Pediatric Orthopedics

Transcription

1 Pediatric Orthopedics Alexander Rogers, MD Associate Professor Emergency Medicine and Pediatrics Michigan Medicine/University of Michigan Disclosures I have no conflicts of interest to disclose I will not be talking about off label use of medications 1

2 Scope of the problem In 2010, analysis of National data showed more than 7.5 million pediatric ED visits for injuries and poisoning the top visit category (Wier LM, Yu H, Owens PL, Washington R. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); Jun) Immaturity of pediatric skeletal structures leads to different fracture patterns than adults, with different short and long term risks Learning goals Review common pediatric specific injuries Recognize when we need to intervene Cover some non-traumatic presentations 2

3 Pediatric Musculoskeletal System Pediatric skeleton less densely calcified than adult Bones are lighter and more porous More porous= more pliable less strength increase fractures Actively growing structure: long bones contain growth plates/physes end of bones contain epiphysis Pediatric Musculoskeletal System Bones of child surrounded by thick and active periosteum Ligaments and periosteum stronger than bone itself physis is weak link fractures more common than sprains in younger children Response to trauma age dependent 3

4 Salter-Harris Classification SH I fracture through physis may be displaced SH II- through physis and metaphysis SH III through physis and epiphysis SH IV through metaphysis, physis and epiphysis SH V crush to physis In general higher grade Associated with higher risk of growth abnormality 5 yo upper extremity injury (or why I work in Pediatrics ) Doctor: What brings you in today? Patient: I jumped off a chair and hurt my arm Doctor: oh, why did you jump off the chair? Patient: I was trying to fly Doctor: Did you? Patient: A little bit! 4

5 Distal Forearm fractures Common fracture type 2 view radiographs key Acute reduction can avoid the OR Reduce if > degrees angulated If not reduced acutely end up needing OR for pinning Distal Radius and Forearm fractures Orthop Rev (Pavia) Apr 22; 6(2): Multiple recommendations regarding acceptable alignment parameters Younger age have more remodeling potential Age > 9 higher risk after skeletal maturity tx as adult Distal fractures remodel better If initial reduction is not adequate these are difficult to manage in the office* *A friendly plug from my orthopedic colleagues 5

6 Forearm fracture variants 6 yo with fall from the monkey bars Pain in mid-forearm Subtle swelling/deformity Bowing fracture Plastic deformity of long bone (in this case the ulna) If > 20 degrees of deformity can prevent remodeling of the other bone Increased need to reduce if > 10 yo Reduce with either weights or slow, constant traction 6

7 Forearm fracture variants 5 yo FOOSH Still using affected arm, but decreased Pain with supination No swelling or deformity Buckle/Taurus fracture Distal Radius most common but can be any bone Can usually treat with prefabricated splints and your patients will thank you for it!* *Williams KG et al. A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference. Pediatr Emerg Care May;29(5):

8 Forearm Fracture variants 9 yo fall from a giant yoga ball that was next to a tree at family camp Monteggia Fracture Monteggia fracturedislocations consist of a fracture of the ulnar shaft with associated dislocation of the radial head. The ulnar fracture is usually obvious, whereas the radial head dislocation can be overlooked 8

9 Monteggia Fracture Monteggia Fracture Ulnar fracture + radial head dislocation Uncommon (2% all elbow fx s) but peak age 4-10 Can be easily missedmust have films of both elbow and forearm Isolated ulna fractures rare If unrecognized and not reduced, can lead to permanent disability Closed reduction possible in children, less likely with increased age Galleazzi Fracture Classic: - Fx distal 1/3 radius - dislocation of distal ulna Disruption of radioulnar joint Peak age 9-12 years Suspect in angulated distal radius fractures Difficult to recognize Requires ortho consult in ED and reduction MUGR fractures Monteggia has fractured Ulna Galeazzi has fractured Radius 9

10 Pediatric Elbow 6 ossification centers around the elbow joint C= Capitellum ( 1 yr) R = Radial head ( 3-5 yrs) I = Internal/ medial epicondyle- (4-6 yrs) on ulnar side of elbow T = Trochlea (6-8 yrs) O = Olecranon (8-10 yrs) E= External/ lateral epicondyle ( yrs) due to anatomical position lateral epicondyle on radial side of elbow Elbow Fractures and Anatomic Landmarks Anterior Fat Pad May be normal Posterior far pad Always abnormal if visible Treat a posterior fat pad as an occult fracture even if the rest of the structures are normal 10

