Pediatric Orthopedic Emergencies

1

• Pediatric Orthopedic Emergencies
• Tracy Merrill MD

Division of Pediatric Emergency Medicine
Childrens 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
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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?

3
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

4
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

5
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

8
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 WBCs
  10,000-250,000 (normal is less than 200), gt75
  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 gt37 degrees Celsius (37.7 vs. 36.6)
• WBC gt11,000/mL (18.2 vs. 8.2)
• CRP gt1mg/dL (10.1 vs. 0.66)
• ESR gt20mm/h (79.2 vs. 20.3)
• Joint space difference gt2mm 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
• lt2 months of age oxacillin or nafcillin plus
  gentamicin for Gram negatives
• 2 months to 3 years ampicillin-sulbactam or
  ceftriaxone
• gt3years oxacillin, nafcillin, or ceftriaxone
• Adjust based on gram stain and culture results
• Consider Clinda or Vanc if suspect MRSA

14
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

• 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

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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

21
SCFE Grades of severity
22
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 contra-
  lateral 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 SCFEs are treated
  effectively with minimal complications, makes up
  gt90 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

• 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 51
• 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

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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 its 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 gt90 (note your bone scan wont 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

• 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

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Osteomyelitis - Outcomes

• 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

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Compartment Syndrome

• 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

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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 Ps
• 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

• Delayed union slower than normal healing
• Malunion healing in an unsatisfactory position
• Nonunion failure of bone healing
• Occult cant 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

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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

50
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

51
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

52
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

53
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

54
Pediatric Fractures

• 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

55
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

56
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

57
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

58
Proximal Humerus Fractures
59
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

60
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

61
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

62
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

63
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

64
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

65
Boxers 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

66
Femur Fractures

• 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 MVCs,
  sports accidents
• Under the age of 12 months or in any child who is
  not yet walking, 80 are due to non accidental
  trauma

67
Femur Fractures

• 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

68
Femur Fractures

• Pavlik harness

• Spica cast

69
Femur Fractures

• Remodeling of an infant treated with Pavlik
  harness

• Flexible intramedullary nailing in an older child

70
Femur Fractures

• External fixation

• Rigid intramedullary interlocking nails

71
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, MVCs, 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 arent surgically corrected unless persist
  into adolescence

72
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

73
Toddlers 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

74
Ankle Fractures

• 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

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Ankle Fractures

• Normal Pediatric Ankle

• Medial malleolus avulsion fracture

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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 80-90 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???