Transcript Paediatric Orthopaedic Emergencies

Paediatric Orthopaedic
Emergencies
Kelly Millar
Overview

Traumatic Emergencies
Fractures
 Dislocations


Medical Emergencies
Infectious
 Developmental

Developing Bone - Anatomy
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Epiphysis
Physis
Metaphysis
Diaphysis
E
P
M
D
The Developing Bone
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Blood supply
Epi / Meta arteries
 Infancy:
transphyseal
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
Physis
Multiple zones
 Rapidly dividing
 Not yet calcified

The Developing Bone
Thicker periosteum
 Bone is more elastic
 Allows for unique fracture types

Torus (buckle)
 Greenstick
 Bowing


Avulsion before tendon rupture
Pediatric Fractures
Heal more rapidly than adults
 Capable of remodeling deformity
 What favors remodeling?

Younger > older
 Closer to physis > midshaft
 Only angulation in the plane of the adjacent
joint will remodel

Growth Plate Injuries
Upper Limb Fractures
Forearm Fractures
Most common site of fracture (50% of all #)
 Physeal injuries of the distal radius (+/- ulna)
 Metaphyseal fractures radius/ulna
 Midshaft radius/ulna
 All usually fairly straightforward to identify –
the question is which ones can you leave
alone, which need reduction, and which
need ortho!

???
Physeal Injuries of the Radius
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Usually Salter I or II
Usually displaced
posteriorly (collestype)
Smith’s-type less
common
Complications
uncommon
Physeal Injuries of the Radius

Reduction?
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
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

Want physeal injuries close to anatomic
Normally have 0-11º volar tilt at distal
radius
Want angulation at least neutral and
minimum displacement
Needs good molding – about 11% will
slip
Call ortho?


Unable to correct dorsal angulation
More than 10% displaced
Metaphyseal Injuries of the Radius
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Buckle fractures
Greenstick
Complete
Buckle vs Greenstick
Be careful !!!
 Buckle #

Cortex on opposite side must be unaffected
 These are stable fractures
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Greenstick #
Cortex # on one side and bent on other
 These are unstable – they tend to move back
to the position of maximal deformity
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Distal Forearm - Buckle #
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
Stable Fractures
Management controversial:
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Immobilize? 60% (PEM) 70% (ortho)
Cast? 60% (PEM) 50% (ortho)
Many opt for splint
Wrist buckle fractures. A Plint et al. CJEM March 2003


Who might benefit from cast? More severe
buckle, v. young, v. active
How long do we immobilize? 2-3 wks
Does this need a reduction?
What is acceptable angulation in the distal radius?
12 yo male
Distal Forearm - Greenstick &
Complete #

Reduction?

Radial or ulnar angulation
 Rotational deformity
 Infants: >30º angulation
 Children: >15º angulation
 Peripubertal: need 2-3 yrs growth to remodel
Practically, most of us are more aggressive

How about this midshaft #?
What is acceptable angulation in a midshaft #?
8 yo female
Midshaft Radius/Ulna Injuries

Reduction?
Any radial / ulnar angulation
 Any rotational deformity
 Infants: >25º
 Children: >10º
 Peripubertal: need 2-3 years to remodel
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Acceptable displacement?
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If young, as much as 90%
Forearm Reductions & Casting
Greenstick #: Many advocate breaking far
cortex to prevent recurrence of deformity
(but run the risk of bayonet)
 Remember that thick periosteum is your
friend !!
 Good 3 point molding essential
 Apply above elbow cast for all reductions

What about Bayoneted # ?
When can you give them a go?
Bayoneted Fractures
Prepubecsent ~ if distal or midshaft, can
give it a try ~ often difficult to get ulna back
on (most of us discuss the options with the
parents)
 Peripubertal / Teens

may consider trying metaphyseal #
 Midshaft or proximal – refer to ortho
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
Is this a problem?
2 yo male
Bowing deformity
• These will NOT
remodel !!
• Must be reduced if
visible deformity or
restricted ROM – but
difficult
• If attempting
reduction – check for
full supination &
pronation
• Need early ortho f/u
Ouch !!! What’s This?
Galeazzi Fracture
Radial fracture + distal radio-ulnar
dislocation
 Rare in kids
 Always call ortho!

