Transcript Slide 1

EMORY-Children’s Center
Pediatric Orthopedic Emergencies
Tracy Merrill MD
Division of Pediatric Emergency Medicine
Children’s Healthcare of Atlanta at Egleston and
Emory University School of Medicine
Use * † ‡ if there are authors other than our group, using
* to demark us, if its only us take out *
The Limping Child
 4 year old child presents to the emergency
department with a chief complaint of limping for two
days
 No report of trauma
 Afebrile
 No additional systemic symptoms
 PMH negative for joint problems or chronic disease
 Nontender to palpation and no pain with passive
ROM but limps when bears weight
 Differential?
 Workup?
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Transient Synovitis - Definition
 Also known as “irritable hip” or “toxic synovitis”
 The #1 cause of acute hip pain in children
 Benign self limited disease of uncertain etiology
most commonly affecting the hip joint
 Usually occurs in children age 3 to 10 years
 4 cases in adults have been reported
 Almost always unilateral
 Causes pain and limitation of the movement of the
hip, with or without an effusion
 Pain is the worst when walking, usually presents
with a limp or refusal to bear weight
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Transient Synovitis – Etiology, Treatment
 Due to transient sterile inflammation of the
synovium of the hip
 No clear precipitants, ?post viral
 Sudden onset, gradual resolution
 Self limited, usually lasts 4-7 days
 Treated with OTC analgesics: ibuprofen and tylenol
 Study done showed ibuprofen decreased median
duration of symptoms from 4.5 days to 2 days
 No residual long term deficits
 Most important thing to do is distinguish it from
septic arthritis
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Septic Arthritis - Definition
 Results from bacterial invasion of the joint space
 Can occur at any age but 50% of cases reported
occur in children under the age of 3 years
 Acute onset
 Usually monoarticular
 Usually the large peripheral joints
 Organisms can invade the joint by three possible
mechanisms:
• Usually through hematogenous seeding
• Adjacent osteomyelitis
• Direct inoculation from a penetrating wound
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Septic Arthritis - Bugs
• Staphylococcus aureus
• Streptococcus
 GBS
 S pneumoniae
 S pyogenes
• Neisseria gonorrhoeae
• Haemophilus influenzae
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Septic Arthritis - Presentation
 Most commonly involves the
hip joint “septic coxitis”
 Symptoms include:
• Fever
• Joint pain
• Limp and an inability to
bear weight
• Pain with active or
passive range of motion
• Joint swelling, effusion,
warmth, tenderness
 The patient holds their leg in
a flexed, abducted,
externally rotated position
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Septic Arthritis - Presentation
 May be extremely difficult to diagnose in infants and
nonverbal children
 Fever, irritability, and decreased po intake may be
your only clues
 May fuss more when handled due to movement of
the affected extremity
 May have decreased movement of an extremity
 Predisposing factors include recent URI or otitis,
skin or soft tissue infections, traumatic puncture
wounds, femoral venipunctures, underlying chronic
disease, or immunosuppression
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Septic Arthritis - Differential
 Differential can include:
• Transient synovitis
• Viral arthritis
• Traumatic arthritis
• Periarticular cellulitis
• Osteomyelitis
• JRA
• Acute rheumatic fever (JONES criteria)
• Lyme disease
• Post-infectious reactive arthritis
• Oncologic process (eg. leukemia, osteosarcoma)
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Septic Arthritis - Diagnosis

Laboratory:

CBC with diff shows elevated white count with a left
shift

Blood cultures are positive 40-50% of the time

CRP elevated

ESR elevated

Joint aspiration shows elevated WBC’s 10,000250,000 (normal is less than 200), >75% segs, and
decreased glucose
 Imaging:
• Plain films may show a displacement or blurring of
periarticular fat pads as well as an increased hip joint
space
• MRI
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Septic Arthritis - Diagnosis
 Study done by Jung, et al. (2003*) found five
predictors that correlated with a high probability of
septic arthritis to help distinguish from transient
synovitis whose presentation can be similar
• Temperature >37 degrees Celsius (37.7 vs. 36.6)
• WBC >11,000/mL (18.2 vs. 8.2)
• CRP >1mg/dL (10.1 vs. 0.66)
• ESR >20mm/h (79.2 vs. 20.3)
• Joint space difference >2mm between the
affected and unaffected sides (difference of
4.0mm vs. 1.2mm)
