Trauma-related Pediatric Orthopedic Emergencies. Javier Gonzalez del Rey, M.D. Professor Pediatrics Cincinnati Children s Hospital Medical Center
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1 Trauma-related Pediatric Orthopedic Emergencies Javier Gonzalez del Rey, M.D. Professor Pediatrics Cincinnati Children s Hospital Medical Center
2 Room # 10 7 month old sick since birth
3 Room # 11 5 y/o Fell off Monkey Bars Complaining about Elbow Pain..
4 Same However What else is wrong?
5 Elbow Injuries - Radiographic Fat pads Anterior humeral line middle 1/3 capitellum Radiocapitellar line center capitellum all views Hour Glass Sign Radial Head Ossification centers Evaluation
6 Elbow Fractures Management?
7 Room # 12 3 y/o Playing with his brother comes running to his mother crying and holding the arm in the following position...
8 Subluxed Radial Head Nursemaid s Elbow Pull on pronated forearm Rare after age 5 yr. Annular ligament is torn and some fibers roll over the radial head Presentation Arm in pronation Elbow slight flexion No swelling Rarely associated with fracture Reduction techniques Supination with flexion Pronation with flexion Extension hyperpronation Radiographic evaluation not necessary Give time to child after reduction and reevaluate for pain
9 Room # 13 Time to show off 7 y/ o fell off tree..arrives to ED by EMS...
10 Forearm Fractures Proximal Olecranon Radial Head Monteggia s Distal Torus Greenstick Salter Harris I-IV Galeazzi s Colles Smith s Barton s Hutchinson s
11 Monteggia s Fracture Fracture proximal ulna with radial head dislocation 2% of elbow fx Caveat - isolated fx of ulna, expect to find radius injury Orthopedic referral - reduction of radial head & ulnar fracture Don t miss - permanent disability
12 Galeazzi s Fracture Fracture of radial shaft, usually at junction middle/ distal thirds with disruption of radioulnar joint More common teenagers & adults Suspect in angulated fractured distal radius Orthopedic consult
13 And you will use the following splint...
14 Room # y/o Complaining of Pain Right there after a fall...
15 Carpal Bone Fractures Scaphoid (Navicular) Largely cartilaginous in childhood - rare fracture Scaphoid - most commonly fractured Examination in ulnar deviation of wrist Most pediatric scaphoid fracture diagnosed at time of injury heal without complication The more proximal the fracture line > chance of avascular necrosis
16 And you will use the following splint...
17 Metacarpal Fractures Uncommon - Mechanism of injury - direct blow P.E. - flexed fingers should all point the same direction Most common fracture - 5th MC boxer s Splint with degree flexion MCP, mild wrist extension with 15 if < 30 degrees angulation Referral all intra-articular 1st MC or oblique shaft MC 1,2,3 if > 20 degree 4th 5th angulated > 30 degrees
18 Rotational Deformities Never acceptable in fracture of metacarpal or phalanges (little remodeling) Acceptance of angulation deformities in metacarpal or phangeal fractures is dependent on the degree of angulation and bony mobility Angulation is unacceptable in stationary bone (ie. 2nd or 3rd metacarpal)
19 Phalangeal Fractures - Treatment Middle phalanx - less frequent than proximal SH I or II and not angulated (refer others) finger splint or buddy tape Distal phalanx - SH I or II, not angulated bulky dressing, splint or buddy tape
20 Interphalangeal Dislocations & Tendon Injuries Uncommon in young children - common in adolescents Radiographic evaluation prior to manipulation to rule out concomitant fractures Perform reduction under digital block or nitrous sedation May require orthopedic referral Post reduction films and splints for 3 weeks
21 Tendon Injuries - Finger Mallet finger (baseball finger) Boutonniere finger Jersey finger Gamekeeper s Thumb (skier s)
22 Room # 15 5 y/o Fell off his bike (this one was wearing his helmet!) pale and lethargic HR your diagnosis is?
23 Room # y/o AA female complaining of Left Knee Pain seen by PMD Knee X-Rays are negative Presents to your ED so??
24 Room # 17 2 y/o.(get it = a 2 y/o) Refusing to Walk No Hx of trauma or Fever...
25 Fractures of the Tibia and Fibula Tibial and fibular shaft fractures are the most common fractures of the lower extremity in children Toddler s Fracture Acute gait disturbance - refusal to walk History of minor accident (or no Hx.) Subtle physical findings Spiral or oblique fracture of distal tibia Splint or short leg cast