Elbow
Supracondylar #
 Lateral condyle #
 Medial epicondyle #
 Proximal radius #
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Ossification Centers of The Elbow
C
R
I
T
O
E
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capitellum
radial head
“internal” m. epicondyle
trochlea
olecranon
“external” l. epicondyle
2 mo – 2 yrs
3 – 6 yrs
4 – 7 yrs
8 – 10 yrs
8 – 10 yrs
10 – 13 yrs
Ossification Centers - CRITOE
Ossification Centers - CRITOE
Approach to reading the film
Is the film adequate -look for the hourglass
 Fat pads

anterior “sail sign” (bulging fat pad)
 posterior fat pad (always abnormal)

Anterior humeral line
 Radial line

Elbow X-ray – Is it Adequate?

If you do not have an adequate lateral:
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You can miss the fat pad signs
 You

may miss a fracture!
You cannot count on the anterior humeral line
 You
may overcall a supracondylar fracture!
Fat Pads - Elbow Effusion
A flat anterior fat pad is often present in
normal children
 A bulging anterior fat pad “sail sign” is
always abnormal
 A visible posterior fat pad is always
abnormal

Anterior Humeral Line
Should pass through the middle third of the capitellum in the lateral view
Radial Line
Should bisect the radius in ALL views
What’s this?
Supracondylar Fracture
75% of elbow #s
 95% due to FOOSH
 Classification:

Type 1 – non-displaced / minimally displaced
 Type 2 – displaced, but hinged on posterior
cortex (may be rotated as well)
 Type 3 – completely displaced, posterior
cortex disrupted
 Beware of compression of medial column

Type I
Type II
Type III
Supracondylar Fracture
Management

Type I
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
Type II
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Backslab at 90º, ortho in 1 week
If mild angulation (<10º) and no rotation, may
attempt closed reduction by flexing at elbow,
then placing in backslab at 90º
When to call ortho:

All type III’s, any rotation, type II with
++angulation or failed reduction,
neurovascular compromise
What are the common complications of
supracondylar fractures?
Supracondylar Fracture
Complications
Very high rate of complications!!
 Acutely:
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Neurologic injury (8-15%)
 Ant
interosseuous branch of median n
 Radial and ulnar nerves also may be involved
Radial artery (2% overall, 50% in Type III)
 Compartment Syndrome
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Longer term:
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Cubitus varus, Volkmann’s ischemic contract.
What’s this?
Lateral Condyle Fracture
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15% of elbow #s
Usually Salter-Harris IV
Peak age 4-10 years
If displaced <2mm, backslab at 90º, early ortho
f/u as inherently unstable
If displaced >2mm, pinned
Lateral Condyle Fracture
What’s This?
Medial Epicondyle Fracture
Usually seen in adolescent boys
 Do not involve the joint surface
 Check for ulnar nerve injury
 50% associated with dislocation –
 If diplacement < 4mm – backslab
 If displacement > 5 mm - pinned

Medial Epicondyle Fractures

Difficult to identify in
young children (so
much cartilage)
NORMAL →
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Ossification centre
should follow smooth
contour
Medial Epicondyle Fracture
What’s this?
Proximal Radius Fractures
Most common in ages 8 - 12
 Usually involve the metaphysis or the
physis, and not the radial head
 Management?

< 15° angulation - posterior slab, F/U with ortho
 15-30º - posterior slab – early to ortho
 > 30° angulation – call ortho for reduction

Proximal Radius
What’s this?
Monteggia Fracture
Monteggia
Ulnar fracture + proximal radial dislocation
 "Monteggia equivalent" with plastic
deformation of the ulna occurs in 17%
 8--17% associated neurologic deficits
(usually posterior interosseous branch of
the radial nerve
 Management: call ortho!

