Pediatric Orthopedics

Transcription

1 Pediatric Orthopedics Paul Allegretti, DO, FACOEP Program Director, Associate Professor of Emergency Medicine, Midwestern University, Chicago College of Osteopathic Medicine, Downers Grove

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3 Notes I. INTRODUCTION PEDIATRIC ORTHOPEDICS A. Understanding the diagnosis and treatment of musculoskeletal injuries in the adult patient provides a basic foundation for pediatric orthopedics. Remembering the differences from adult injuries, however, is the key to successful diagnosis and treatment of musculoskeletal injuries in the child. In this respect, children are not always just little adults. 1. Chronobiologic variation - The developing pediatric skeleton is a dynamic entity, constantly changing with maturation. The resiliency of bone becomes progressively more static and the varying areas of growth change in relative strength as ossification and growth occurs. This affects not only injury patterns, but also radiographic appearance and treatment. 2. Patterns of failure differ - Due to this chronobiologic variation, stressing the skeleton results in unique and varying patterns of failure not seen in adults (physeal injuries, torus and greenstick fractures, etc.). 3. Fractures are more common - In the pediatric age group, fractures occur even after seemingly minimal trauma. Skeletal trauma accounts for 10-15% of all childhood injuries. 4. Joint injury, dislocation, and ligamentous disruptions are much less common - Collateral ligaments are resilient and stronger than the nearby associated physis (epiphyseal plate), resulting in physeal failure rather than sprain or dislocation. As skeletal maturity approaches, adult sprain and dislocation patterns progressively prevail. 5. Diagnosis is more difficult - History regarding the true mechanism of injury is typically lacking, and cooperation for an adequate physical exam is often limited. The radiolucent physis and varying appearance of secondary ossification centers make radiographic interpretation more difficult. 6. Remodeling is more extensive than in adults In certain cases, a less than anatomical reduction may right itself over time. The younger the patient, the greater the capacity for remodeling. Angular deformities may correct, especially when in the plane of motion of a nearby hinge joint. Rotational deformities will not correct. 7. Growth aberration is possible - Injury at or about the physis can lead to areas of growth arrest. Overgrowth due to a reactive increase in blood supply, or tethering across the physis due to bony bridging, can also lead to growth deformity. 8. Comminuted fractures are rare - Due to the resilient, plastic nature of immature bone, shattering" of bone and multiple Pediatric Orthopedics Page 1

4 fragments is uncommon. 9. Open reduction and internal fixation - Is less frequently performed, except in cases of Salter 3 or Salter 4 injuries. 10. Some complications are more common - (refracture, Volkmann s ischemia, post-traumatic myositis ossificans). 11. Some complications are less common - (delayed union, nonunion, post-traumatic joint stiffness, fat embolus) 12. Bone healing is more rapid - The younger the patient, the more osteogenic the periosteum, the faster the healing. This reduces immobilization times but dictates prompt orthopedic referrals before bone formation can hinder reductions. Notes II. PHYSEAL INJURIES The presence of a relatively vulnerable physis is a major determinant in the patterns of orthopedic injury encountered in the pediatric population. A. Anatomy 1. The physis occurs at the junction of the epiphysis and the metaphysis. 2. This growing area of calcifying new cartilage is the most vulnerable area to stress and a frequent site of fracture in the immature skeleton. Unfortunately, this cartilaginous area is radiolucent on radiographic exam. B. Classification 1. The Salter-Harris classification serves as the means of communication for describing physeal injuries in North America. 2. It is based on the radiological appearance of the adjoining epiphysis and metaphysis. (Figure 1) Pediatric Orthopedics Page 2

