Orthopedic Emergencies Peter Gutierrez, MD Pediatric Emergency Medicine Children s Healthcare of Atlanta
Disclosures I have no relevant financial relationships to disclose I do not intend to discuss unapproved uses for commercial products 2
Quick Poll Who s in attendance? Community Pediatricians Hospital-based Pediatricians Community Emergency Physicians PEMs Who has.. X-ray capabilities? Splinting capabilities? 3
Topics Fractures Dislocations Infection Overuse Injuries/ Misc Buckle Fractures Nursemaid s Elbow Septic Arthritis Osgood-Schlatter Disease Clavicular Fracture Patellar Dislocations Osteomyelitis Sinding-Larsen- Johansson Disease Supracondylar Fractures Sever Disease Scaphoid Fracture Slipped Capital Femoral Epiphysis Salter-Harris Fracture 4
Buckle Fractures- Mechanism and Presentation Mechanism FOOSH (fall on outstretched hand) injury Axial loading Presentation May present late due to stability of fracture Most commonly in children less than 10 Mild edema and tenderness over the fracture 5
Buckle Fracture- Radiographic Findings Buckling of the cortex May be difficult to see on one view, so need two 6
Buckle Fracture- Management Prefab wrist splint for 3-4 weeks No need for orthopedics referral (stable fracture) When to refer to ED: When diagnosis is in doubt Other associated fractures If there is neurovascular compromise 7
Clavicular Fractures- Mechanism and Presentation Mechanism Usually fall onto shoulder Presentation Shoulder pain Swelling over the area of the clavicle Shoulder asymmetry Pain with or inability to abduct arm Point tenderness 8
Clavicular Fracture- Radiographic Findings and Management Radiographic Findings Middle third is the most commonly injured Management Sling for comfort or sling and swathe for 3 weeks, then 3 weeks of restriction from sports activities (or until pain resolves) 9
Clavicular Fracture- Management When to send to the ED: Open fractures Taught tenting of the skin (impending open fracture) Respiratory distress or chest pain Any neurovascular compromise Other associated fractures When to refer to ortho: displaced lateral clavicular fractures; Controversy about which types of fractures need operative management. In general, if there is significant displacement (more than 1cm) of the two fragments, or significant pain or restricted ROM after 3 weeks of conservative therapy, refer to ortho 10
Supracondylar Fractures- Mechanism and Presentation Mechanism FOOSH injury Presentation Occur in children 3-10 years Most commonly 5-7 years Pain and swelling to the elbow Pain with flexion/extension of the elbow +/- deformity 11
Supracondylar Fracture- Type 1 Both cortices appear intact Soft signs present Anterior humeral line Posterior fat pad Anterior fat pad Management Posterior long arm splint 12
Supracondylar Fracture- Type 2 Anterior cortex disrupted Management Depends on degree of angulation 13
Supracondylar Fracture- Type 3 Disruption of anterior and posterior cortices Management Almost exclusively operative management 14
Supracondylar Fractures- Neurovascular Status Thumbs up- radial nerve OK sign- anterior interosseous nerve (branch of the median nerve) Crossing fingers- ulnar nerve Checking for radial and ulnar pulses Checking capillary refill 15
Supracondylar Fracture- Management Posterior Long Arm splint Photo removed for copyright compliance Type 1 Need only splint F/u with ortho in 1 week Type 2 and 3 Splint for comfort and refer to emergency department 16
Scaphoid Fractures- Mechanism and Presentation Mechanism FOOSH injury, especially when wrist is hyperextended and radially deviated Most commonly fractured carpal bone Presentation Edema Decreased ROM Tenderness over the anatomic snuffbox (between the extensor pollicis longus and brevis) Pain with axial loading of the thumb Photo removed for copyright compliance 17
Scaphoid Fracture- Radiographic Findings - Usually normal - Fracture may not show until repeat films are performed in 1-2 weeks 18
Scaphoid Fracture- Management Splint using a thumb spica Referral to orthopedics in 1-2 weeks When to send to the ED Multiple fractures or concern for dislocation 19
Salter Harris Fractures- Mechanism and Presentation Mechanism- any injury FOOSH Direct injury Distraction Axial loading Plant and pivot Presentation Pain and edema at site of injury Non-weight bearing if lower extremity Decreased ROM 20
Salter Harris Fractures- Types Photo removed for copyright compliance 21
