ORTHO PUZZLERSSTICKS AND STONES SUCK

CHRISTOPHER S. AMATO, MD, FACEP, FAAP

MORRISTOWN MEDICAL / GORYEB CHILDREN’S HOSP.

EMERGENCY MEDICAL ASSOCIATES

MORRISTOWN, NJ

ENVISION PHYSICIANS GROUP

DISCLOSURE

Financial Interests

Sponsorship

NONE

NONE

Disneyland releases ~300 feral cats at night to deal with some cousins

The Evil Queen intermittently appears in the window above Snow

White’s Scary Adventure

OBJECTIVES

Describe how the anatomic and physiologic differences that exist in pediatric patients affect the management of pediatric orthopedic injury.

Discuss growth plate-related injuries and the typical ages that they close.

Review specific types of orthopedic injuries that are fraught with medical-legal issues and how to spot them in the first place.

Discuss the level of urgency, emergency, and non-urgency of these conditions.

Review the complications of these conditions.

THEORTHOPEDIC EMERGENCIES

Open Fractures Acute Compartment Synd. Neurovascular injuries Dislocations Septic Joints Cauda Equina Syndrome

PEDIATRIC FRACTURES

• Salter-Harris Classification

• Greenstick – incomplete angulated long bone fracture

• Torus – incomplete fracture with cortical buckling/wrinkling

PEDIATRIC GROWTH PLATES

SITE AGE of Closure

Proximal Tibia 16-20

Distal Tibia 17-18

Distal radius 17-19

Proximal Femur 16-18

Distal Femur 16-19

Proximal Humerus 18-21

https://www.slideshare.net/harjotsgurudatta/orthopaedic-fractures-in-children

C-R-I-T-O-E= 1-3-5-7-9-11 yrs.Capitulum-Radius-Internal (Med) Epicondyle-Trochlea-Olecranon-External Epicondyle

CASE #1

HISTORY

2 year old female brought by father (PEM doc) due to fall down stairs.

Holding L wrist and crying in pain

PMHx: her father has dropped her beforeOlder sibling has hx of Femoral fx…hmmm

PHYSICAL EXAM

VS: WNL

Gen: Awake and alert

Ext: Left arm: (+) minimal swelling of L upper extremity at distal wrist

WHAT DO WE DO IN THE ED????????CSF

Do we even need to call Ortho?

CPS?

His wife?

Masked to protect the identity of this moron

WHICH BONE IS BROKEN THE MOST?

Clavicle? only takes 8 lbs. of pressure to break the collar bone

Radial fractures are by far the most common pediatric fractures (40% to 50%)

TORUS AKA BUCKLE FX

Multiple studies challenge routine casting {acceptable angle <15°}

Splints: may remove after 3 weeks without orthopedic follow-up. An interval visit with a primary care provider at 10-14 days after injury to reassess

the child and provide anticipatory guidance about splint use may be reassuring to the caregiver.

Fracture without displacement during healing

Thus, additional radiographs are unnecessary1. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. Pediatrics. 2006;117(3):691–72. Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial. Boutis K, Willan A, Babyn P, Goeree R, Howard ACMAJ. 2010 Oct 5; 182(14):1507-12.3. Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures. Randsborg PH, Sivertsen EA. Acta Orthop. 2009;80(5):5854. The role of serial radiographs in the management of pediatric torus fractures. Farbman KS, Vinci RJ, Cranley WR, et al. Arch Pediatr Adolesc Med 1999; 153:923

SPLINT VS. CAST

Degree of initial pain

Degree of anticipated activity of the child

Parental preference.

can be removed for showering and minor activities

cast offers more protection of the fracture site in active children

Small trial (84 children from single Children’s hospital)

↑duration of pain fiberglass molded splint vs. cast (med. 6 vs. 3d, p <0.01)

A 4 y/o male is brought to the ED with limp noted on the right legNo reported trauma or signs/symptoms of illness No PMHx or comorbid diseasePE: (+) limp with gait, Otherwise (-) findingsRadiographs: Normal

LIMPChoban S, Killian JT. Evaluation of acute gait abnormalities in preschool children. J Pediatr Orthop. 1990 Jan-Feb;10(1):74-8.