What’s this?
Proximal Humeral Fractures
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Proximal humeral physis
Usually SH type I or II
 ++ potential for remodelling
 Age 1-5
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 70º
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Age 5-12
 50º

angulation, 100% displacement
angulation, 50% displacement
Age >12
 30%
displacement
Proximal Humeral Fractures
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Management
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Sugar tong splint & sling, f/u ortho
Clavicle
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10–15% of all pediatric #s
90% middle third
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Sling
Pain management
Warn parents about the
bump
F/U fam doc in 6-8 weeks
Sling vs Figure of 8
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Treatment of clavicular fractures. Figure-ofeight bandage versus a simple sling.
Andersen K. Jensen PO. Lauritzen J. Acta
Orthopaedica Scandinavica. 58(1):71-4, 1987
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RCT:
79 pts
figure-of-eight bandage vs simple sling
simple sling caused less discomfort and perhaps
fewer complications than figure-of-eight
The functional and cosmetic results of the two
methods of treatment were identical and alignment of
the healed fractures was unchanged from the initial
displacement
Proximal / Distal Clavicle Fractures

Proximal clavicle #’s (<2%)
Usually involve growth plate – SH I or II
 If clavicle displaced posteriorly, may get
tracheo-esophageal compression – if so talk
to ortho and get CT
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Distal clavicle #’s
Usually involve growth plate – SH I or II
 Often difficult to distinguish from AC sep
 Ortho f/u if grossly unstable
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Lower Limb Fractures
Distal Fibula – Salter I
9 yo boy
Distal Fibula – Salter I
Clinical diagnosis
 Widening on x-ray often not appreciated
 If unsure, posterior slab, f/u 1 week for
reassessment
 If fairly sure, below-knee cast for 3 weeks
(walking cast OK)

Adolescent Ankle
What’s this?
Tillaux Fracture
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Often caused by lowenergy trauma
Forced external
rotation of the foot or
medial rotation of the
leg on the fixed foot
Stress placed on
anterior tibiofibular
ligament
Avulsion #
Tillaux Fracture
Fracture of the antero-lateral tibial epiphysis
 Salter III injury
 Low threshold for CT
 Call ortho
 Closed reduction may be attempted – will
accept max of 2mm displacement

What’s this?
Triplane Fracture
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Talk to ortho
Often need CT
Closed reduction in
30-50%
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20 mo
Playing with sibs in
bedroom
Found crying
Refusing to walk
What’s this?
Toddler’s Fracture
Common
 Low energy mechanism
 Spiral fracture of tibia – often subtle
 Above knee cast 3 weeks

Tib / Fib Shaft Fractures
If minimally displaced, attempt closed
reduction
 Non-displaced and successfully reduced #
are placed in above-knee cast, f/u ortho 1
week
 For significant displacement, or
involvement of the proximal physis or
metaphysis – d/w ortho

What’s this?
Tibial Spine Fracture
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Ages 8 to 14 (often bicycle-related)
Usually the anterior intercondylar eminence
Anterior spine fracture is analogous to an ACL
injury in the skeletally mature
If non-displaced - immobilize (Zimmer) early
ortho F/U
May be more extensive than appears on x-ray
(ortho has low threshold for CT)
If ++ displaced d/w ortho
Femur Fractures
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Consider femoral block
Buck’s traction
All admit to ortho
Thinks abuse in young kids!
What’s this?
14 yo girl
sudden L hip
pain while
playing soccer
Pelvic Avulsions
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Most common in athletic adolescents
Unexpected, explosive muscle contraction
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Example: "kicking out" at the end of race
Athletes most often affected: Hurdler, Sprinter
Symptoms: sudden onset of hip pain
Limp may be present
Specific apophysis sites of tenderness:
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anterior superior iliac spine (sartorius)
anterior inferior iliac spine (rectus femoris)
Ischial tuberosity (hamstring)
Pelvic Avulsions

