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Pediatric Orthopedic Emergencies

Patrick Mahar, MD

The Children's Hospital University of Colorado Health Sciences Pediatric Emergency Medicine February 28, 2011

Why We Care?

Musculoskeletal injuries ~12% of the 10 million annual visits to US pediatric emergency departments Rate of fractures increasing

Approximately 50% of all children will fracture a bone during childhood

Pediatric Bones

Periosteum of pediatric bone:

­ Greater osteogenic potential ­ Metabolically more active ­ Thicker and stronger,

Limits fracture displacement, Reduces the likelihood of open fractures, Maintains fracture stability

The pediatric periosteum responsible for some of the unique fracture patterns seen in children.

Structural Differences: Pediatric vs Adult Bone Presence of growth plate physeal fractures More porous & pliable more susceptible to incomplete fractures Ligaments stronger than bone "sprains" rare Extensive remodeling corrects large degrees of angulations and displacement Non-union is rare



6 y.o. fall

6 y.o. female presents for right arm pain after she fell while running at playground. Mild swelling and deformity to right wrist Tenderness at distal radius and ulna NVI throughout

6 y.o. fell while running

Buckle Fracture

Buckle Fractures

Follow compression failure Often located at the junction between the porous metaphysis and the denser diaphysis. These injuries typically occur in the distal radius after longitudinal trauma (eg, FOOSH), but are also seen in the distal tibia, fibula, and femur. Buckle fractures are also known as torus fractures

Treatment of Buckle Fractures

Stable fractures Can be managed with Volar splint PCP or orthopedic follow-up visit in 1-2 wks

12 y.o. girl with shoulder pain

Pt playing soccer and fell on to shoulder when opponent made slide tackle C/o not being able to move her shoulder

What to order?

A. Shoulder x-rays including Y-view B. Humerus x-ray C. Clavicle x-ray

D. MRI shoulder

Clavicle Fracture

Frequently fractured bone in children Mechanism fall on out-stretched hand or direct blow/fall on to shoulder PE deformity, tenderness, pain with

shoulder abduction Rx Sling x 3-4 wks, then rest x 3 wks

­ Figure of 8 wraps: no added benefit, more discomfort

20 mo refusing to walk for 24 hours

Pt won't put weight on right leg Cries when parents have him stand Crawling instead of walking No know significant trauma, but falls often when cruising/learning to walk Exam:

­ ­ ­ ­ No swelling/bruising Full flexion/extension at knee and hip Cries more with internal/external rotation of leg No significant tenderness

What to do?

A. U/S hip to rule out septic joint B. X-ray femur C. X-ray Tib-fib

D. CBC, ESR, CRP. Blood cx

E. X-ray foot

Now What?

A. Skeletal Survey looking for other B.

C. D. E.

fractures Call CPS b/c fracture w/out history and 24 hours before seeking medical care Bone scan to confirm fracture Posterior long leg splint and follow up with orthopedics in 3-5 days All of the above

Toddler's Fracture

Spiral fracture of tibia Occur in children when the child's body rotates around a fixed foot

­ In older children, the force is often substantial (eg, skiing, contact sports) ­ In toddlers this injury often results from relatively minor trauma

Toddler's Fracture

Usually no swelling or deformity May illicit pain by placing the hands at the knee and ankle and gently twisting in opposite Pain often seen with gently grinding the heel of the foot into the distal tibia The full range of motion at the hips, knees, and ankles is preserved and should be documented.

Toddler's Fracture

Often fracture not seen on initial X-ray, thus if highly suspicious treat anyhow Treatment:

­ Posterior long leg splint ­ F/u ortho for casting ­ Stress NO WALKING

3 y.o. fall on to arm

3 y.o. brought in by parent after he fell while running MOC reports patient fell/rolled onto arm under his body. Gross deformity noted of forearm NVI throughout

3 y.o. fall on to arm

Greenstick Fracture

Describes a bone that is bent with a fracture line that does not extend completely through the width of the bone. Reduction may require completion of fracture

6 y.o. fell while on trampoline

Crying and not wanting to move arm Swelling noted at elbow Reports falling on to arm

Now What?

A. Reduce radial head via supination and

flexion at elbow B. X-ray elbow

The Pediatric Elbow

Normal or Abnormal?

Reading Pediatric Elbow X-ray

Need true lateral Hour glass sign Anterior humoral line Radiocapitellar line

Ossification Centers of the Elbow

Capitellum (1 year) Radial Head (3 years) Medial or Internal Epicondyle (5 years) Trochlea (7 years) Oleacranon (9 years) Lateral or External Epicondyle (11 years) "Come Ride My Truck Of Luck"

6 y.o. fell while on trampoline

Anterior humoral line displaced Disruption of anterior and posterior cortex

How do you classify supracondylar fractures?

How do you classify supracondylar fractures?

Type I: Undisplaced Type II: Displaced with intact posterior cortex Type III: Displaced with no cortical contact

Type I Supracondylar Fracture

View B is injured arm and View C is opposite arm for comparison

Type II Supracondylar Fracture

Type III Supracondylar Fracture

How do you treat a supracondylar fractures?