Salter Harris Fracture- Management Appropriate splint for fracture Distal radius- sugar tong splint Distal tibia- Cadillac splint Distal femur- posterior long leg Phalanx- static finger splint Clinical SH1 fracture Tenderness at the physis with normal radiographs Treat as potentially fractured f/u with ortho in 1 week for re-imaging When to refer to the ED- splint for comfort Any displaced SH fracture Any fracture with neurovascular Children s compromise Healthcare of Atlanta Emory University 22
Nursemaid s Elbow- Mechanism and Presentation Mechanism Pulling or traction of the forearm Presentation Affected arm is flexed at the elbow, half-way between flexion and extension, and held close to the body Won t want to use it On exam No swelling at the elbow Has some pain at the extreme of flexion, but most pain with supination 23
Nursemaid s Elbow- Radiographic Findings - Not needed unless diagnosis is in question - Malalignment of the radio-capitellar line in either view of the elbow 24
Nursemaid s Elbow- Reduction Flexion with hypersupination Extension with pronation Make sure to have a thumb on the radial head while attempting to feel the pop and to held push back in place Check to make sure child is willing to use the arm about 10-15 minutes later (have them grab for an object or treat) No need for splint or sling afterwards When to refer to the ED When the diagnosis is in question; concern for associated fracture 25
Patellar Dislocation- Mechanism and Presentation Mechanism Occurs when the foot is planted, then child abruptly pivots in the opposite direction or lateral force applied to the knee Presentation Severe knee pain Obvious malposition of the patella, always laterally Inability to completely extend the knee May spontaneously reduce before arrival- will have tenderness just medial to the patella and a positive apprehension test 26
Patellar Dislocation- Radiographic Findings Radiographs are not usually required for diagnosis Once reduced, will need knee radiographs to evaluate for osteochondral fracture of the lateral femoral condyle or of the medial patella facet (difficult to see) 27
Patellar Dislocation- Management Reduction Can give analgesia or anxiolysis beforehand, but not necessary; reduction will give the most pain relief Apply lateral to medial force on the patella using your thumbs, with the knee in approximately 20 degrees of flexion Once reduced, obtain films and place in a knee immobilizer with crutches Needs to follow-up with orthopedics in 1-2 weeks When to send to the ED Unable to be reduced Unable to obtain films after reduction Associated fracture with reduction 28
Septic Arthritis- Mechanism and Presentation Mechanism Occurs via seeding from the blood stream, direct inoculation into the joint space, or contiguous spread from a nearby infection (cellulitis or osteomyelitis) Presentation Warm, swollen joint Inability to fully extend or flex the joint (fluid in the space makes the joint stiff) +/- Fever Limp or inability to bear weight if involving lower extremities In infants- can have irritability and pseudo-paralysis If hip involved, tend to hold affected hip in flexion, abduction, and external rotation 29
Septic Arthritis- Management - Send them to the emergency department - Will need labs, +/- imaging, and possibly joint aspiration - If septic-appearing, call EMS 30
Septic Arthritis- Management IF Feeling cavalier Have access to labs Hip is the joint involved Kocher Criteria Non-weight bearing Fever of 38.5 or higher WBC >12 ESR >40 Septic arthritis of the hip 99% chance with 4/4 92% chance with 3/4 40% chance with 2/4 3% chance with 1/4 31
Osteomyelitis- Mechanism and Presentation Mechanism Occurs via seeding from the blood stream, direct inoculation into the joint space, or contiguous spread from a nearby infection (cellulitis or osteomyelitis) Presentation History of indolent course; be concerned with h/o instrumentation or SCD; may get history of minor trauma In lower extremities in 70% of children +/- fever (up to 90%) Localized pain and tenderness Pain with movement or refusal to bear weight +/- erythema or edema Neonate- pseudo-paralysis; +/- paradoxical fussiness 32
Osteomyelitis- Management Send them to the emergency department Will need labs and imaging (MRI or technetium bone scanning) >90% will have an elevated CRP WBC elevated only in 1/3 of patients X-rays can be normal for the first 1.5-2 weeks of illness After that, may show lytic changes or a periosteal reaction If possible, may need bone aspirate with orthopedics 33