• No significant difference found in platelet count
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Septic Arthritis - Treatment
 Treatment:
• Prompt orthopedic consultation
• Surgical debridement of the hip through
arthrotomy
• Hospitalization until fever defervescence and
signs of clinical improvement post operatively
• Intravenous antibiotics for 4 weeks
• Usually requires central line placement for home
administration of antibiotics
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Septic Arthritis - Treatment
 Antibiotic Therapy
• <2 months of age: oxacillin or nafcillin plus
gentamicin for Gram negatives
• 2 months to 3 years: ampicillin-sulbactam or
ceftriaxone
• >3years: oxacillin, nafcillin, or ceftriaxone
• Adjust based on gram stain and culture results
• Consider Clinda or Vanc if suspect MRSA
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Septic Arthritis - Outcomes
 Complications
• Osteomyelitis, osteonecrosis
• Avascular necrosis due to the pressure on blood
vessels and cartilage in the femoral head area
• Epiphyseal separation
• Pathologic dislocation
• Growth arrest and subsequent leg length
discrepancies up to several inches
• Sepsis
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Septic Arthritis - Outcomes
 Prognosis
• Joint destruction can occur within days leading to
longterm disability, residual deformity, arthritis,
and decreased range of motion
• Prior to the discovery of antibiotics, pediatric
mortality rates averaged 50%
• If diagnosed early before changes seen on plain
films, have an improved prognosis
• Note that joint destruction as a result of
gonococcal infection is uncommon
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SCFE: Slipped Capital Femoral Epiphysis
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 An acquired growth plate injury
 The separation of the proximal femoral epiphyses from
the metaphysis at the level of the growth plate
 Most commonly occurs in adolescents and
preadolescents who are vulnerable to slippage due to
widened and weakened growth plates during periods
of rapid growth
 Occurs in 2-10 per 100,000 adolescents in the US
 Peak age is 10-13 in females and 12-16 in males
 Rarely occurs after menarche
 More common in males, male to female ratio is 2.5 :
1.6
 More common in Pacific Islanders and African
Americans
SCFE - Etiology
 The epiphysis is located at
the top of the femur and is
connected to the
metaphysis via the physis or
growth plate
 The head of the femur stays
within the acetabulum while
the femur slips
 Occurs when the shearing
stress exerted onto the
femoral head is greater than
the resistance provided by
the physis
 Occurs in the hypertrophic
zone, the weakest zone of
the physis
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SCFE - Risk Factors
• Obesity resulting in mechanical overload of an
immature growth plate, 81% of cases are in
children over the 95th percentile for BMI
• Local trauma
• Hypothyroidism
• Panhypopituitarism
• Growth hormone administration
• Renal osteodystrophy
• Previous radiation therapy
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SCFE - Presentation
• Limp
• Hip, groin, thigh, or knee pain
• Hip pain often referred to the knee due to the pathways of
the obturator and femoral nerves
• 15% of patients report pain only in the distal thigh and
medial knee
• If stable, can still bear weight
• As the slip progresses, eventually get external rotation of
the toes when walking
• Decreased range of motion of the hip
• If chronic or unrecognized, may develop atrophy of the
thigh and gluteal muscles
• A stable chronic slip may suddenly worsen and become
unstable with what seems like minor trauma
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SCFE - Diagnosis
 Radiography: bilateral
A/P and frog leg x-rays
of the hips
 “Ice cream falling off
the cone” the femoral
head is the ice cream
that falls off the femur
which is the cone
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SCFE – Grades of severity
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SCFE - Treatment
• Screw fixation under fluoro to
prevent further slippage
• Strict non weight bearing
leading up to surgery and then
partial for 6-8 weeks after
surgery
• Never attempt to reduce the
slip during surgery or will
increase the risk of avascular
necrosis
• For severe slips, a corrective
osteotomy may be required
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SCFE - Treatment
• Technically only need
fixation until the growth
plate fuses but would be
too invasive to remove
the screw, so they are
usually left in unless
complications develop
• Some will do prophylactic
pinning of the contralateral hip if at high risk