Type I: Posterior long-arm splint and ortho follow-up in 1 week Type II: Posterior long-arm splint and ortho f/u in 24-48 hrs for possible pinning Type III: Reduction and pinning in OR

Fat Pad Sign

7 y.o. forearm injury

7 y.o. male fell on stairs when attempting to ride skateboard down 4 concrete steps Pt in severe pain Mild deformity to forearm NVI throughout

7 y.o. fall on stairs

Plastic Deformity (Bowing Fracture)

Occurs when a longitudinal force exceeds the bone's ability to recoil to its normal position. If the tension side cannot propagate the fracture, microscopic fractures can occur to dissipate the impact energy, thus creating a plastic deformity. Most commonly seen in the ulna, the radius, and occasionally in the fibula. If the deformation is less than 20 degrees or if the deformity occurs in a young child (<4 years of age), the angulation often corrects itself.

­ Otherwise, closed reduction or operative intervention may be necessary to straighten the bone.

9 year old FOOSH after falling off of slide.

Monteggia's Fracture

12 year old FOOSH while rollerblading

Galeazzi Fracture

Fracture of the radius with dislocation of the distal radioulnar joint. Classically involves an isolated fracture of the junction of the distal third and middle third of the radius with associated subluxation or dislocation of the distal radio-ulnar joint;

8 y.o shoulder pain

At ski park and fell on rail hitting left shoulder against rail Can not abduct or adduct arm at shoulder NVI throughout

Humerus Fracture

Proximal fractures most common Shaft much less common in children PE point tenderness, ROM (check axillary nerve and radial pulse) Rx reduction only rarely necessary, sling and swathe, follow-up w/ ortho

8 w.o. w/ swelling of ankles

Brought in by MOC for swelling of right foot/ankle No known trauma Crying more over past few days

­ MOC said "He has colic"

No fevers Lives with parents

8 w.o. w/ swelling of foot

Now What?

A. D/C home; no treatment needed -Pt is nonambulatory so no need for cast B. Posterior Long Leg Splint and ortho f/u

C. Skeletal Survey and call CPS

Metaphyseal corner fracture

Bucket Handle Fx

8 w.o. w/ right foot swelling

8 w.o. w/ right foot swelling

Abuse Fractures

Inconsistencies and/or discrepancies in caretakers' accounts of the circumstances surrounding the injury Unwitnessed injuries Injuries attributed to the patient's siblings/pets Injuries inconsistent with the child's developmental stage

­ Example: 3 week old rolling off bed with resulting fractures

Injuries inconsistent with the mechanism of injury offered

­ For example, children who have inflicted musculoskeletal injuries are often said to have fallen from a piece of furniture. However, when young children fall from furniture, the risk of fracture is low (<2 percent)

Abuse Fractures

Fractures that are highly suggestive of NAT

­ ­ ­ ­ ­ ­ Metaphyseal corner fractures Rib fractures Fractures of the sternum, scapula, or spinous processes Multiple fractures in various stages of healing Bilateral acute long-bone fractures Skull fractures in children younger than 18 months of age, particularly without a corresponding history

Fractures less frequently associated with abuse include:

­ Isolated long-bone fractures ­ Clavicle fractures

11 y.o. with right knee pain

One year history of right knee pain Knee recently "gave way" when running down the stairs Pain described as deep achy pain on the medial aspect of his knee No history of trauma Pain has recently started to limited his activities Pt denied numbness, paresthesias, or weakness in his right leg. He denied fevers, chills, and any recent illnesses.

11 y.o. with right knee pain


­ Obese adolescent male in no acute distress. Weight- 59 Kg(>95%) ­ Right knee appeared atraumatic w/out point tenderness ­ Diffuse pain in the knee with passive ROM ­ Examination of the hips revealed no tenderness ­ Increased external rotation and decreased internal rotation of the right hip compared to the left ­ No gait abnormalities

AP Bilateral Hips

Frog-leg Lateral View

What's the Diagnosis?

A. Early arthritis from being overweight B. Legg-Calve-Perthes C. SCFE

D. Osgood-Schlatter Disease

Klein's Line

AP Bilateral Hips

Epiphyseal-shaft angle of Southwick

Frog-leg Lateral View

42° 10°

Slipped capital femoral epiphysis (SCFE)

Displacement of the capital femoral epiphysis from the femoral neck through the physeal plate. It is one of the most common hip disorders of adolescence. ­ Approximately 15 percent of patients present with isolated thigh or knee pain ­ Occurs in approximately 1 per 1000 to 1 per 10,000 children and young adolescents The typical patient is an obese child in early adolescence. ­ The mean age of presentation is 12 years in girls and 13.5 years in boys, near the time of peak linear growth ­ male-to-female ratio is approximately 1.5:1 Bilateral in 20-40% of cases at presentation ­ In children who present with unilateral disease, the contralateral hip slips in an additional 30-60%

Now What?

A. Immediate Ortho Consult B. Ortho referral to be seen in 2-3 weeks C. Admit and must be non-weight bearing

D. Discharge home/NSAIDs/loose weight

E. A and C


Thanks Patrick Mahar, MD The Children's Hospital University of Colorado Health Sciences Pediatric Emergency Medicine [email protected]


Pediatric Fractures

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