5 FIGURE 1. Salter-Harris Classification. Percentages indicate relative incidence. Dotted lines indicate fracture path. Notes a. Salter 1 - The fracture line extends through the physis only. Radiographically, the diagnosis is simple if the epiphysis is obviously displaced. If it is not displaced, the radiograph will appear normal. When this is the case, yet there is an appropriate mechanism of injury with tenderness about the epiphyseal plate, the diagnosis of an undisplaced Salter 1 fracture is made. This is a clinical diagnosis. Salter 1 injuries are most common in the very young. Since the physis is not disrupted, healing is typically uncomplicated, and growth complications rare. b. Salter 2 - The fracture line enters along the physis and exits the metaphysis. The metaphyseal fragment is often subtle radiographically. This is the most frequently encountered Salter injury and is most often found after the age of 10. As with Salter 1 fractures, the physis remains intact and growth aberration is not common. Pediatric Orthopedics Page 3

6 c. Salter 3 - The fracture line propagates through the physis and exits the epiphysis. This is a more severe type of injury because it disrupts the continuity of the physis, greatly increasing the risk of growth aberrancy, and because it is intra-articular. Some orthopedists consider this an absolute indication for ORIF since an anatomic reduction is necessary. Growth deformity may occur. d. Salter 4 - The fracture line involves the metaphysis and the epiphysis, crossing the physis. As in Salter 3 fractures, the physis is injured and the fracture is intra-articular. ORIF is likely, and the incidence of growth aberration is significant. e. Salter 5 - The physis is crushed due to a compressing axial load. This is a rare injury and is virtually impossible to diagnose acutely. It is more likely that the initial diagnosis of a nondisplaced Salter 1 fracture will be made, and only with growth complication will the true nature of the injury reveal itself. f. Salter 6 - This classification was coined by Rang and describes an injury to the perichondral ring surrounding the physis (direct blow, burn, local infection). Although the physis is uninjured, the inflammatory process may lead to bone formation, bridging the epiphyseal-metaphyseal junction, effectively tethering growth at the physis and resulting in a progressive growth deformity % of physeal injuries result in growth aberrations. Parents should always be educated and informed from the onset that a physeal injury may lead to a growth aberration later. Notes III. GREENSTICK AND TORUS FRACTURE These are confined to the pediatric group, and are a result of the extreme plasticity and porosity of immature bone. A. Greenstick fractures - occur when stress is applied to a long bone such that the cortical bone fails in tension but not in compression. Only part of the cortex appears fractured on X-ray. The intact cortex typically undergoes compression and plastic deformity due to radiographically invisible microfracture. Plastic deformity may hinder the ability to adequately correct angulation and hold the reduction at the fracture site (hence, the practice of completing the fracture prior to reduction and immobilization). B. Torus fractures - are seen as bumps, most typically in the metaphysis. These bumps result when an axial compressive load causes microfracture and localized plastic deformity rather than a radiographically apparent cortical break. These are stable impaction fractures which are splinted largely for comfort. Pediatric Orthopedics Page 4

7 Notes IV. SPECIFIC ORTHOPEDIC INJURIES AND LESIONS: UPPER EXTREMITY Upper extremity injuries account for about 70% of children s fractures, as arms are extended protectively in falls and other forms of trauma. The distal forearm leads the elbow in the overall incidence of injury. A. Fractures of the hand are relatively uncommon (5-7% of fractures) and only 1/3 involves a physeal injury. Rapid healing is the rule, so prompt orthopedic referral is necessary (healing in malposition may make a minor injury more problematic). General principles of adult orthopedic care tend to apply. 1. Mallet injury equivalents (Figure 2) FIGURE 2. Pediatric Mallet Equivalent above is a displaced Salter I injury of the distal phalanx, typical of the preadolescent. Below is the Salter 3 injury of the adolescent. a. In the preadolescent, forced hyperflexion at the DIP causes a Salter 1 or Salter 2 fracture of the distal phalanx. b. In the adolescent (with partial fusing of the epiphysis), a Salter 3 injury of the distal phalanx may occur with the same mechanism. c. In open injuries, gently hyperflexing the DIP will lift the base of the nail from the nail fold to allow adequate irrigation. The nail is preserved. Splinting, prompt orthopedic follow-up and oral antibiotics are indicated. d. As in adults, the DIP is splinted in full extension. 2. Crush injuries of the distal phalanx Pediatric Orthopedics Page 5