for a bilateral slip
• Casting or bracing not
required postop
• Sports restrictions for 3-6
months
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SCFE - Complications
• Avascular necrosis: altered blood supply to the
proximal femoral head and physis leading to
bone death, most commonly occurs in severe or
unstable slips, can lead to rapid hip deterioration
and severe progressive arthritis
• Chondrolysis: necrosis of the articular cartilage,
can progress to severe pain, decreased range of
motion, and contracture of the hip
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SCFE - Prognosis
• Occurs bilaterally in 25-40% of cases
• Most contralateral slips occur within 6-12 months
of the index case
• Most stable or chronic SCFE’s are treated
effectively with minimal complications, makes up
>90% of all slips
• The more severe the slippage, the more altered
are the mechanics of hip movement, and the
sooner the hip wears down, leading to premature
arthritis
• The most severe cases may eventually require
total hip replacements
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Legg-Calve Perthes Disease
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 Aseptic necrosis of the femoral head and neck
 Results from a disruption of the blood supply
 Onset usually between the ages of 4-8 years
 Male to female ratio of 5:1
 Bilateral in 10% of cases
 Present with a limp
 Pain may refer to the knee, medial thigh, or groin
along the distribution of the obturator nerve
 Exam reveals limited hip abduction and medial
rotation
 More advanced cases may show leg length
shortening or thigh muscle atrophy
Legg-Calve-Perthes Disease
 The exact cause is unknown but can be related to anything
that may damage the blood supply to the hip:
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Legg-Calve-Perthes Disease
 Radiographs show:
• Smaller denser femoral head
• Relative osteopenia of the adjacent proximal femur and pelvis
• Widened joint space
• Subchondral lucent area
• Irregular physeal plate, fragmented in later stages
• Blurred and lucent metaphysis
 Confirm with MRI or bone scan
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Legg-Calve-Perthes Disease
 A temporary condition
 Occurs in 4 phases:
• 1. From several months up to one year, blood
supply is absent, portions of the bone die, the
femoral head collapses and looses it’s shape
• 2. From one to three years, the dead cells are
replaced with new bone cells
• 3. Also from one to three years, the femoral head
begins to remodel and obtain its shape again
• 4. Completion of the healing process
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Legg-Calve-Perthes Disease
 Treatment:
• Rest, often with the aid of crutches, wheelchair
• Activity restrictions
• NSAIDS
• Traction, casting, or bracing to hold the femoral head in the
hip socket to preserve the round shape of the femoral head
during remodeling
• Surgery to secure the femoral head in the hip socket
• Physical therapy to keep the hip muscles strong and
maintain range of motion
 Complications:
• Limited hip motion
• Leg length differences
• Arthritis long term
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Osgood-Schlatter Disease
 Tibial tubercle apophysitis
 Due to traction of the patellar ligament on the tibial
tuberosity
 An overuse syndrome
 Occurs most frequently in boys age 11-15 years
who are active in sports
 Pain to palpation of the tibial tubercle, pain with
quadriceps contraction
 May have overlying soft tissue swelling
 Radiographs are either normal or may show an
irregular tibial tubercle with or without fragmentation
 Often mistaken for avulsion fractures
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Osgood-Schlatter Disease
 Self limited
 Cured by fusion of the
tubercle
 Treatment is limitation of
physical activity to the point
of pain tolerance and RICE
• Rest
• Ice
• Compression with ace
wrap or neoprene sleeve
• Elevate
 NSAIDS may help with
acute pain exacerbations
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Osteomyelitis - Definition
 An infection of the bone
 90% of cases involve a single bone
 Pathogens can spread to the bone from the blood
stream from distant infections, from direct
penetration from trauma, or from spread from
overlying soft tissue infections
 Long bones of the lower extremity are the most
commonly affected from hematogenous seeding
 Usually beneath the epiphyseal plates in the rapid
growth areas
 Up to 25% may occur in short or nontubular bones
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Osteomyelitis - Bugs
• Staphylococcus aureus is the number one
cause in any age group! 70-90% of cases!