Conservative therapy for ASIS or AIIS
avulsion
RICE
 NSAIDs
 Crutch walking as needed
 Return to sport when able to participate
without pain
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Osgood-Schlatter’s Disease
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During growth spurt, boys >
girls
Pain/bony prominence of the
tibial tuberosity
Repeated microevulsion #
Do x-ray to r/o other pathology
Management: rest, stretching
Pain resolves in 1-2 years
(bump does not)
Osgood-Schlatter’s Disease
Dislocations
Elbow, Shoulder, Patella
 Largely managed as per adults

Patellar Dislocations
In young children, recurrent dislocations
usually associated with patellar/condylar
dysplasia or neuromuscular disease
 In older children, acute dislocations
managed as in adults

Post reduction films with skyline views
 Immobilization

What’s this?
Shoulder Dislocation
Shoulder Dislocations
Some children with joint laxity will be able
to voluntarily dislocate their shoulders – if
discouraged from doing so, they will
usually grow out of it
 Traumatic dislocations require reduction,
films to r/o # and immobilization – children
with traumatic dislocation are at high risk
of chronic instability (up to 50%)
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Hill-Sachs #
Bankart #
Axillary nerve
HS
Elbow Dislocations
Usually in adolescents
 90% posterior
 Commonly associated fractures:

Medial epicondyle
 Radial head / neck
 Coronoid


Associated neurovascular injury high
(ulnar nerve in 10%)
Elbow dislocation
Medical Emergencies
Case 1
7 yo boy
 Presents with several week hx of limp and
R knee pain

Case 1
R knee exam normal
 R hip – painful passive ROM
 Afebrile, otherwise well
 Labs normal

Case 1
Legg-Calvé-Perthes Disease
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Epidemiology:
1 in 3000 children, boys > girls
 Peak age 4 – 9 years
 Familial in 20% of cases
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Pathophysiology:

avascular necrosis of femoral head, with
trabecular collapse and secondary growth
disturbance and deformity
Legg-Calvé-Perthes Disease

Symptoms


Pain in area of hip or referred to knee
Signs
Child walks with a limp
 Decreased hip range of motion


Imaging

Order AP and frog leg views of the hips
Legg-Calvé-Perthes Disease
This is late disease. In early disease, see widening of
articular cartilage (appears as joint space widening),
small dense epiphysis – gets irregular and flattened
with time
Legg-Calvé-Perthes Disease
Legg-Calvé-Perthes Disease
Prompt ortho referral
 Difficult management

Bracing and casting for up to 1-2 years
 Surgery will allow child back to activity in 4-6
months


Complications
Severe degenerative hip disease in some
 Requires hip replacement by middle age in
50% cases

Case 2
14 yo obese male
 Several month hx of limp and R hip pain
 Worsening – having difficulty bending over
to tie shoes

Case 2
Slipped Capital Femoral Epiphysis

Epidemiology:
Incidence: 4 per 100,000
 Adolescents (during growth spurt)
 Blacks > caucasian
 Obesity is a risk factor
 Tall and slender is a risk factor

Slipped Capital Femoral Epiphysis

Pathophysiology:
Shearing displacement through the zone of
hypertrophic cartilage
 Occurs before the growth plate closes
 During maximal growth spurt

 Males:
age 13 to 15 years
 Females: age 11 to 13 years
Slipped Capital Femoral Epiphysis

Classification by duration:
Acute
 Acute on chronic
 Chronic
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
Classification by stability:
Stable (able to walk) – 90%
 Unstable (unable to walk) – 10%

Stable SCFE


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Usually a history of intermittent limp and pain of
several weeks' or months' duration
Often poorly localized to the thigh, the groin or
the knee. Hip pain is reported less frequently
A vague history of antecedent trauma calls
attention to the limp and pain
As the epiphysis continues to slip, the child loses
hip motion, including internal rotation, flexion
and abduction
Unstable SCFE
Present with extreme pain, often after
sports-related trauma or a fall with a
twisting injury
 Most children have no prior history of
symptoms.
 Much higher rate of avascular necrosis
related to disruption of epiphyseal
vascularity