8 a. Typically the soft tissue injury predominates over the fracture itself. b. Open fractures are cleaned and irrigated with minimal debridement. Nail beds are repaired with absorbable sutures. The eponychial fold is stinted with the cleaned nail or Vaseline gauze. c. Partial tip amputations are reapproximated and do remarkably well with even minimal remaining pedicle. 3. Middle and proximal phalangeal fractures are most commonly Salter 1 or Salter 2 injuries of the proximal phalanx with the ring and small digit most commonly involved. Ulnar deviation in a proximal phalangeal fracture of the ring or small finger is referred to as an extra octave finger. Placing the MCP in flexion provides the stability necessary for reduction. a. Rotational deformities are best appreciated by examining the attitude of the nail beds with the phalangeal joints in flexion. b. These are best immobilized in gutter splints, paired with the uninjured digit. As with adults, the MCPs are immobilized in 70 O to 90 O of flexion, to prevent shortening of the collateral ligaments. 4. The carpals are cartilaginous and resilient. Fracture is uncommon. Scaphoid fractures are not seen until 10 to 12 years of age, and as with adults, a high level of suspicion is required. Emergency management includes immobilization in a thumb spica splint with prompt follow-up. 5. The metacarpals are infrequently fractured. The most common injury is the boxer s fracture through the distal neck of the 4th or 5th metacarpal. For all intents and purposes, it is handled as adult boxer s fracture with a gutter splint. Notes B. Wrist and forearm 45% of pediatric fractures occur in the radius. 80% of these are in the distal third. The mechanism is typically a fall on an outstretched hand with a hyperextended wrist. The most common pediatric orthopedic injury is the Salter 2 fracture of the distal radius. 1. Distal radius fractures are typically Salter 1 or 2 physeal injuries, torus or Greenstick fractures of the distal metaphysis, or complete fracture (both radius and ulna). a. Complete fractures typically have the silver fork deformity similar to adult Colles fractures. b. These are usually radiographically obvious. Occult wrist fractures may cause anterior displacement of the normal pronator quadratus fat pad seen on the lateral view along the volar aspect of the radial metaphysis). Always X-ray the entire forearm when a distal fracture is found, to rule out proximal injury. Pediatric Orthopedics Page 6

9 c. Neurovascular complications and intra-articular injury are rare. d. Emergency department reduction is indicated for severe deformity with tenting or compromise of overlying skin, or neurovascular compromise. Lesser degrees of deformity can be treated with immobilization and prompt referral. Remember in any physeal injury, multiple reduction attempts are not advised - each manipulation can further injure the physis. 2. Middle and proximal forearm fractures a. As in distal fractures, they are described as Greenstick, torus, or complete fractures, and further defined by the level (proximal third or middle third). As in adults, an obvious fracture of the ulna should prompt evaluation for radial head displacement (Monteggia fracture). Complete fracture in this area is particularly prone to refracture in the first six months. b. Fractures of the forearm may rarely lead to forearm compartment syndrome (Volkmann s ischemia). c. Immobilization with a long arm posterior mold is indicated. Notes C. The elbow The child with a swollen and/or painful elbow provides quite a diagnostic challenge. The possible injuries range from the innocuous nursemaid s elbow to the potentially disastrous supracondylar fracture. Of upper extremity fractures, those about the elbow constitute about 10%. While the peak incidence for physeal injuries in general is between 10 and 13 years of age, most physeal fractures about the elbow occur in the more immature skeleton of the 5- to 8- year-old. The mechanism is again a fall on the outstretched arm. Radiographic interpretation in this area is difficult due to the chronobiologic variation of secondary and epiphyseal ossification centers. The mnemonic, CRITOE, assists in confirming what one expects to see on X-ray (Table 1). However, the liberal use of comparison films is of great help in assessing these injuries. Table 1. Chronological appearances of the ossification centers of the pediatric elbow. Capitellum Radial Head Internal (Medial) Epicondyle Trochlea Olecranon External (Lateral) Epicondyle 2 yr 4 yr 6 yr 8 yr 10 yr 12 yr Pediatric Orthopedics Page 7