LIMP CHARACTERISTICS

LIMP: Differential based on 1) AGE 2) Examination3) Pain characteristics:

a. Constant pain→ infection or malignancy

b. Morning pain → inflammatory disorder

c. Pain after activity → overuse injury

d. Nighttime pain → ? malignancy

EVALUATION OF LIMP

• History and Physical

• Pain control – lead with NSAIDs (unless obvious fracture and NPO)

• Radiography

• LABS: CBC/d, CRP, ESR (LYME if endemic)

• Serial examinations

TRANSIENT (TOXIC) SYNOVITIS

• Transient Synovial inflammation

• Males>Females

• Age 4- 10 years

• Usually unilateral

• EXAM: • (+) pain radiates to thigh / knee

• Held in flexion, adducted, w/ internal or external rotation

• Radiography / Ultrasound

TRANSIENT (TOXIC) SYNOVITIS

• Radiography:• X-ray may reveal effusion

• Ultrasound: Effusion noted in 95% cases

• Laboratory:• CBC: NML or slight ↑

• ESR: NML or slight ↑

• CRP: NML or slight ↑

• MANAGEMENT: • Rest, NSAIDs, close follow up

A 4 y/o male with limp noted on the right leg(+) T 39.5, P130, RR24, Bp 100/70, PulsOx RA 99%Fell 2 days prior but without apparent issues sincePE: (+) will not move Right leg Radiographs……………

SEPTIC ARTHRITIS• Radiography:• X-ray may reveal effusion

• Ultrasound: Effusion noted in 95% cases

• Laboratory: Kocher: • CBC -- elevated >12K/ml

• ESR -- elevated >40 mm/hr

• CRP -- elevated >2mg/dL

• FEVER >38.5

• Weight Bearing No

0/4 = 0.2% chance of having septic arthritis1/4 = 3% chance. 2/4 = 40%. 3/4 = 93% chance of septic arthritis4/4 = 99.6% probability of septic arthritis J. Bone Joint Surg. Am. 1999;81:1662-70

Blood Cx (+) in 40% of casesLog roll test (passive supine rotation; Freiberg test)

Pathophysiology: Hematogenous SpreadBacteremia from Soft-tissue or other infectionSpread from Osteomyelitis (10%)

Trauma (minor or major) or Surgery

•MANAGEMENT: •Admit & consult Pediatric Orthopedics•Aspiration / wash out•Empiric Antibiotic Therapy:

May be altered based on age

SEPTIC ARTHRITIS

A 6 y/o boy with limp for months is brought to ED •Patient complains of groin and thigh pain, otherwise well. •Exam reveals a well appearing male who walks with a slight limp on the left; limited in abduction on the left

LEGG-CALVES-PERTHES

• Aseptic necrosis of femoral head • Flattening of femoral head

• Males>Females

• Age 4- 12 years

• Unilateral 85%; bilateral 15%

• Onset possibly over years• Medial thigh, groin, or knee pain

• (+) spasm of musculature

EXAM: limited range of motion•especially abduction•Length discrepancy ?

A 16 y/o boy with acute pain•Patient complains of groin and thigh pain, otherwise well

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Klein’s line - a line from superior cortex of femoral neck parallel to greater trochanter

SLIPPED CAPITAL FEMORAL EPIPHYSIS

• Typically obese male (weight >90%)

• Males 12-15 yrs., Females 10-13 yrs.

• Males>>Females

• Gradual hip/thigh/knee pain• Can present acutely following minimal trauma

• Hip externally rotated

• 10-25% bilateral

• X-rays – widen physis, Klein line• Include frog-leg view

SCFE VS. LCP

SCFE Insidious onset common May have inciting event

Male > female

Peak 12-14 years

Bilateral in up to 25%

Limp/hip pain

Tx: Admit for ORIF

LCP Insidious onset common

Male > female

Peak 5-7 years

Bilateral in up to 20%

Limp/hip pain

• Tx: NSAIDs, decreased activity

• Non-weight bearing – casting/ braces

WHAT IF?????