• Haemophilus influenzae
• GBS and enteric rods in neonates
• Salmonella in sickle cell patients
• Pseudomonas aeruginosa in foot
punctures
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Osteomyelitis - Presentation
 Symptoms:
• Limp
• Difficulty bearing weight
• Bone pain, gradual onset, constant
• Infants are usually fussy, febrile, and may not be
moving all extremities equally
• Fever over 38.5 C in up to 80% of patients
 Physical Exam:
• Point tenderness on exam
• Local erythema and edema once purulent
material has ruptured through the bone cortex
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Osteomyelitis
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Osteomyelitis - Diagnosis
• Laboratory
 White blood cell count is normal in up to two thirds of
cases!
 An elevated ESR is more sensitive, elevated in up to
90% of cases, peaks at day 3-5 of treatment, normalizes
by 3 weeks
 CRP is best for monitoring response to treatment,
elevated in up to 98% of cases, peaks at day 2 of
treatment, normalizes in as little as one week in
uncomplicated cases
 Blood culture yields an organism in 30-50% of cases
• Bone aspiration for gram stain and culture yields an
organism in 50-70% of cases
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Osteomyelitis - Diagnosis
 Radiographs may be normal early in the course but as
bony destruction occurs, may see periosteal reactions
(in 3-10 days) or lytic lesions (in 10-12 days)
 Technetium-99 bone scan will show areas of
increased blood flow due to inflammation, sensitivity
>90% (note: your bone scan won’t be affected by
needle aspiration)
 If have a poor treatment response, consider MRI
which can aid in finding drainable subperiosteal
abscesses
 If have a pelvic osteomyelitis, consider MRI early in
the course of evaluation due to an increased
occurrence of abscesses in these cases, or can use
MRI to replace bone scan in the diagnosis of these
cases
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Osteomyelitis
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Osteomyelitis
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Osteomyelitis - Treatment
• All cases must be admitted for IV antibiotics
• Immediate orthopedic consultation is required for surgical
debridement and draining of any subperiosteal abscesses
• Total antibiotic course of 3-4 weeks, up to 6 weeks in
complicated or extensive cases
• Sickle cell patients who may have areas of poorly perfused
bone as well as immunocompromised patients require longer
treatment duration
• Use the max dosage range listed for the antibiotic chosen
• IV route until clinical symptoms improved and afebrile for at
least 3-5 days
• Can then complete treatment course with oral high dose
antibiotics
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Osteomyelitis - Treatment
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 Antibiotic Therapy:
• Anti-staphylococcal penicillins:
 Oxacillin (and gentamicin) in neonates
 Nafcillin or oxacillin monotherapy in older
children
• First generation cephalosporins
 Ancef (cefazolin)
• Clindamycin if suspect MRSA
• Vancomycin if clinda resistant or D test positive
for inducible clinda resistance
• Linezolid as last resort for highly resistant
organisms
Osteomyelitis - Outcomes
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 Complications:
• Bony and cartilaginous destruction
• Growth arrest
• Permanent deformity
• Sepsis
• Chronic or recurring osteomyelitis
 Prognosis:
• Complications occur in only ~5% of cases,
usually when there was a delay in diagnosis
or treatment
• Recurrences can occur up to 30 years later,
usually the same organism, often reactivated
by local trauma
Compartment Syndrome
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 Due to an increase in intracompartmental pressure
 From anything that decreases compartment size:
• Tight closure of fascial defects
• Tight dressings or casts
 Or from anything that increases comparment
components:
• Bleeding from fractures or trauma
• Increased capillary permeability from burns
• Venous obstruction
• Muscle hypertrophy
 Can result in ischemic muscle necrosis and
subsequent contracture and dysfunction
Compartment Syndrome
 The lower leg is most susceptible due to its small
fascial compartments
 Irreversible muscle injury may occur in as little as 6
hours from onset of ischemia
 Diagnosis “The Five P’s”
• Pain out of proportion to the injury, exacerbated
by passive stretching of the muscle
• Paresthesia
• Pallor
• Paralysis
• Pulselessness
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Compartment Syndrome
 Treatment