10 Notes 1. Nursemaid s elbow (subluxation of the radial head or acute annular ligament interposition) a. A distraction force pulls the radial head from the annular ligament when the arm is pulled. b. The child refuses to use the affected extremity (most commonly the left), and often guards it from any motion. The elbow is held in slight flexion and the forearm in pronation. c. A strong history and otherwise unremarkable exam preclude the need for X-ray evaluation (which will appear normal). When history is lacking, X-rays are obtained to rule out a supracondylar fracture prior to manipulation. d. Reduction is accomplished by flexing the elbow while supinating the forearm. A click is felt over the radial head. e. Hyperpronation is also effective. f. The child quickly resumes normal use of the extremity and no immobilization is necessary. g. It is most common in the 2 to 3 year age group and rare after age 7. h. 25% recur. Parental education regarding the typical mechanism can help reduce recurrence. FIGURE 3. Pediatric Elbow Fractures. A. Supracondylar; B. Lateral Condylar; C. Medial Epicondylar. 2. Supracondylar fractures a. Age assists diagnosis - it is almost exclusive to those less than 10 years, peaking at 5 to 8 years, with males predominating over females 2 to 1. Pediatric Orthopedics Page 8

11 b. Extension-type supracondylar fractures make up 98% of these injuries, and occur with the elbow hyperextended. The distal fragment lies posterior. c. The child presents with a painful elbow and local swelling. A severely displaced fracture may give an overt dinner fork appearance. d. Radiographic appearance may range from an obvious transverse fracture to only the presence of an exaggerated anterior fat pad, a posterior fat pad, or subtle posterior displacement of the distal humerus. To assess posterior displacement the anterior humeral line is evaluated on the lateral elbow X-ray. It should intersect the ossification center of the capitellum in its middle third. (Figure 3) Notes FIGURE 4 The Anterior Humeral Line should intersect the ossification center of the capitellum in its middle third. e. The incidence of associated soft tissue injury is high. 7% have associated nerve injuries, most frequently radial and seldom ulnar. Vascular compromise of the brachial artery from direct injury, spasm, intimal tear, or external compression from soft tissue swelling leads to Volkmann s ischemic contracture in up to 1%. Thorough, ongoing distal neurovascular exams are paramount with these injuries. Compartment syndromes and varus deformity have decreased dramatically in recent years, with percutaneous pinning overtaking hyperflexion to maintain reduction. Any forearm pain with passive movement of the wrist and fingers is indicative of compartment syndrome. f. Fractures with obvious neurovascular compromise require immediate reduction by applying forearm traction with the elbow in slight flexion. Pediatric Orthopedics Page 9

12 g. All but minimally displaced supracondylar fractures without significant soft tissue swelling require hospitalization for neurovascular checks. The vast majority will be admitted. h. The injury is immobilized with a long arm posterior mold, the elbow as close than 90 O of flexion to allow for swelling without compromising arterial or venous flow. Care must be taken to allow for swelling in the forearm and antecubital fossa when the splint is applied. 3. Lateral condyle fractures a. They make up 15% of pediatric elbow fractures. (Fractures of the medial condyle are rare in children). b. Peak incidence is 5-6 years of age. c. These are Salter 4 injuries and typically require ORIF to reduce complications (nonunion, malunion, or progressive valgus deformity with tardy ulnar palsy). Closed reduction with percutaneous pinning is being tried with success when the articular surface is not involved and displacement is <2 mm. d. The mechanism of injury is a varus stress to the elbow with traction on the lateral condyle by the extensors of the forearm. e. Acute neurovascular injuries are rare. f. Immobilize with a long arm posterior mold with prompt orthopedic follow-up. g. These can be nondisplaced, and present only with mild swelling and/or point tenderness. 4. Medial epicondylar fractures a. These account for 15% of distal humerus fractures. (Fractures of the medial condyle, however, are rare in children). b. The medial epicondyle is a traction apophysis to which the flexors of the forearm are attached. c. These may occur as a pure avulsion injury when falling on the arm with hyperextended wrist and fingers, in association with posterior elbow dislocation (about 50% of the time), and, rarely, from a direct blow. Peak incidence is 9-12 years and males lead females by 4 to 1. d. Radiographically these may be extremely subtle due to the normal appearance of the epicondyles ossification center, necessitating comparison views for confirmation. e. The epicondyle becomes entrapped in the joint after reduction of a posterior elbow dislocation 15 to 20% of the time. The medial epicondyle must always be identified when a spontaneously reduced elbow dislocation is suspected, or in post-reduction views to prevent this entrapment from going unnoticed. Inability to reduce an elbow dislocation may be due to an entrapped medial epicondyle, mandating open reduction. Notes Pediatric Orthopedics Page 10

