Ouch, That s Gotta Hurt! Pediatric Fractures & Injuries

Transcription

1 Ouch, That s Gotta Hurt! Pediatric Fractures & Injuries Greg Canty, MD Medical Director, Sports Medicine Center Attending Physician, Emergency Medicine Children s Mercy Kansas City 2011 Children s Mercy Hospitals and Clinics. All Rights Reserved. June 2011

2 Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity I do not intend to discuss any unapproved/investigative use of a commercial product/device in my presentation 2

3 The Game Plan Review the unique features of pediatric bone Understand how to best assess suspected fractures in the urgent care Implement the latest evidence for acute management of fractures and injuries 3

4 Fractures in Pediatrics? 1/3 of patients will have a fracture before age 17 42% boys & 27% girls 10 15% of all childhood injuries involve a fracture Most common Distal forearm Clavicle Fingers Ankle 4

5 The Pediatric Skeleton Bone porous and flexible unique fractures Periosteum is very thick & active Ligaments are strong relative to the bone Presence of the physis weak link Ligament injuries & dislocations are less common kids don t sprain Fractures heal quickly and have the capacity to remodel 5

6 Anatomy of Pediatric Bone Epiphysis Physis Metaphysis Diaphysis Apophysis 6

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8 The Physis aka Growth Plate

9 Pediatric Fracture Language Buckle/ Torus compression, stable Plastic Deformation Bowing esp. fibula or ulna Greenstick plastic deformity w/ partial fx on one side of the bone Complete Spiral, Oblique, Transverse Physeal involves growth plate Salter Harris fx Avulsion involves an apophysis 9

10 Buckle (Torus) Fracture Buckled Periosteum Metaphyseal/ diaphyseal junction 10

11 Greenstick Fracture Cortex Broken on Only One Side Incomplete 11

12 Plastic Deformation 12

13 Physeal Fractures - General Weak link of pediatric bone (cartilage) Adults=sprains...kids=fractures! Rapid healing (1/2 time of shaft fractures) Anatomic alignment critical Risk of premature growth arrest leading to limb length discrepancy or angular deformity 13

14 Physeal Fractures: Salter Harris 14

15 Salter- Harris 3 Salter-Harris 4 Salter- Harris 1 15

16 The History Kids are not good historians Mechanism - Any Fall Sports/Trampolines/ Monkey Bars/ Skating May not be much swelling, bruising or deformity Non-weight bearing Limp Not using the arm Be suspicious! 16

17 Musculoskeletal Physical Exam 1) Inspection: swelling, bruising, deformity, skin intact? 2) Gentle Palpation: focus on bony structures, crepitus, stepoffs, & growth plates 3) ROM: flexion, extension, abduction, adduction, 4) Neurovascular: motor function, sensation, and strength 5) Special maneuvers: ligaments, tendons, laxity 17

18 X Ray s Consider 2 3 views = AP, Oblique, Lateral Focus XR beam: try to pinpoint pain Minimize radiation when possible 18

19 Splinting: General Principals Inspect for any open wound, swelling, or deformity Check distal pulse and neuro status In general, immobilize the joint above and below the fracture Pad all rigid splints (minimum 2 layers, with 3 around bony prominences) When in doubt, splint! A sugar tong is safe choice. 19

20 Case #1 8 yo skateboarder fell yesterday onto his wrist Mild swelling but persistent pain Parents waited a few days because it didn t look too bad 20

21 The FOOSH Fall On the Out Stretched Hand Common mechanism Forearm fx s #1 Distal radius fractures = ¼ of all pediatric fx s Excellent remodeling capability Growth disturbance is unusual 21

22 Splint vs. Cast for Buckle fractures of the Distal Radius Level I Splint as good as a cast for prevention of refracture or loss of alignment No difference in pain Easier to bathe Better function at 14 & 21 days No need for return for cast removal or re xray

23 Case #2 16 y/o basketball player lands on outstretched hand after getting undercut while getting rebound (FOOSH) Now c/o Right Wrist Pain 23

24 Scaphoid Fracture Pain on radial side of wrist Palpate snuffbox region Immobilize if any concern! Tricky blood supply Scaphoid view xrays Consider MRI if persistent symptoms and negative xrays Thumb spica x 6 weeks or longer 24

25 Case #3 15 y/o QB is tackled hard and crashes into the ground landing on his right shoulder He has severe shoulder pain and refuses to raise his Right arm 25

26 Differential to Consider Acromioclavicular sprain Shoulder separation Fracture Sternoclavicular dislocation Glenohumeral dislocation 26