14 year old playing soccer – went to kick ball and then had immediate pain????

RUNNER / JUMPER

http://www.radiologyassistant.nl/data/bin/a5518160776b4f_17-avulsion.jpg

A 4 y/o male is brought to the ER with left arm pain. Child was playing at the monkey bars when he fell and stopped the fall with his left arm. PE: (+) left distal forearm pain. Your order left forearm X-Ray.

COMMON DISTAL FOREARM FRACTURES

Torus Fracture Greenstick FractureBOWING / PLASTIC DEFORMITY

http://eu-csite-storage-prod.s3.amazonaws.com/www-eurorad-org/mediafiles/0000002791/000002_text.jpg

A 4 y/o male is brought to the ER with left arm pain. Child was playing at the monkey bars when he fell and stopped the fall with his left arm. PE: (+) left distal forearm pain. Your order left forearm X-Ray.

MONTAGGEIA FRACTURE

Fracture of the proximal 1/3rd of ulna combined with dislocation of the radial head

https://www.google.com/search?q=galeazzi+fracture&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwjaiNPCr7zTAhVlxlQKHY1tCYoQ_AUIBigB&biw=1507&bih=852#tbm=isch&q=montaggeia+fracture&imgrc=a-RCOim-CZwI_M:

GALEAZZI FRACTURE

radial shaft fracturecommonly at the junction of the middle and distal third

dorsal angulation

Dislocation of the distal radioulnar joint

ELBOW FRACTURES

40

Radiocapitellar line should intersect the capitellum in all views

Make it a habit to evaluate this line on every pediatric elbow film

ELBOW FRACTURESRADIOGRAPH ANATOMY/LANDMARKS

Anterior Humeral Line Drawn along the

anterior humeral cortex

Should pass through the middle of the capitellum

Variable in very young children

TYPE 1NON-DISPLACED

Note the non- displaced fracture (Red Arrow)

Note the posterior fat pad (Yellow Arrows)

-Skaggs. The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999;81:1429. -Bohrer. The fat pad sign following elbow trauma. Its usefulness and reliability in suspecting “invisible” fractures. Clin Radiol. 1970;21:90.

TYPE 2ANGULATED/DISPLACED FRACTURE WITH INTACT POSTERIOR CORTEX

In many cases, the type 2 fractures will be impacted medially Leads to varus angulation

The varus malposition must be considered when reducing these fractures Apply a valgus force for

realignment

TYPE 2ANGULATED/DISPLACED FRACTURE WITH INTACT POSTERIOR CORTEX

TYPE 3COMPLETE DISPLACEMENT

Mother presents and states there is “something wrong with her Right leg” (6 wk. old) daughterNo history of trauma, previously healthyChild alert, held by motherPE: (+) Not moving Right leg (+) mid thigh hematoma

HR 132, RR 42, BP 80/67, T 37.3°C, O2 sat 96%

NON-ACCIDENTAL TRAUMA

For each case of child maltreatment reported, 2 go unrecognized

Follow the guidelines of:

Listen, Look, Explain, Evaluate, Record, Report

Follow a multidisciplinary approach:

Clinicians, social services, law enforcement

NON-ACCIDENTAL TRAUMA

Differential Dx: Osteogenesis imperfecta

Hypophosphatasia

Rickets

Leukemia

Primary and metastatic bone tumor

Management Give proper analgesia.

Splint inured limb.

Notify child protection services.

Consult appropriate services:

Child abuse

Orthopedics

Genetics

STRANGEST ORTHO CASE TO DATE:

Strangest Ortho case to date:

THE END…

QUESTIONS?

Christopher.amato@atlantichealth.org

http://gomerblog.com/wp-content/uploads/2015/12/parenting.jpg

THANK YOU!

ACKNOWLEDGEMENTS

Ariel Vera, MD

Dhwani Patel, DO

Marianne Gausche-Hill, MD

Univ. of Hawaii.edu, pediatric radiology case studies

LSU Medical Student Clerkship, New Orleans, LA

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