13 f. Acute and delayed ulnar nerve dysfunction may occur, especially in cases of entrapment. (50%) g. No growth aberrancies are associated with injuries to this (or any other) traction apophysis. h. Immobilization in a posterior long arm mold and prompt orthopedic referral is indicated. i. Little League Elbow is a closely related chronic, stressinduced injury of the medial epicondyle. Young pitchers present with tenderness and swelling at the medial epicondyle with a mild loss of elbow extension. This is a so-called traction apophysitis. Inciting activities should be reduced. 5. Fractures of the mid and proximal humerus are uncommon in children. Notes V. SPECIFIC ORTHOPEDIC INJURIES AND LESIONS: LOWER EXTREMITY Lower extremity injuries are much less common than those of the upper extremity. A. The Pelvis, hip, and thigh 1. Fractures of the proximal femur and pelvis are rare. Their presence should suggest high velocity trauma. Look aggressively for associated injuries and life threats. 2. Slipped Capital Femoral Epiphysis (SCFE) is a transepiphyseal separation of the proximal femoral epiphysis. a. This is usually a chronic progressive injury, but an acute separation can occur. b. It may present with limp, hip pain, anterior thigh pain, or knee pain. Remember that any complaint of knee pain mandates a hip examination. c. More commonly this occurs in obese boys ages 10 to 16. (Peak age is 13 years for males and 11 years for females, and males exceed females, 2 to 1. 25% of these involve both hips.) d. The femur is held in slight flexion and external rotation. Radiographically, the displacement of the femoral epiphysis may be subtle; evaluation of Shenton s line on the AP pelvis view and the appearance on the frog leg (external rotation and abduction) view of the hip help identify the injury. The examination of Kline s line will further improve diagnostic accuracy. (Figure 5) e. Severe separations with displacement require closed reduction prior to pinning. f. Patients are hospitalized and kept non-weight bearing until operative intervention occurs. g. Avascular necrosis is a dreaded complication. Pediatric Orthopedics Page 11

14 h. There is an association with endocrine disturbances (hypothyroidism) but the vast majority occurs in the absence of such. Notes FIGURE 5. A. Kline s Line; B. Shenton s Line 3. Congenital hip dislocation a. At birth, the superior acetabulum is poorly developed, and dislocation of the femoral head can occur. b. Females are affected 6 to 8 times more than males. c. These do not typically present ; they are found on neonatal and well baby exams, most commonly via the Ortolani maneuver (abduction of the flexed hip). A click is discernible with reduction. d. Early diagnosis is important - after 3 months, they may be difficult to reduce. After 18 months, open reduction may be necessary. 4. Transient synovitis of the hip a. Joint inflammation may be due to an allergy or viral infections. The role of trauma is controversial. b. Boys are affected more than girls with peak incidence at 3 to 6 years. c. Presentation varies from pain to frank limp, usually of less than 2 weeks duration. d. The child appears well and allows passive range of motion of Pediatric Orthopedics Page 12