• Loosen all restrictive dressings or splints
• Direct measurement of compartment pressures if
pain not immediately relieved
• Incisional release or fasciotomy required if any
compartment pressures are over 30mmHg
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Fractures: Definitions
 Alignment: refers to angulation or rotation of the fracture
fragments in reference to each other
 Apposition: refers to the amount of end to end contact
between the fractured bone fragments
 Avulsion: “chip fracture”, small fracture near a joint that usually
has a ligament or tendon attached
 Closed: “simple fracture”, no overlying open wound
 Open: “compound fracture”, open wound present
 Comminuted: multiple fragments
 Dislocation: “luxation”, disruption of the continuity of a joint
 Displaced: the two bone ends are separated
 Epiphyseal: involves the growth plate or epiphysis
 Greenstick: incomplete fracture
 Impacted: broken ends are driven into each other
 Intra-articular: involves the joint surface of a bone
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Fractures: Definitions
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Delayed union: slower than normal healing
Malunion: healing in an unsatisfactory position
Nonunion: failure of bone healing
Occult: can’t see the fracture on the plain films but other
positive signs suggest a fracture such as a posterior fat pad
on a lateral elbow film
Pathologic: due to an underlying bone weakness, usually
cysts, neoplasms, or metabolic bone disease
Stress: occurs when weak bone is stressed normally or when
normal bone is stressed excessively, usually in weight bearing
bones
Subluxation: partial disruption of a joint, an incomplete
dislocation, most common in pediatrics is nursemaid elbow
Torus: “buckle fracture”, caused by compression of the cortex,
most commonly occurs in the distal radius
Pediatric Fractures
 Fractures in children differ from those in adults
 Nonunion is rare due to the active periosteum and
abundant blood supply surrounding the growing
bone
 Continued bone growth after the fracture is healed
allows for correction of minor deformities
 The closer the fracture is to the end of the bone and
the younger the patient, the greater the amount of
angulation that is acceptable
 The distal radius may correct up to 10-15 degrees
per year
 Side to side apposition is acceptable in long bone
fractures in boys under 12yrs and girls under 10yrs
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Pediatric Fractures
 Slight shortening (overlapping of 2 bone ends) is
acceptable and may even be desirable in leg
fractures due to the acceleration of growth seen
after a displaced fracture, the tibia and femur may
overgrow up to 1cm
 Exceptions:
• Rotational malalignment will not correct itself
• Angulated midshaft fractures will not realign
 Sprains are rare in children under age 12 yrs, if
tenderness is present over a growth plate coupled
with overlying soft tissue swelling, assume a
fracture even if x-rays are negative
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Epiphyseal Fractures
 The epiphyseal plate consists of zones or layers:
• Germinal cell layer, closest to the joint
• Zone of proliferation
• Zone of hypertrophic cartilage
• Zone of provisional calcification
 Most epiphyseal fractures occur through the weakest zone,
the zone of hypertrophic cartilage
51
Epiphyseal Fractures
 Salter I and II fractures are
transverse and do not
extend vertically across the
germinal cell layer,
prognosis for normal healing
is good
 Salter III, IV, and V fractures
extend vertically across the
growth plate and have the
highest risk for growth
disruption and angular
deformity, accurate
reduction is mandatory and
often requires surgery
 Salter V fractures are crush
injuries and have the worst
prognosis
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Pediatric Fractures
 Call orthopedics for all of the following fractures:
• Open fractures, often require meticulous cleaning
and debridement to prevent infection
• Femur fractures, require prolonged traction,
special casting, or surgery
• Displaced supracondylar humerus fractures
• Salter III, IV, or V fractures (except fingers, toes)
• Any closed angulated or displaced fractures for
which reduction attempts are unsuccessful
• Any injury involving neurovascular compromise
or signs of compartment syndrome
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Pediatric Fractures
54
 Immediate care when patient presents to the ER:
• Elevate and ice
• Stabilize obvious fractures on an armboard, in a
sling, or on a stack of towels
• NPO except for pain meds
