4/19/2019

Atlanta Trauma Symposium:

Uncommon Pediatric Conditions Seen in the Office

Jorge A. Fabregas, MD Education Director at Children’s Healthcare of Atlanta at SR Chief Of Pediatric Orthopaedics at AMC

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When you hear hoof-beats...

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Your eyes see what your mind knows

Ortho- Osteopetrosis

General surgeon- hernia

Family - Is that Poop?

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Leukemia

• Most frequent childhood malignancy • ALL ~ 80%; peak at 4 y.o. (> boys, whites) • Symptoms: lethargy, pallor, purpura, hepatosplenomegaly, lymphadenopathy and bleeding • Musculoskeletal pain in 20-50% (joint, bone pain, etc) • Limp as a chief complaint 12% • 75% of children with ALL have radiographic changes

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10 year old

• Broke arm in playground • Seen in ER • Placed in Sling

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Unicameral Bone Cyst

• Common • Usually found at time of pathologic fracture • 90% proximal humerus and proximal femur • Purely lytic, central • Tx – Steroids – Bone graft – BMP Inj

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Not to be confuse with… Non ossifying Fibroma

• Eccentric Cortically Based • Metaphysis of Long Bones • 30% of Population • Observation • Mayo > 50% treat

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Steroid Injection - UBC

• Scaglietti- 1970’s (JBJS 61B: 200, 1979) • Established method of Tx • G.A. with fluoro. visualization • 18 or 20 gauge needle • Renografin 60 • Methylpreonisolone (Depomedrol) 50- 250 mg • Repeat injection every 4-6 weeks until evidence of healing • Inject up to 5 - 6 times

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Newer Methods (Decompression - oriented) – Multiple K-wires, left in place Chiagra et al: 6 pts, recurrence rate 33% – Decompression with Enders nails, Rush rods Santori et al: healing in all 11 pts. short term f/u – Roposch et al, JBJS 82A Oct 2000: 32 pts (30 with patho #), all responded, 14 healed completely, 9 required change of nails

– Mechanism: Relieving pressure of interstitial fluid?

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From: Roposch et al, JBJS 82A Oct 2000

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Percutaneous IM decompression and delivery of medical grade calcium sulfate

 Radiopaque  Placed percutaneously  Biodegradable  Reabsorbed in 30-60 days  Not intended to provide structural support

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Operative Technique:

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Operative Technique:

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Operative Technique: IM decompression

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Operative Technique: Bone Graft

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Other Techniques

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Not Sever’s …..

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Growing Pains

• Athlete • Knee pain • 4 months duration • Osgood Schlatter • Sinding-Larsen- Johansson • Unilateral • Swelling • Soft tissue mass • Night Pain Tumors Children’s Healthcare of Atlanta 18

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Osteosarcoma : Pre-chemo MRI

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Referred Out

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Knee Pain

• Adolescent • Overweight • Knee or thigh pain • Pain to internal rotation of hip • External rotation during gait • Obligate external rotation with Hip flexion SCFE

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Endocrinopathies - infrequent

• Hypothyroidism • Hypogonadism ? • Parathyroidism Valgus • Hypopituitarism Slip • Pituitary tumor • Growth hormone abnormality ? • Renal osteodystrophy • ?Obesity

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Valgus SCFE

Anterior Cut Posterior Cut

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Radiographic Appearance

• AP x-rays: – Physeal widening, irregularity – Decreased epiphyseal height – Increased density (whiteness)

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Radiographic Appearance

• AP x-rays: – “Blanch Sign of Steel” (overlap of the epiphysis and the femoral neck on the AP x-ray)

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Radiographic Appearance

• AP x-rays: – Kline’s line: a line drawn along the lateral femoral neck on the AP x-ray should intersect a portion of the femoral head

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Radiographic Appearance

• Lateral or cross-table lateral x-ray: – Reveals the posterior displacement – Helps define the minimal slip, “step off”

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Radiographic Appearance • MRI – Shows physeal change of pre-slip and early slip – Before CT and X-ray • CT scan – To define complex anatomy in severe slips

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Treatment - to stabilize the slip

• In situ pin fixation: – Treatment of choice – Single pin for stable slips – Two pins for unstable slips – Central axis is safest – Place perpendicular to head (may require anterior insertion site)

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Basic Concepts: Pinning

• Pin placed within the middle 1/3 on AP and Lat. X-ray • Perpendicular to diameter of head • No more than 3mm to joint

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Simple Method: Valgus Hip • Draw line with pin perpendicular to center of head

• AP and Lateral

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Beware!!!!

• Arterial injury: - Draw line from ASIS to center of patella - Guide pin must enter bone lateral to this line - If close: incision, identify vessels and nerve

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Simple Method: Valgus SCFE

• Insert screws • Check alignment • Flouro thru ROM

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Thank You !

Jorge A. Fabregas, MD Cel (770)880-8029 [email protected]

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