15 the hip, with pain only at end range. e. X-rays are normal, and CBC and sedimentation rate are unremarkable. f. Only arthrocentesis will rule out a septic joint (in severe cases). g. Treatment is rest. 5. Septic hip a. The hip is the most commonly infected joint in childhood. b. Many agents cause septic arthritis but the vast majority are due to various strains of Staphylococcus and Streptococcus c. These children appear ill, although infants may not mount a fever. They do not tolerate PROM of the hip. The hip is held in flexion, abduction, and slight external rotation. d. X-rays may demonstrate joint space widening or effusion. e. WBC and sedimentation rate are elevated, and arthrocentesis gives findings typical of septic joint. f. Arthrotomy and antibiotics are indicated. 6. Legg-Calve-Perthes Disease a. Avascular necrosis of the femoral head occurs due to transient ischemia (of unknown etiology). b. Peak incidence is 6 years of age (3 to 10 years) with boys affected 4 times more than girls. c. Other contributing factors: trauma, alteration in coagulabilty of blood, endocrine and metabolic disorders. d. Patients present with hip pain or antalgic gait of insidious progression over weeks to months. e. Stages: Synovitis, necrosis or collapse, fragmentation, reconstitution. f. X-ray may show flattening of the femoral head, subchondral lucency at the proximal epiphysis, and irregular calcification and fragmentation of the epiphysis. Bone scans may aid diagnosis. g. Multiple treatment approaches exist, all of which incorporate bracing to maintain abduction and flexion of the hip to contain the femoral head within the acetabulum. Notes B. The knee and leg 1. Fractures of the distal femoral epiphysis a. These are more common than other physeal injuries of the hip or about the knee, but less common than fractures of the ankles or upper extremities. They account for about 5% of physeal injuries b. Most commonly, these are Salter II injuries occurring in vigorous adolescent. These do well. c. Popliteal artery and peroneal nerve injury may occur with severe displacement. 2. Fracture of the proximal tibial epiphysis Pediatric Orthopedics Page 13

16 a. These are uncommon. When severely displaced, popliteal artery injuries can occur. 3. Osgood-Schlatter Disease a. Seen in as many as 10% of active adolescents b. A so-called traction apophysitis of the tibial tubercle. Repetitive microavulsion injuries occur with repeated traction of the patellar ligament during ossification of the tubercle. c. Acute tibial tubercle avulsion is rare. d. 25% have bilateral injury involvement (as in SCFE). e. Most frequently affects males 11 to 15, who present with a history of intermittent pain and swelling at the tubercle, aggravated by running, jumping, etc. f. X-rays are necessary only in unilateral disease to rule out tumor or infection. The lateral knee view shows enlargement of the tibial tubercle with small fragments seen anterior and superior in the patellar ligament. Using soft tissue technique will enhance these findings in early cases. g. Treatment is symptomatic with cessation of the aggravating activity until bone maturity occurs. 4. Patellar fractures a. These are infrequent. When present, a small radiographically innocuous appearing avulsion of the calcified distal pole may be associated with a large portion of the radiolucent articular cartilage (the sleeve fracture ). 5. Patellar dislocations a. These are relatively common in children (unlike all other dislocations). b. Slightly aberrant biomechanics at the knee allow the patella to sublux laterally with tension of the quadriceps mechanism. (Patella alta, genu valgum, and flattening of the lateral femoral condyle are contribution factors). c. Most frequent in obese, adolescent females 16 to 20 years of age. d. These often spontaneously reduce before presentation. Patients will guard the patella, however ( patellar apprehension ). e. The dislocated patella is obvious clinically and easily confirmed on X-ray. f. Placing the hip in full flexion and the knee in full extension, the patella is pushed easily into normal position. A knee immobilizer is then applied to the extended knee. g. X-rays after reduction is indicted to evaluate for an osschondral fracture (5% incidence) especially from the medial margin of the patella. 6. Fracture of the fibular and tibial shafts a. These are the most common lower extremity fractures in children. b. Most involve only the tibia. Isolated fibular fractures are rare. Notes Pediatric Orthopedics Page 14