• Pain control depending on severity
 IV Morphine
 PO Lortab
• Document last po intake
• Consent signed for sedation if has obvious
deformity
• Assess neurovascular status distal to the injury
Buckle Fractures
 Torus or buckle fracture of
the distal radius
 The most common fracture
in the pediatric population
 Occurs from a fall onto an
outstretched hand
 May present a few days
after the injury with mild
wrist pain
 Stable fracture, treated
mainly for comfort
 Treat with a lower arm
sugartong splint in the ER
 Later get a short arm cast or
a removable volar wrist
splint for 3-4 weeks
55
Clavicle Fractures
 Occurs from a fall onto the shoulder or falling onto an outstretched hand
 Surgical correction only if open, skin tenting present, comminuted, or
has neurovascular injury
 Better to accept angulation/deformity than to attempt open reduction in
most cases
 The scar from an open reduction is usually more displeasing to the
patient and family than the bony prominence of a malunion
 Simple sling and swathe for 2-3 weeks or until painfree
56
Proximal Humerus Fractures
 Common between the ages of 9-15yrs
 Occurs from a fall onto the arm or a direct hit
 The proximal humeral growth plate has an amazing
ability to remodel
 Reduction is only needed in patients near skeletal
maturity whose fracture has more than 50-70
degrees of angulation, in open fractures, or if has
neurovascular injury
 Most common complication is axillary nerve injury,
test deltoid function and sensation lateral deltoid
 Immobilize in a simple sling for 3-4 weeks
 Gentle pendulum exercises and shoulder range of
motion exercises can be started in the second week
57
Proximal Humerus Fractures
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Supracondylar Fractures
 Make up 60-80% of all pediatric elbow fractures
 Peak incidence ages 5-7 years
 Results from a fall with the elbow hyperextended, the
hyperextension forces the olecranon into the olecranon fossa
transmitting the force up into the distal humeral metaphysis
 The distal fragment is usually displaced posteriorly
 The anterior humeral line which should bisect the capitellum, is
malaligned anterior to the capitellum
 Has the highest complication rate of any pediatric fracture
including neurovascular injury, compartment syndrome, and
malunion
• Vascular injury occurs in ~2.5%, most commonly the
brachial artery
• Neuronal injury occurs in ~17% of Type III fractures, can
affect the radial, median, or ulnar nerve
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Supracondylar Fractures
 Type I is nondisplaced
 Type II is displaced partially
with the posterior periosteal
hinge intact
 Type III is displaced
completely with no contact
between fracture fragments
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Supracondylar Fractures
 Type I can be treated with a posterior long arm
splint with the elbow in 90-110 degrees of flexion,
will later get a long arm cast for 3-4 weeks
 Type II and III are usually treated with closed
reduction and percutaneous pinning
61
Forearm Fractures
 The distal radius physis is the most commonly injured physis
in the body
 Salter II fractures are the most common type of radial physis
injury
 Most displaced fractures involve apex volar angulation with
the distal fracture fragment being displaced dorsally
62
Forearm Fractures
 Most distal forearm fractures
can be treated with closed
reduction, but midshaft
fractures are more unstable
and often require pinning or
plate fixation
 Remodeling of the distal radius
may correct up to 10-15
degrees of angulation per year
 Therefore, angulation up to 30
degrees may be accepted in
children under the age of 10
years, and up to 15 degrees in
children older than 10 years as
long as they have open physes
 Remember, rotational
deformities will not remodel
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Forearm Fractures
 Place a sugartong splint in
the ER and then a cast for
4-6 weeks
 Most common complication
is growth arrest, occurs
more commonly with difficult
or open reductions
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Boxer’s Fracture
 Distal 4th or 5th metacarpal
fractures
 Results from hyperflexion of
the metacarpal neck due to
punching or hitting a hard
object or wall
 Treated with an ulnar gutter
splint, then a cast for 3-4
weeks
 Never reduced in the ER, all
go to ortho clinic for follow
up and have outpatient
surgical repair if residual
dysfunction is present
65
Femur Fractures
66
 62% occur in the shaft of the
femur or diaphysis
 One of the most common
fractures in children
 The most common fracture
requiring hospitalization
