Lower Extremity Pediatric Trauma

Transcription

1 Lower Extremity Pediatric Trauma Shelby S. Edwards PA-C The Pediatric Skeleton The Skeleton as Dynamic Physes Injuries specific to skeletally immature Physeal effects on metaphysis = usual failure spot for fractures California Academy of Physician Assistants October 10, 2014 The Pediatric Skeleton Salter-Harris Fracture Classification System what it means and why it s used 10% to 100% risk for growth arrest Physes and adjacent bone can be many times weaker than ligaments until age 8 Kids break, they don t sprain The Pediatric Skeleton Incidence increases with age, physeal (Salter-Harris) fxs more common in older kids Boys 50% Girls 30% Pediatric Fractures Pediatric Orthopedic Physiology Epiphysis Physis Metaphysis Ossific nucleus Anatomy = elbow epicondyles Pediatric Fractures Bones have more collagen, less bone matrix More elastic More cancellous (spongy) bone Reduces tensile strength Reduces tendency of fracture to propagate Fractures unlikely to be comminuted Reduced compressive strength (from cortex) results in the common buckle (torus) fracture Periosteum is thick and strong 1

2 Pediatric Fractures Age Related Fracture Patterns: Points of strength and weakness change with age, typical sites of fracture change with them Good news on Healing: Periosteum very metabolically active Healing much more reliable Reduced risk of nonunions, delayed union in children Now for Some Fractures Recognition, Initial Management 11yof with 3 days of right hip pain. Atraumatic, not an athlete. Grandma thinks she may be limping as well. Slipped Capital Femoral Epiphysis SCFE: Think of as emergency We admit and fix promptly NONWEIGHTBEARING A: perthes disease C: SCFE B: trochanteric avulsion D: A heart in the pelvis 12yof soccer player with sudden Lt knee pain. Nothing traumatic during game, but occasional pain and limping after. Swelled up the next morning, continued pain x past few days. a. Tibia fracture b. Femur fracture c. Not entirely but sort of d. B and C are correct Answer: D Osteochondritis Dessicans OCD can be acute injury, or insidious Also talus, capitellum in kids WBAT, but no sports! Follow up with ortho in couple weeks Bonus (Blue Arrow): fibrous cortical defect (an incidentalloma) 2

3 14yom caught spray painting Oakland Tech. Jumped over the janitor and torqued lt knee. A. Tib ia fracture b. Fe m ur fracture c. Pate llarfracture d. No ob vious fracture B: Fe m urfracture Segond Fracture - avulsion p ie ce of LCL Fracture isn t significant b ut wh at it h e raldsisa b it of doom >97% ACL te ar >95% m e niscalte ar Ge t it to se e orth o with in a we e k, W BAT, ROM, NO SPORTS. 14yof played soccer and went for the ball, slipped and hurt her knee yesterday. Tibial spine fracture. ACL inserts here and there is a physis there. Kids can get intrsubstance tears also, but this is also not uncommon. Many will need surgery, some don t. Refer to ortho, WBAT, immobilize, f/u in a few days to a week. 1yo was on mom s lap going down the slide at the park. Right foot got caught between mom and the slide, toddler didn t want to walk afterwards. A: tibial fracture B: lateral malleolus fx C: Cuboid fracture D: talus fracture 3

4 B: Toddle r sfracture te e ny, sub tle tib ialsh aft fracture in toddle rs Can b e e x tre m e ly sub tle to not visib le on x -rays Splint, follow up, W BAT Most are unicorticalfracture s and ve ry stab le, we cast th e m for4 we e ksforsufficie nt h e aling th e m turn th e m loose Mom m ay b e traum atize d 16yo next Tony Hawk was making a skateboarding demo video for You Tube and his last trick was a fall off the railing and onto the right ankle. Yes, we watched it in the office. Triplane Fracture : (disp lace d, visib le on x -ray, ne e dsorif High inde x of suspicion. Olde rkids, ge t th e se, th e ph ysisclose to closing. May b e sub tle! Ge t 3 vie ws! Mortise m ay b e wide Tillaux: just eiphysis. Caution: it can be hiding! Triplane: has metaphyseal component 10yom was playing soccer and slipped. Lt ankle pain Most of these with so much slippage of the metaphysis on the physis will need to be reduced. Triplane fx. 4

5 7yom was skateboardingand fell off, inversion injury to ankle. Points to lateral ankle when asked to localize. A word about accessoryossicles: they re everywhere. Combine with mechanism of injury, point tenderness on exam. Can be distal tips of tibia (here), fibula, numerous in the foot. Of course splint if hurting, it doesn t do any harm in kids. Sometimes hard to tell from acute fractures. Salter 1 of the lateral malleolus: normal x-rays Radiographically negative, with STS and pain, injury. Splint, WBAT, crutches if needed Follow up with ortho or in primary care (PCP can manage these as well) 10yo with inversion injury to right foot. Painful over base of 5 th metatarsal. Which one is the fracture? A. Yellow arrow B. Blue arrow A is the fracture: Jones nomenclature is not used in kids. The growth plate runs parallel to the metatarsal shaft, fractures are perpendicular. Peroneus brevis attachment site Ossification begins age 7ish Iselin disease is traction apophysitis on area more insidious usually Splint, WBAT is ok. 5yom with left foot pain for several weeks, occasional limping, not impressive on exam, but child does limp. No history of injury that parents can define specifically. Active kid, otherwise healthy. B: AVN of the navicular called Kohler s Disease in children Etiology unknown Kids age 5-10 History variable from very little pain to limping, lots of pain (and those are just the ones we know about) Immobilize, WBAT a. Fracture b. Avscaular necrosis c. Osteomyelitis Follow up with ortho Refrain from prognosticating or discussing likely management 5

6 9 yobm mom noticed painless limping for at least a month. Brought to PCP, not sure what was wrong. Sent to us. Limping: examine hips, back, knees, ankles. Watch walk. Prone hip measurements bestfor kids Remember it s counter-intuitive: B is internal rotation (25 left, 45 right), C is external (25); D is 0 Perthe s Disease AVN of the femoral head in kids WBAT, send to ortho for consult What we do is widely variable This kid got a spica cast for 4 months, but still went on to develop this x-ray 14yo soccer player went to kick ball, another player opposed him and he felt a pop in the hip. Pain in the right hip, in front with ecchymosis and edema. Limited ROM rt hip. ASIS avulsion fracture: WBAT, follow up with ortho and no, no sports. Sartorius attachment. Rectus = AIIS also happens. 12yom slipped on stairs in house, fell on knee 6

7 15yom fell dancing. Huge left foot. 15yom fell bowling 17yof fell off a wall of some sort? Thank you! 7