17 c. The mechanism of injury is usually torsional stress. d. Fractures here are often undisplaced. e. Vascular involvement is rare, but proximal metaphyseal fractures are at greater risk. f. Patients are immobilized in a long leg posterior splint and monitored for signs of compartment syndrome. 7. The ankle and the foot a. Most are due to rotational stresses coupled with eversion or inversion. b. In the skeletally immature, sprains are less common. There is more likely a physeal injury. The common lateral sprain of the adult manifests itself as a Salter 1 injury of the distal fibula. The presence of tenderness over an open distal fibular physis gives a clinical diagnosis of a Salter I injury. c. Fracture of the distal tibial physis occurs most frequently in boys age 11 to 15 and is typically Salter II. d. The Tillaux fracture can occur in the presence of a partially fused distal tibial epiphysis. (Figure 6) As skeletal maturity is approached, the central and medial portions of the distal tibial epiphysis fuse first. During this dynamic period of evolving bony architecture, a rotational stress can lead to avulsion of the lateral portion of the tibial epiphysis due to traction by the anterior tibiofibular ligament (a Salter 3 injury). The diagnosis is apparent on X-ray but the lateral ankle view must be closely inspected to rule out a triplane fracture, with its posterolateral tibial metaphyseal spike. Tillaux fractures are usually minimally displaced and treated with closed reduction. Notes FIGURE 6. (above) Tillaux Fracture. The anterior tibiofibular ligament pulls the unused lateral epiphysis, resulting in a Salter 3 injury. Pediatric Orthopedics Page 15

18 Notes 8. Triplane fractures also occur in the distal tibial epiphysis undergoing fusion. These are more complex (and severe) than the Tillaux fracture, occurring in the sagittal, coronal, and transverse planes (hence, triplane). There are 2 to 4 resulting fragments. Plain films are often difficult to interpret, but the posterolateral spike of the distal tibial epiphysis is seen. CT or MRI imaging is sometimes necessary to fully define these injuries and plan appropriately for ORIF. 9. In general, most Salter I and II injuries of the distal tibia and fibula are treated with closed reduction. More severe Salter injuries require ORIF. 10. Talar fractures are uncommon. 11. Calcaneus fractures a. Due to better imaging techniques, these are found more frequently than in the past, but overall are uncommon. Closed injuries without marked displacement are the rule and they do very well with no significant complications. Immobilization in a short leg posterior mold and RICE therapy are appropriate in the acute setting. Evaluation for an associated lumbar spine injury should be considered when the mechanism involves a jump or fall. 12. Metatarsal fractures a. Metatarsal neck fractures are most common here due to their relatively small diameter. The mechanism of injury is a torquing stress to the forefoot. b. Extensive soft tissue injury and swelling may mandate admission for RICE as foot compartment syndrome can occur. Typically, outpatient management in a posterior short leg mold will suffice until a walking cast is applied. c. Fractures of the base of the fifth metatarsal are also common in children. They are avulsion injuries due to traction by the peroneus brevis at its insertion. This traction apophysis is not radiographically apparent until age 8, and is fused by age 12 in females, and by age 15 in males. True Jones fractures are typically seen in the over 15 year age group. d. Stress fractures of the foot do occur, although in a lesser frequency than in adults. 13. Toddler s fracture a. A variety of subtle fractures in infants and young children b. May involve the calcaneus, tibia, fibula, cuboid, or metatarsals. c. Diagnosis is suspected with and limp and localized tenderness d. X-ray may be normal; MRI may be needed. Pediatric Orthopedics Page 16

19 Notes VI. CHILD ABUSE A. Estimates as high as 30% of all musculoskeletal injuries in children less than 3 years old presenting to an orthopedist are associated with child abuse. Up to 55% of abuse cases involve fractures. Highly specific lesions which are seen in the abused child include metaphyseal lesions, posterior rib fractures, scapular fractures, spinal process fractures and sternal fractures. Moderately specific lesions include the presence of multiple fractures of similar or different ages, vertebral fractures, and digital fractures. Commonly encountered clavicle, long bone, and skull fractures are unfortunately nonspecific for abuse. The metaphyseal lesion ( corner fractures or bucket handle lesions) is virtually pathognomonic for infant abuse. The fundamental anatomic alterations are similar in these metaphyseal lesions. Stresses applied to the long bones are transmitted to the periosteal attachments at the metaphysis/epiphysis boundary. Avulsion of bone here appears as a corner fracture at the metaphyseal margin. If a more crescentic fragment is avulsed, the bucket-handle lesion can be seen. Periosteal new bone formation or periosteal elevation (seen over a subperiosteal hematoma) can be seen along the diaphyseal bone. These findings should alert a physician that severe stress has been applied to these bones, and that child abuse is potentially present. Pediatric Orthopedics Page 17