27 8 weeks CLAVICLE FRACTURE An Example of Pediatric Healing Potential

28 Be Careful! Palpate both ends of the clavicle! 28

29 Treatment Sling for pain/protection vs. Figure of 8 brace Pain Control Progressive ROM/Strengthening RTP?? Clavicle fx: Contact sports ~ 8 weeks 29

30 Case #4 9 yo fell off monkey bars earlier today C/o elbow pain and swelling Refuses to fully extend elbow due to pain and swelling 30

31 Multiple physes Look for swelling Effusion Elbow Fractures Loss of flexion/ extension No loss of supination/ pronation Typically supracondylar in the very young and radial head in the older child 31

32 Ossification Centers of the Elbow (CRITOE): C = Capitellum R = Radial Head I = Internal (Medial) T = Trochlea O = Olecranon E = External (Lateral) 2 Years 4 Years 6 Years 8 Years 10 Years 12 Years 32

33 Elbow Fat Pads Anterior normal if lying flat against the humerus, abnormal if elevated sail sign Posterior always pathologic! Indicates hemarthrosis

34 Occult Fracture 34

35 Case #5 16 yo male football player injured left 4 th finger while tackling an opposing player 35

36 Jersey Finger Mechanism forced extension of a flexed distal phalange Flexor digitorum profundus tendon avulsed (+/ bony fragment) Inability to flex the DIP when the PIP joint is stabilized Splint in comfortable position MUST RECOGNIZE EARLY!! Requires repair within 7 10 days 36

37 Case #6 15 yo female basketball player injured her index finger while catching a pass 37

38 Mallet Finger Mechanism is direct blow onto an extended distal phalanx; Jammed finger Occurs when catching ball Extensor digitorum ruptures & DIP assumes flexed position (? pain) Xray for avulsion fracture 38

39 Mallet Finger Treatment Constant splinting of the DIP in full extension/hyperextension x 6 8 weeks May RTP with proper splint when pain controlled 39

40 Visual Inspection Give every hand & finger injury the Kentucky Quick Eye Test

41 Phalangeal Fractures Assess closely for angulation and need for reduction Beware of malrotation! Tx if stable/ nondisplaced/ nonangulated.buddy tape and splint for sports x 3 4 weeks

42 Case #8 15 yo football player presents on Sat morning He recalls an inversion ankle injury when he stepped on another player s foot He was able to limp afterwards but unable to run 42

43 Ottawa Ankle Rules Ankle x-rays if ankle pain with: 1) bony tenderness along the posterior edge/tip of lateral or medial malleolus or 2) inability to bear weight for 4 steps Foot x-rays if foot pain with: 1) bony tenderness at the base of the 5th metatarsal or 2) bony tenderness of the navicular bone or 3) inability to bear weight for 4 steps

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45 The Pediatric Ankle Sprain Distal Fibula Fractures Common in youth and pre-adolescent athletes Always palpate the physis! Salter Harris I fractures are a clinical diagnosis Excellent Prognosis 45

46 Removable Ankle Braces Isolated distal fibula fractures are very common Most are very low-risk Casting vs. splinting Quicker return to baseline activities 57% casted group would have preferred brace! 46

47 Ankle Injuries with Foot Pain 5 th Metatarsal Avulsions Caused by pulling of the peroneus brevis Always feel the bump! CAM walker boot 47

48 Toddler s fracture Any toddler with a mechanism and refuses to bear weight Regardless of exam or xray Wee Walker 48

49 Case #8 A 13 y/o gymnast presents with right hip pain and the inability to bear weight. She felt a pop in her hip while doing the splits. 49

50 Her most likely diagnosis is a) Femur fracture b) Hamstring strain c) Pelvic avulsion fracture d) Slipped capital femoral epiphysis(scfe) 50

51 Ischium Avulsion On exam she had limited ROM with hip flexion, hip IROM, knee extension. She was tender to palpation over the ischium. 51

52 Pelvic Avulsion Fractures Occur with aggressive, athletic motions AIIS soccer/rugby ASIS sprinters/soccer Ischium gymnasts/hurdlers Crutches, NWB, pain control 52

53 Case #9 16 yo runner (XC and track) presents with L hip pain x month Worse w/ running Does not recall injury 53

54 Femoral Neck Stress Fracture 54

55 Preventing fractures 55

56 Summary The pediatric bone is unique and the forces may change during bony development Proper fracture recognition and initial management is important in urgent care Removable splinting wonderful for many fractures 56

57 Sports Medicine Center (816) 701-HURT (4878) Sports-related fractures Acute sports-related injuries & dislocations Sports-related concussion Overuse syndromes Stress fractures Sports-related concerns Exercise induced bronchospasm Spondylolysis Mono in the athlete, etc 57

58 Questions? 58