 Between the ages 1-6 yrs,
usually due to falls
 Between the ages 6-9 yrs,
usually due to auto vs. ped
 Over the age of 10 yrs,
usually due to MVC’s, sports
accidents
 Under the age of 12 months
or in any child who is not yet
walking, 80% are due to non
accidental trauma
Femur Fractures
67
 Treatment is often age dependent
• Newborns to age 6 months: Pavlik harness
• 6 months to 5-8 years: spica cast
• 6-12 years:
 Traction followed by a spica cast
 External fixation
 Flexible intramedullary nailing, no casting, just
a knee immobilizer needed post op, rods are
removed 9-12 months later
• Skeletally mature with closed physes:
 Rigid intramedullary locking nails
 Compression plate fixation
Femur Fractures
 Pavlik harness
68
 Spica cast
Femur Fractures
 Remodeling of an infant
treated with Pavlik harness
69
 Flexible intramedullary
nailing in an older child
Femur Fractures
 External fixation
70
 Rigid intramedullary
interlocking nails
Tibia Fractures
 50% occur in the distal third of the
tibia
 39% occur in the midshaft region
 30% have associated fibular fractures
 Due to falls, sports, MVC’s, and auto
vs pedestrian accidents
 Proximal third tibia fractures are rare
but the most complicated, tend to heal
with a valgus deformity, treated with a
varus molded long leg cast with knee
flexed 10 degrees for 4-6 weeks,
some valgus deformities resolve
spontaneously so they aren’t
surgically corrected unless persist into
adolescence
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Tibia Fractures
 Middle and distal third tibia fractures require long leg splints in
the ER followed by casting
 Casting duration dependent on age
• Young children wear a long leg cast for 3-4 weeks
• Adolescents wear a long leg cast for 4 weeks, then switch
to a short leg cast for 4 weeks, then an aircast walking boot
for 4 weeks
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Toddler’s Fracture
 Nondisplaced spiral fracture
of the distal third of the tibia
 The most commonly
identified fracture in
preschool-aged children
presenting with a limp
 Occurs from a fall that
causes a twisting torque on
the lower leg
 Typically seen in patients
aged 1-3 years as they are
learning to walk, but can
occur in children as old as 6
years
 Long-leg or below-the-knee
walking cast for 3-4 weeks
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Ankle Fractures
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 Ankle inversion/eversion injuries can cause
avulsion fractures of the lateral/medial malleolus
tips respectively, or distal fibular physis fractures
 Avulsion fractures of the distal medial or lateral
malleolus may persist radiographically despite
casting
 Sometimes confused with a normal ossification
center, if tender with overlying soft tissue swelling,
treat as a fracture
 Salter Harris I fractures of the distal fibula account
for 15% of pediatric ankle fractures, often cannot be
seen radiographically, it must be presumed in a
growing child with tenderness over the physis
Ankle Fractures
 Normal Pediatric Ankle
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 Medial malleolus avulsion
fracture
Nursemaid Elbow
 Subluxation of the radial head
due to a pulling or sudden
traction injury followed by
entrapment of the annular
ligament between the radial
head and the capitellum
 Age 1-5 years
 Left side more common
 Slightly higher incidence in girls
 Usually caused by someone
lifting up a toddler by the lower
arm or when a child suddenly
pulls away or drops down while
holding hands with a parent,
also occurs from swinging a
child as in playing “airplane”
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Nursemaid Elbow
 Presents with the arm
hanging limp down by the
side, nontender to palpation,
but the child refuses to use
the arm
 Can reproduce pain with
elbow flexion or supination
 Reduced by applying
pressure to the lateral
aspect of the radial head
while applying traction to the
lower arm followed by
supination and flexion at the
elbow
 This method works in 8090% of cases
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Nursemaid Elbow
 An alternative method is hyperpronation at the wrist
 If unable to reduce, splint with elbow flexed at 90
degrees and send for orthopedic clinic follow up
 Often hear or feel a click
 Child usually cries briefly
 10 minutes later the child is using it fully and
reaches for a toy or popsicle
 No splinting or sling necessary
 Motrin or Tylenol for soreness
 Tends to recur in 26% of cases
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» The End… Questions???
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