Slipped Capital Femoral Epiphysis

Presentation:
Hip held in abduction and external rotation
 Limited internal rotation


Radiology: Hip XRay – AP & frog leg
Widened epiphyseal plate
 Displacement of femoral head

SCFE – Klein’s sign
Slipped Capital Femoral Epiphysis
Stable
Slipped Capital Femoral Epiphysis
Unstable
Often Bilateral – careful with weight
bearing
SCFE - Management

Stable:
Strict non-weight bearing
 Refer to orthopedic surgeon (next 1-2 days)
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
Unstable:
Strict non-weight bearing
 Admit to ortho
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Case 3
3 yo female
 Refusing to walk today
 Fever 38º
 Tender ROM L hip
 Just getting over URTI
 What should you do?

Case 3
WBC = 11
 ESR = 8
 X-rays normal
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What is the most likely diagnosis?
Transient Synovitis of the Hip
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
Inflammatory arthritis of the hip
Incidence: 3% of kids before age 14
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Presentation:

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Most common cause of limp with hip pain < age 10
Peak age: 3 to 8 years
Boys:girls 4:1
3-6 days after URTI
95% unilateral
Signs:


Pain in hip, anteromedial thigh and knee
Reduced hip range of motion
Transient Synovitis
vs Septic Arthritis

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WBC is not statistically different
↑ ESR 90% sensitive in SA but not specific
Mean ESR:



Kunnamo: CRP > 20 + temp > 38.5:


Transient synovitis: 18
Septic arthritis: 55-82
100% sensitive, 87% specific for SA
Del Beccaro: ESR > 20 + temp > 37.5:

97% sensitive, 53% specific
Transient Synovitis
vs Septic Arthritis
Range of
Motion
Transient
Synovitis
gaurded hip
rotation
Septic Arthritis
Fever
low grade
pronounced
spasm,
gaurding, and
fixed position
higher
ESR
<15
> 20
Synovial fluid
clear
WBC, bacteria
Transient Synovitis of the Hip
Imaging:
 Hip X-ray


Bony landmarks normal
May see widened joint space
Hip Ultrasound


Often have joint effusion
Management:
 Rest & NSAIDS
Case 4
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4 yo
Fell at pool yesterday
– injured R leg
12 hr hx fever – 40 in
ER
Unable to walk
What do you want to
do?
Case 4

Severe pain and limited ROM R hip
WBC 31
 ESR 39
 CRP 29

Septic Arthritis
Most common in large joints – hip, knee,
elbow, shoulder
 Presentation:

Infant: fever, irritability, sepsis, abnormal
posture, “pseudoparalysis”, joint pain
 Child: fever, severe pain, muscle spasm


Organisms: staph aureus, strep spp,
Neisseria in sexually active teens
Septic Arthritis - Investigations

Labs:
WBC unreliable
 CRP and ESR usually elevated


Imaging:
Plain film to r/o other pathology, may see
capsular swelling
 Ultrasound hips to detect effusion


Joint aspiration – in ER or u/s guided (hip)
Septic Arthritis – Age
Considerations



less than 3 months: up to 60-100% of neonates
w/ septic arthritis have adjacent osteomyelitis –
due to transphyseal blood vessels which
disappear by age 6 months
from 6 mo to 2 yrs: search for evidence of other 50% of children septic arthritis have evidence of
an associated infection
unimmunized: meningitis may occur in up to
20% of patients w/ septic arthritis due to H flu
Osteomyelitis
Acute osteomyelits
 Subacute osteomyelitis
 Chronic osteomyelitis
 Chronic recurrent multifocal osteomyelitis