Osgood-Schlatter Disease (OSD)- Mechanism and Presentation Mechanism Apophysitis of the tibial tuberosity Apophysis- growth plate under the insertion of a tendon Repetitive micro-injury, usually from strong contraction of the quadriceps muscles Usually running and jumping athletes between 11 and 15 years of age Resolves when growth plates close Presentation Unilateral or bilateral knee pain with exercise (usually just below the knee) May start off without pain, but worsens with time playing/practicing Tender over the tibial tuberosity 34
OSD- Radiographic Findings Not typically indicatedwill be normal early in the course May appear more frayed if prolonged Indications- inability to weight bear, inability to extend knee from a seated position In severe cases, can see avulsion of tibial tuberosity 35
OSD- Management Refrain of activity while actively having pain Icing 20 minutes twice a day Anti-inflammatory medications Returning to play Emphasize quadriceps and hamstring stretching exercises (decreases tension on the patellar tendon) Compression band or neoprene knee sleeve over the tibial tuberosity Referral to a Sports Medicine Physician if a higher level athlete Most will resolve in 12-24 hours with conservative therapy When to send to the ED Avulsion injury of the tibial tuberosity- requires surgical pinning 36
Sinding-Larsen-Johansson (SLJ) Disease- Mechanism and Presentation Mechanism Apophysitis of the inferior pole of the patella Similar to OSD- repetitive micro-trauma due to forceful contracture of the quadriceps muscles Occurs in jumping athletes, usually younger than OSD (9 to 14 years) Presentation Unilateral knee pain and swelling Tenderness over the inferior aspect of the patella May start without pain, but then worsens with practice/playing 37
SLJ- Radiographic Findings Normal early on Can progress to small avulsion of the inferior pole of the patella 38
SLJ- Management Refrain of activity while actively having pain Icing 20 minutes twice a day Anti-inflammatory medications Returning to play Emphasize quadriceps and hamstring stretching exercises (decreases tension on the patellar tendon) Referral to a Sports Medicine Physician if a higher level athlete Referral to orthopedic surgeon if not resolving with conservative management Most will resolve in 12-18 hours with conservative therapy When to send to the ED- not indicated 39
Sever Disease- Mechanism and Presentation Mechanism Apophysitis of the calcaneus Similar mechanism as OSD and SLJ Repetitive micro-injury to the calcaneus at the insertion of the Achilles tendon Presentation Occurs in athletes that do lots of running (soccer players, longdistance runners) and jumping Peak incidence 10-12 years Usually bilateral heel pain that worsens with exercise Calcaneal Squeeze test- pain with squeezing the bottom third of the calcaneus Radiographic Findings Not indicated; can see a fragmented calcaneal apophysis in normal patients Photo removed for copyright compliance 40
Sever Disease- Management Refrain of activity while actively having pain Icing 20 minutes twice a day Anti-inflammatory medications Returning to play Emphasize calf stretching exercises (decreases tension on the Achilles tendon) Use of heel cup orthotic Usually can return to play in less than 2 months When to send to the ED- not indicated 41
Slipped Capital Femoral Epiphysis (SCFE)- Mechanism and Presentation Mechanism Salter-Harris type 1-like fracture through the physis of the femoral head (perichondrium is intact) Presentation Tends to occur in obese males between the ages of 11-13, while going through a growth spur Usually unilateral pain (25% in both sides) and limp of acute (<3 weeks), subacute, or chronic (>3 weeks) onset Pain may be referred to the thigh, knee, or groin Exam: May have hip flexion and external rotation at rest Has decreased and painful passive ROM with hip flexion, internal rotation, and abduction If severe, may see limb length shortening and have anterior hip tenderness. 42
SCFE- Radiograph Findings AP and frog-leg views of the hip On AP view, evaluate the Klein line Draw a line over the superior aspect of the femoral neck It should touch the femoral head If not, concerning for SCFE On frog leg view Draw a line from the center of the femoral neck Should be in the center of the apophysis 43
SCFE- Management Make non-weight bearing (decrease the likelihood of continued slippage) Immediate referral to the emergency department 44
References Fleischer and Ludwig s Textbook of Pediatric Emergency Medicine. 7 th Edition Yang S, Andras L. Clavicle Shaft Fractures in Adolescents. Orthop Clin N Am 48 (2017) 47 58 Wheeless s Textbook of Orthopedics. www.wheelessonline.com- multiple topics Emedicine- Sever Disease, SCFE Medcomic.com 45