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21 Notes PEDIATRIC ORTHOPEDICS PEARLS 1. The weakest part of a child s bone is the physis (epiphyseal plate). Epiphyseal injuries are categorized by the Salter-Harris classification (Types I-V). Type I - separation of epiphyseal plate Type II - above plus metaphysis Type III - fracture through epiphyseal plate and epiphysis Type IV - fracture through epiphysis and metaphysis, across the Epiphyseal plate Type V - crush to epiphyseal plate 2. Nursemaid s elbow is a common injury seen in children between 1 and 5 years of age, caused by stretching of the annular ligament and subluxation of the radial head. Reduction can be accomplished by supinating and flexing the elbow. 3. Supracondylar fractures are seen primarily in children less than 15 years. They have a high incidence of complications, including vascular compromise and forearm compartment syndrome, leading to Volkmann s ischemic contracture. They require hospitalization for neurovascular checks. 4. Gradual onset of knee or hip pain in children between years should cause one to suspect a slipped capital femoral epiphysis. Diagnosis can be confirmed by AP views of both hips and a frog-leg view of the involved side. There may be a loss of Shenton s or Kline s line. 5. Most cases of septic arthritis of the hip involve the very young (under 4 years), are usually hematogenous, and are most commonly caused by Staph (although Strep pyogenes and H. flu also occur). It should be distinguished from transient synovitis of the hip which is very common, tends to occur in well appearing older children with at most a low-grade fever, and tends to follow a viral illness. Definitive diagnosis can be made by aspirating the joint. 6. Pain and swelling over the tibial tuberosity in adolescents may be a manifestation of Osgood-Schlatter Disease. X-rays may initially be normal. Treatment is rest with avoidance of forced knee extension such as running and jumping. Pediatric Orthopedics Page 19

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23 Notes REFERENCES AND SUGGESTED READINGS 1. Rockwood CA, Wilkens KE, King RE: Fractures in Children, 6th Edition. JP Lippincott, Philadelphia, Rosen s Emergency Medicine, Concepts and Clinical Practice, 7 th Edition, Simon R., Sherman S., Emergency Orthopedics, The Extremities, 5 th Edition, Staheli, L, Practice of Pediatric Orthopedics, Causey AL: Missed Slipped Capital Femoral Epiphysis: Illustrative Cases and a Review. JEMS, Vol. 13, No. 2, p , Gillingham BL: Editorial, Advances in Children s Elbow Fractures. J PED ORTHO, 15: , Gregg JR, Naranja J: Description and Significance of the Pediatric Fracture Without Radiographic Abnormality (FWORA). Pediatric Emerg & Crit Care, Vol. 9, No. 3, March Blakemore LC et al: The Role of Intentional Abuse in Children 1 to 5 years of Age With Isolated Femoral Shaft Fractures. PED EMERG CRIT CARE, Vol 9, No. 3, March Rittenberry TJ, Piotrowski J: General Pediatric Orthopedics in Handbook of Orthopedic Emergencies, Lippencott-Raven Publishers, Philadelphia, October Rittenberry TJ, Towns D: The Pediatric Upper Extremity, in Handbook of Orthopedic Emergencies, Lippencott-Raven Publishers, October Rittenberry TJ, Oyasu K: The Pediatric Lower Extremity, in Handbook of Orthopedic Emergencies, Lippencott-Raven Publishers, October Tintinalli, JE: Emergency Medicine. A Comprehensive Study Guide, McGraw-Hill, /10 Pediatric Orthopedics Page 21

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