26 Room # y/o Presents to ED with pain, ankle not able to walk Your diagnosis
27 Next Step...
28 Room # 19 Painful swollen ankle
29 Tillaux Fracture
30 Tillaux Fracture SH III of the tibia caused by GP closing medial to lateral
31 Ankle Fractures May have any SH fracture of tibia or fibula SH I fibula common cast for 2 week intervals SH II tibia Most common tibial fracture Tibia = higher energy Treatment posterior splint sugar tong with foot plate
32 Tillaux Fracture Triplane Bimalleolar Trimalleolar
33 Ankle Sprains Prior to growth plate closure = SH I fracture Most common = inversion injury Eversion = higher rate of fractures Ottawa criteria pain in the area of the malleoli inability to bear weight - immediately & 4 step ED bony tenderness distal tibia or fibula
34 Sprains - Rehabilitation Rest Ice Compression Elevation Motion Medication
35 Room # 20 The student wants to present a new case a 1 month old spitting up after 5 formula changes
36
37 Room # 2 14 y/o fell at gym practice
38
39 ABC s Initial Approach Evaluate involved limp for: Neurovascular compromise Open fractures / compartment syndrome Fractures with increased risk for significant bleeding - Pelvic Fractures / Femur Fractures Consider associated injury PAIN MANAGEMENT! Radiographic evaluation
40 ABC s Initial Approach Evaluate involved limp for: Neurovascular compromise Open fractures / compartment syndrome Fractures with increased risk for significant bleeding - Pelvic Fractures / Femur Fractures Consider associated injury PAIN MANAGEMENT! Please splint Radiographic evaluation
41 Room # 4 3 y/o presents to PCP s office refusing to use the right hand and foot.? Hx of a fall you send them for X-Rays...
42 Radiographic Evaluation Should be ordered if: Point tenderness Large amount of swelling Severe pain Persistent symptoms after 3-5 days High risk mechanism Pain with axial / transverse loading Joint above and below injury Comparison views
43 Room # 5 Piece of cake broken leg need to call Ortho in this great Sunday afternoon please Describe... Femur Fx. Diaphysis Transverse Overriding Shortening
44 Radiographic Findings Articular Subcapital Cervical Supracondylar Transcondylar Intercondylar Malleolar
45 Radiographic Findings Longitudinal Transverse Oblique Spiral Impacted Comminuted
46 Radiographic Findings Displacement Angulation Overriding Shortening Distraction Rotation
47 Orthopedic Referral Open fractures Neurovascular compromise Obvious deformity Significant joint or growth plate involvement Dislocation of major joints other than the shoulder Pelvic fractures or spinal injuries
48 Room # 6 typical family of 3 after a soccer practice
49 So this is a?
50 And this is?
51 Fracture Unique to Children Greenstick Torus (buckle) Bowing Avulsion Physeal
52 Room # 7 as usual cousins, relatives and neighbors who heard that everyone is having a great Sunday at the all inclusive ED
53 Room # 7 as usual cousins, relatives and neighboors who heard that everyone is having a great Sunday at the all inclusive ED free meals, free soft drinks, movies, toys and free rides (wheelchairs in the waiting room)
54 Please tell me what these are...
55
56
57
58 Physeal Fractures Salter Harris Classification
59 Room # 8 12 y/o Fell of bike (head is ok - he was not wearing a helmet) and presents to your Urgent Care with left shoulder pain so what do we do?
60 Clavicle Fractures Most frequently fractured bone in childhood Usually result from direct trauma and from direct forces transmitted by falls onto an outstretched hand More than 50% in children younger than 10 years of age Most are greenstick to the midshaft Typically child complains of shoulder pain or injury is initially unnoticed until a lump appears as the callus forms Treatment- figure of eight or sling and swath + education
61 Room # 9 14 y/o Male presents to your ED with severe left shoulder pain...
62 Next step...
63 Shoulder Dislocations Shallow joint with wide range of motions Age adolescent or older 95% of dislocations are anterior. Arm is abducted and externally rotated and then forced posteriorly
64 Anterior Dislocations Subcoracoid (most common) Subglenoid Subclavicular
65 Management - Reduction Adequate analgesia and muscle relaxation Several reduction maneuvers: Stimson Scapular rotation prone / sitting External rotation Traction counter traction Eskimo technique Immediately immobilize Post-reduction xray Orthopedic follow-up
66 Stimson And Scapular Rotations...
67 Eskimo.And External Rotation...
68 Traction Counter Traction
69 In Conclusion... ABC s Careful history and physical examination Pain management Radiographic evaluation - remember SH Think fracture before sprain When in doubt - SPLINT!!
70
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