11 Radiography and Anatomic Landmarks Anterior humeral line Follow anterior humeral cortex Should pass through the middle 1/3 of the capitellum Note the visible posterior fat pad! Radiography and Anatomic Landmarks Radiocapitellar line (need a good lateral film!) Should intersect the middle 1/3 of the capitellum If not think radial head dislocation/monteggia fracture Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rid:

12 Supracondylar fractures Fall on outstretched arm with hyperextension Neuropraxia Absent pulse in 7-12% Volkmann contraction with brachial artery compression after repair Supracondylar types Type 1 Type 2 Type 3 Abnormal fat pad Posterior splint Pain control Outpatient ortho for casting Posterior cortex intact Posterior splint Pain control Operative repair in vs outpatient Both cortices disrupted Check pulse and nerve function! Posterior splint Pain control Urgent/emergent OR 12

13 Supracondylar Reduction If pulseless extremity and delay in transport to definite care, consider closed reduction Traction Milking of displaced portion Hyperflexion of elbow Follow by documentation of pulses and splinting Do not delay transport for reduction if pulses are thready but capillary refill is adequate closed reduction is a last resort as often slips! Heading down 13

14 Lower Extremity Injuries/Kids who won t walk Limping Teenager 14 yo male with 1 month hx of limp and progressive knee pain No known trauma 100 kg male Pain with internal rotation of hip 14

15 Slipped Capital Femoral Epiphesis 14 yo male with 1 month hx of limp and progressive knee pain No known trauma 100 kg male Pain with internal rotation of hip Slipped Capital Femoral Epiphysis (SCFE) Male>Female, African American, obese Often present as knee pain AP, Frog leg view of both hips Urgent operative repair Worsening slip can lead to AVN Family Case Study 18 month old male being swung in circle by father (me) and swings free Fall approximately 8 inches with rotational torque Won t bear weight No deformity noted Mother of child (my wife) not happy 15

16 Toddler s Fracture Nondisplaced spiral fracture of tibial shaft Ambulatory children < 3 yo Can occur with low energy mechanism Up to 40% of initial films are negative (? US dx) Pain control and casting sometimes empiric for 3 weeks Casting preferable to splinting (kids escape splints) Hip pain and fever 3 year old male with recent fall off bike URI one week ago Now with fever, unwilling to bear weight Complains of pain with movement of the right hip 16

17 Hip Septic Arthritis vs. Transient Synovitis Both can cause patients to be unwilling to bear weight and have pain with hip movement Risk factors in order of importance Fever (38.5) > CRP (>2.0) > ESR(>40) > refusal to bear weight > WBC (>12) Caird et al. The Journal of Bone & Joint Surgery. 88(6): , JUN 2006 Non-accidental trauma Close to 1% all children victims of abuse 1/3 of these kids will be reinjured 1-5% of these kids will die if returned to original environment Abuse is 2 nd leading cause of death infants and children Risk factors*: child < 4 years of age (majority are < 2) parental substance abuse young parents, single parents, large # children Nonbiological, transient caregivers in the home disability * 17

18 Orthopedic injuries and abuse Fractures associated with NAT Bucket handle and corner fractures are considered Classic Metaphyseal Lesions Torsional force applied to immature bone Highly suspicious and should prompt a skeletal survey if < 2 (NOT a babygram), 3200 and NAT workup or transfer to appropriate facility 18

19 Fractures associated with NAT Posterior rib fractures often found in contiguous ribs and different stages of healing if repetitive trauma Compressive force applied to sternum and costovertebral junction during violent shaking Highly suspicious and should prompt a skeletal survey if < 2 (NOT a babygram), 3200 and NAT workup or transfer to appropriate facility Acknowledgements Thanks to Stuart Bradin, MD Pediatric Emergency Ramon Sanchez, MD Pediatric Radiology Matthew Abbott, MD Pediatric Orthopedics Michelle Caird, MD Pediatric Orthopedics Marco Rogers my son who had the Toddler s fracture 19

20 Thank you to MCEP!!!! Questions? Fractures that only need a sling Humerus fractures with < 50 degree angulation in younger kids Clavicle fractures even with significant displacement in kids < 10 years old Kids approaching skeletal maturity can consider outpatient surgery 20