Common Pediatric Injuries

Dr. Norman Silver Medical Director Minor Injury Clinic for Kids Pan Am Clinic Disclosures • Nothing to Disclose Objectives

• At the end of this session the attendee will be able to: • Recognize and treat common pediatric injuries Outline

• Minor Injury Clinic for Kids • What it is? • Review of some of the most common pediatric injuries • