautions AVN survelence

Complications AVN (3-10%) Myositis ossificians Redilocation Neurovascular injury (5%) Premature DJD





Case #3

Displaced supracondylar humerus fracture

#3 supracondylar fracture Gartland classificatino

Type I: undisplaced

Type II: displaced with bony contact

Type III: severe displacement; no bony contact

Case #3 supracondylar humerus Delay to AM:

No increased rate of open reductinon

No increased risk of neurovascular complications

However: important for frequent neurovascular checks to assess for compartment syndrome and loss of pulse

Operative reduction

OR

Sterile technique

Longitudnal traction with elbow slightly flexed

Correct medial/lateral displacement

Flex the elbow

Pronate if medially displaced; supinate if laterally displadced





#3 supracondylar Consider C-arm

positioning

Optimize screen location

Careful external rotation

Check oblique views

Pin Configuration Medial and lateral

Lateral divergent alone

Medial pin

Open Reduction Irreducable

Where to open?

Vascular embarassment





Post Op Splint/Cast

Follow up at one week

Pins out at three weeks

Case #4Supracondylar Pulseless Extremity After Fracture Vascular supply

Management Closed reduction and

percutaneous pinning always the first step

Then decide if vascular exploration nescessary

Vascular consult





Supracondylar without pulse

Adequate perfusion

CRPPObserve

Elbow in relaxed position

Warm room

PulselessInadequaqte perfusion

Reduce fracture and pin

Explore and repair via anterior approach

Urgent vascular consult

(expertise in small vessel reconstruction)Consider fasciotomy

#5 Compartment Syndrome Compartment syndrome: Symptom complex

caused by elevated pressure of tissue fluid within a confined osseofascial compartment

Etiologies Fracture with muscle

damage and swelling

Trauma with vascular injury

Iatrogenic after osteotomies

Exercise induced/exertional

Pressure from external source

Subjective Complaints Pain

Beware: increasing pain, analgesic requirements, fracture requiring vascular repair

Beware fracture with associated nerve injury (ie. Supracondylar with median N injury)

Pallor

Pulselessness

Consider prophylactic fasciotomy for fractures with vessel repair >8 hrs

Parathesias





Suspected Clinical Findings

Conclusive clinical findings

Unconscious patientInconclusive Clinical

Findings

Compartment pressure measurement

>30 mm Hg

<30 mm Hg

Continuous measurement

Repeat evaluation

Fasciotomy

<30 mm Hg

Positive clinical findings

Compartment Fasciotomy Wound Management





Fasciotomies

#6 Polytraumatized Child ABC

ATLS

Primary and Secondary Orthopaedic Assessment

Damage Control Orthopaedics Introduced in adults in 1990’s

Control hemorrhage, soft tissue management, provisional fracture fixation

Inflammatory mediators with initial trauma

Orthopaedic surgery is “second hit”





Pediatric Damage Control Damage Control

Acidosis with pH<7.2

Hypothermia with temp <35.5

Coagulopathy

Head injury with uncontrollable ICP

Severe pulmonary injury

Expect excessive surgical time or if ill prepared to definitvely fix all injuries

Case by case discussion with trauma surgeon, neurosurgeon, anesthesia, ICU and orthopaedic surgeon

Pearls of Polytrauma Care in Children Failure to assess all major injuries prior to going to OR

Poor radiographs, inadequate spinal eval

Have primary and back up OR plans for all injuries with equipment in the room for both

Trying new techniques is foolish. Do what works for you

Ask for help

The enemy of good is perfection—minor or even major revisions can be done at a later date

Careful repeat assessment and anticipation of complications

#7 Open Tibia Fracture Typically a result from high-energy trauma and

associated with other injuries

ED management

One inspection of wound to note size and contamination

Careful neurovascuar exam

Apply sterile dressing

Splint

IV abx





IV abx Cefazolin (100 mg/kg/day divided Q8 hours)

Gentamycin (5-7.5 mg/kg/day Q8 hours)

Grade II, III injuries

Penicillin (150,000 units/kg/day Q6 hours)

Farm injuries; at risk for Clostridium and anaerobes

Tetanus

If immunization unknown or last booster given >5 yrs ago

Consider tetanus immunoglobulin if unknown and high risk

Timing of Surgery When IV abx initiated in ED, timing of I&D does not

influence infection if done within 24 hrs

Grade I 2%

Grade II 2%

Grade III 8%

Degree of soft tissue contamination, skin loss, exposed bone are best guides for timing.