Osteomyelitis
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75% of osteomyelitis is of hematogenous origin
In children - metaphysis of long bones most
common
Metaphysis has large blood flow and deficient
phagocytes
Nutrient arteries are nonanastomosing, any
blockage can produce tissue necrosis
Venous sinusoids have slow, turbulent flow
predisposing to thrombosis.
Sludging of blood flow as vessels make sharp
angles
Osteomyelitis - Epidemiology
Overall prevalence: 1 per 5,000 children
 Neonatal prevalence: 1 per 1,000
 Annual incidence in sickle cell patients is
approximately 0.36%
 Prevalence after foot puncture may be as
high as 16% (30-40% in patients with
diabetes

Acute Hematogenous
Osteomyelitis - Presentation

Acute onset:
fever
 bone pain
 decreased function


Organisms:
staph aureus
 β-hemolytic strep
 (Salmonella in sickle cell)

Acute Hematogenous
Osteomyelitis - Investigations

Labs:
↑ WBC – not sensitive or specific
 ESR > 20 – 90% sensitive, poor specificity
 ↑ CRP - 98% sensitive (↑ earlier than ESR)
 Blood culture - + in 50% of hematog osteo


+/- joint aspirate to r/o septic arthritis
Acute Osteomyelitis - Imaging
X-ray unhelpful at presentation (until 14-21
days)
 Bone scan – becomes positive on day 2-3

Sensitivity: 84-100%, specificity: 70-96%
 This is your first choice!


MRI - Studies have shown it’s superiority
compared with plain radiography, CT scan,
and radionuclide scanning

Sensitivity ranges from 90-100%
Acute Osteomyelitis - MRI
Acute Hematogenous
Osteomyelitis

Management:
IV antibiotics - penicillinase-resistant penicillin
and a third-generation cephalosporin
 Consult ortho – possible surgery if abscess
demonstrated


Sequelae:
Chronic osteomyelitis
 Impaired/accelerated growth
 Septic arthritis (more common in infants)

Subacute Osteomyelitis
Largely a pediatric disease
 Incidence 1 per 100,000 per year
 May affect multiple joints (multifocal)

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
Metaphysis of tibia and femur most common
Presentation:
Mild, intermittent pain over several weeks
 Few systemic signs
 Loss of function common (esp. in spine)

Subacute Osteomyelitis
Labs: WBC, ESR, CRP may be normal
 Radiologic signs usually well established
at presentation:

75% metaphyseal (tibia and femur)
 Also occurs in calcaneus

Bone absorption and sclerosis
 Bone scans are also helpful

Subacute Osteomyelitis
Subacute Osteomyelitis
Organism – usually staph aureus, some
staph epi
 Management:

IV antibiotics – discuss with ortho before
starting in case biopsy desired (increase yield
of + cultures
 Need for surgical excision of abscess
contoversial (87% cure rate with A/Bx alone)
 However, may want Bx to r/o tumor and to ID
organism

Chronic Osteomyelitis
Follows acute osteomyelitis by months –
years
 In developed countries, usually posttraumatic as hematogenous osteo is
usually identified and treated
 Suspect if chronic pain in site previously
affected by acute osteo or injury
 Bone scan and referral to ortho/ID

Chronic Recurrent Multifocal
Osteomyelitis
Disease of children aged 4-15 years
 Recurrent episodes of localized pain and
swelling involving different sites at different
times
 ? Non Infectious!!! Benign and self-limited
 ? Atypical seronegative arthropathy
 Rx: NSAIDS (no antibiotics)

Chronic Recurrent Multifocal
Osteomyelitis
Developmental Dysplasia of the Hip

Incidence:
Hip instability at birth: 1%
 Hip dysplasia in infants: 0.1 to 0.3%
 Girls 9 times more often than boys
 30% of hip replacements are due to
osteoarthritis 2º to acetabular dysplasia!!!


Pathophysiology:
Femoral head dislocates from acetabulum
 Usually unilateral, but bilateral is common

Developmental Dysplasia of the Hip

Associated Conditions:
Breech presentation in utero
 Congenital torticollis
 Clubfoot
 First degree relative with hip dysplasia

Developmental Dysplasia of the Hip

Signs:
Ortolani’s Test
 Barlow's Test


Management:
Don’t image in the ER
 Ortho referral if suspicious
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