If severe, best managed emergently

OR pearls I&D

Clean bone ends and non-viable tissue

Leave questionable tissue for second look

Consider release of compartments in severe injuries/head injured regardless of pre-op assessment

VAC for large open wounds

Stabilize fractures





Tibial stabilization Consider cast only for Grade 1, minimal swelling, or

intact fibula

Flexible nails

Two antigrade nails

Consider cast for rotation

External fixator

Segmental loss

Severe soft tissue injuries

Not as tolorated as flexible nails

Post op care IV abx for 48 hours

Repeat debridement of severe wounds every 24-48 hours

Careful monitoring for complications

Compartment syndrome

Osteomyelitis

Pin tract infections

Loss of reduction

#8 Cervical spine injury High index of suspicion

Challenging because of osseous development and size of head





C-spine radiographs

Lines

Head vs. Body size





#9 Septic Hip 0.25% of pediatric

hospitalizations

Possibly more common than osteomyelitis

Hematogenous seeding

Contiguous osteomyelitis

Consider in any ill-appearing child with atrumatic mobility limitation

Workup

CBC, ESR, CRP, blood cx, radiographs, ultrasound

DDx Septic Joint

Transient synovitis

Reactive arthritis

JRA

Kawasakis syndrome

Henoch-Schonlein purpura

Rheumatic fever

AVN

SCFE

Trauma

Neoplasa

Lyme disease

Perthes

Other infections Osteomyelitis

Pyomyositis

Septic bursitis

Cellulitis

Septic joint vs transient synovitis Transient synovitis

One of the most common causes of hip pain

0.9% pediatric ED visits in one year





K.S.7 year old female with increasing hip pain, fever, chills, inability to bear weight

K.S.Aspiration and I&D septic hip

Kocher Guidelines n=282 1979-1996

History of fever (>38.5)

History of NWB

ESR >40mm/hr

WBC >12,000

PPD vs variables

0=0.2%

1=3.0%

2=40%

3=93.1%

4=99.6%

Varified later at same institusion

0=2%, 1=9.5%, 2=35%, 3=72% 4=93%





Flynn contribution CHOP

Added CRP to algorithm

Prospective following of 53 aspirations

Temp >38.5

ESR

CRP

Refusal to bear weight

WBC >12,000

5=98% 4=93% 3=83% 2=62% 1=36% 0=16%

Workup Thorough physical exam Back/Spine

Pelvis

Leg

Plain film

U/S hip

CBC with diff, ESR, CRP

Blood culture

? MRI

? Bone scan

Factors of Poor Prognosis Less than 6 months of age

Delay in initiation of treatment >72 hrs

Concomitant osteomyelitis of femur

Inadequate I&D of hip joint

Dislocation of hip





Antibiotic Guidelines Neonate

Strep Gram negative Neisseria gonorrheae

Abx Nafcillin Cefotaxime Gentamycin in high risk Avoid clindamycin Preservative causes apnea

Older infant Staph Kingella kingae Associated with URI, Culture in BACTEC culture

bottle

Hemophilus influenzae If not immunized

Abx Unasyn/Clindamycin Penicillin or Unasyn for

kingella kingae Vancomycin in ill pt

Antibiotic guidelines (ctd.) >5 yrs old

Staph aureus

Salmonella

Pseudomonas

Abx Nafcillin and Clindamycin

Vancomycin and Clindamycin

Ceftazidime and Gentamycin for Pseudomonas

Adolescents Staph aureus

Neisseria gonorrheae

Borrelia bergdorferi

Abx Nafcillin and Clindamycin

Vancomycin and Clinda (if ill)

Doxycycline or Amoxicillin for Borrelia

Treatment Guidelines IV abx inititated with Clindamycin (25-40 mg/kg/day)

or Vancomycin to cover MRSA

Adjust to culture and sensitivity

In absence of osteomyelitis Continue IV until clinically improved, afebrile, CRP <2

Switch to oral for 3-6 weeks

Osteomyelitis requires longer (oral or IV tx)

Follow outpatient labs (CBC, ESR, CRP)

Follow other labs for medical complications (BMP/BUN/CRT, urinalysis, LFT)





Oral Antibiotics Requires identification of organism and sensitivity to

antibiotic

Requires appropriate oral antibiotic availability

Requires patient to tolorate oral antibiotic

Requires compliance of family in administering antibiotic

If Not met: continue IV antibiotic program via PICC or central line

#10 Necrotizing Fascitis

Pearls of Management Early diagnosis

Have high index of suspicion

Supportive measures

Appropriate antibiotics

Prompt surgical debridement





Factors in mortality Delay in treatment >24 hours from symptom onset

Inappropriate antibiotics

Delay in surgical intervention

Failure to agressively debride all involved tissues

Immunocomprimised patient

Streptococcal toxic shock syndrom

Chickenpox

Increased mortality with involvement of abdomen, hip and back

Mortality 5% in pediatrics, 20% in adults

BREAK





Goals Recognition of common injuries and conditions of

pediatric and adolescent athletes

Fractures (some discussed, some left out)

Improved clinical exam

Improved functional anatomy knowledge

Discussion of diagnostic choices in workup

(Some) discussion of treatment(s)

References OKU 9. Injuries and Conditions of the Pediatric and Adolescent Athelete. Chapter 62. Mininder Kocher MD

OKU: Pediatrics 3. Overuse Injuries in Pediatric and Adolescent Athletes. Chapter 3. Kevin Shea MD et al.

Cases from 2008-2009 Fellowship. The Childrens Hospital. Aurora, Colorado.

Lovell and Winter’s Pediatric Orthopaedics. Chapter 32. Sports Medicine in the Growing Child.

Tachdjian’s Pediatric Orthopaedics.

Millers Review of Orthopaedics

6th Annual International Pediatric Orthopaedic Symposium. Orlando, FL 2009 (and 5th, 2008)

Introduction Sports Injuries

increasing Increased

participation Increased recognition

of injuries Improved diagnostic

abilities (MRI, arthroscopy)

Injury patterns Age-specific Sports-specific





Considerations of Young Athlete—Growth and Development

Growth and Development Age-related injury

patterns

Treatment considerations ACL

Anatomic considerations “Miserable

malalignment”

Considerations of Young Athlete--Training

Historically, strength training discouraged

Safe training shown to have benefits Improved performance Strenght Cardiopulmonary fitness

Preadolescent Neurogenic adaptaion

Post-pubertal Neurogenic adaptation Muscular hypertrophy

Risk is no greater than in any other sport As long as proper adult

supervision Proper techniques and safety

precautions

Endurance training controversial

Considerations of Young Athlete--Thermoregulation

Thermoregulatroy disadvantage Increased surface area

to mass Reduced sweating

capacity Greater metaboic heat

per mass unit Slower heat

acclimatization Reluctance of children

to drink

American Academy of Pediatrics recommends prehydration and enforced periodic drinkingDuring prolonged exercise





Considerations of Young Athlete—Performance Enhancement Substances

Increasing with media exposure

Risk increases with social pressure

1990 use of androgenic steroids

4-12% estimated male use

0.5-2% of females

Lyle Alzado

wilkipedia

Adverse Effects Premature epiphyseal closure

Strain/rupture of tendons

Elevated LFT,

Hepatic cysts

Elevated BP, Total Cholesterol,

Reduced HDL

Arterioscelorotic heart disease

Cardiomyopathy

Agression/instability/psychosis

Male Acne

Male pattern baldness

Priapism/impotence

Gynacomastia

Testicular atrophy

• Female• Masculinization

• Deepening voice

• Baldness

“Big Picture” Musculoskeletal

specialist

but

MD

BLS

ACLS

ATLS

Simms—ruptured spleen

Spinal cord injury

Concussions and return to play

Sports hernia

Etc.





Injury Patterns Significant increase in organized sports Largely adolescent females

Trend for shift from “free play” to year-long structured sports programs

3 million new sports related injuries yearly in US 1996 cost $1 Billion Football> wrestling highest rate of injuries Cheerleading highest rate of catastrophic injuries

AAP “The AAP recommends that athletes play sports for

enjoyment, to improve self-esteem, and to improve athletic skills.”

“If these are not priorities in youth sports, then participation in sports potentially is harmful because it can decrease self-esteem, diminish athletic skills, and discourage additional participation in sports”

http://www.aap.org

Pediatric Sports “Big Picture” Preventative

Acute Fractures

Acute Soft Tissue Injury

ACL

Meniscus

Overuse

Tendonitis

Physeal stress





Treatment Principles History

Physical Exam

RICE

Rest

Ice /Immobilization

Compression

Elevation

NSAID (anti-inflammatory)

10 mg/kg Motrin

Further imaging

Xrays

CT

MRI

Bone scan

Ultrasound

Orthopaedic Physical Exam Inspection

Palpation

ROM

“Special Tests”

Red Flags Constitutional

Symptoms

Pain out of proportion to diagnosis or history

Reconsider diagnosis

Repeat physical exam

Reconsider imaging

Reconsider labs





Upper ExtremityClavicle Most frequently fractures

bone

Non-op treatment Sling

Operative Indications Skin at risk

Open fracture

Severe communition/shortening

Acromioclavicular AC separations

Lateral clavicular physeal fractures

Sam BradfordSambradford.com

Millers Review of Orthopaedics

Glenohumeral Instability Traumatic anterior

dislocation Anterior vs. Posterior

Bankart lesion

Hill Sachs lesion

High recurrance

TUBS

MDI Ligamentous laxity

AMBRI





B.W.

14 yo Arthroscopic Bankart Repair; Rotator interval closure

Shoulder DislocationsBeware!

Upper ExtremityGymnastics Overuse physeal injury

Rest

Rest

Rest





Little Leaguer’s shoulder Chronic stress fracture of

proximal humeral physis 11-13 yo pitcher Poor mechanics Frequent throwing

Treatment: Rest Teaching pitching

mechanics Throw counts

Tachdjians

Throw countsLeague age (years) Pitches allowed

Up to 10 75

11-12 85

13-16 95

17-18 105

Pitches Days rest

61+ 3

41-60 2

21-40 1

1-20 none

Age 7-16

Pitches Days rest

76+ 3

51-75 2

26-50 1

0-25 none

Age 17-18

OKU 9

Little Leaguer’s Elbow Throwing athletes High-performance female

gymnast• Medial epicondyle

fragmentation/avulsion OCD of radial head Ulna hypertrophy Olecranon apophysitis With age: UCL and medial

flexor-pronator group problems

Tachdjians





Gymnast elbow--arthroscopy

Hand Thumb MCP joint

most common

UCL “gamekeepers or skiers” thumb

Fractures/dislocations

Mallet finger

Jersey finger

Hand Fractures Hastings and

Simmons (1984) Review of 354

fractures

Majority treated sucessfully non-op

Small percentage=large percentage of complications

HIGH RISK FRACTURES Displaced articular

fractures

Physeal fractures of distal phalanx

Phalangeal neck fractures

Open fractures

.





Risk Factors Associated With Poor Results

Failure to obtain adequate injury radiographs

False assumptions regarding remodeling potential

Falure to evaluate clinical deformity

Mallet Finger

Mallet Finger





Jersey Finger Avulsion of profunds

from distal phalynx

Rugger Jersey Finger





Seymore Lesion Displaced physeal

fracture with interposed nailbed

Failure to recognize: infection, physeal arrest, nail plate deformity

Phalyngeal Neck

“Door jam” in childhoodSports in AdolescentsPoor remodeling potential

Phalangeal neck Displaced acute

CRPP

Late Consider osteocalsis if

fracture line still positive

Chronic malunions: Sucondylar fossa

reconstruction Goal >90 degrees

flexion





Phalanx/Metacarpal fx Phalangeal shaft

Check for malrotation CRPP for

malrotated/angled fracture >10 degrees

Unicondylar fractures Displaced Open vs CRPP Preserve collaterals and

soft tissue attachments

Gamekeeper thumb: SH III fx of P1 thumb ORIF if displaced

Scaphoid

Finger Dislocations Complex MCP

dislocations Often simple dislocation

converted to complex Interposed volar plate

Reduction: Wrist flexion,

hyperextend MCP, volar pressure onto dorsum of phalanx

Open reduction: dorsal





SpineSpondylolisthesis

Spondylolisthesis

Spondylolysis

Hyperextension

Gymnasts

Offensive lineman

Divers

SpineMechanical Back Pain Low back pain

Non-radicular

No constitutional symptoms

Better with rest

NSAIDS

Activity

Films/MRI

Pelvis/HipApophyseal Fractures

Apophyseal Fractures

Iliac apophysis

ASIS

AIIS

Ischial Tuberosity

Greater/Lesser Trochanter





Pelvis/HipHip dislocation/FNFx

Rare injuries

Younger

Lower energy

Older

High energy

Reduce ASAP

Consider floro during reduction

Protected weight bearing

Monitor for AVN

ACL tear Acute Hemearthrosis ACL tear (ligament)

Meniscal tear

Patellar dislocation

Osteochondral fracture

Age <12, Tanner 1-2

12-skeletal maturity

>skeletal maturity





Tibial Spine ACL equivilant injury in

children

Hyperextension/axial load on extended leg/knee

Patellar Dislocation More common dx when

patient presents with “knee dislcoation”

Commonly lateral

Xrays, MRI for osteochondral fragment

Meniscus Fibrocartilage structures

Twisting injury to knee

Pain with twist, deep flexion

Discoid meniscus Painless popping in

young child

Prone to tear

Bilateral





MM15 yo male with symptomatic knee pain, OCD

OCD

MM

Tibial Tuberosity Transitional fractue

Eccentric contraction of quads

Risks

Compartment syndrome

Extensor lag





Thigh Contusion Direct blow to muscular

compartment

Motion as tolorated

NSAIDS

No resistance training

No stretching

SCFE Always remember to

examine hip with knee complaints

Compartment Syndrome Compartment pressure>

perfusion pressure

High index of suspicion

Pain out of proportion

Escilating pain requirements

“P”

Acute

Extertional





Ankle Sprain

AAFP

Transitional Ankle Fractures Distal tibial growth plate

closes eccentrically

Tillaux

Triplane

Thank You Questions?

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San Antonio School of Medicine June 10-12, 2011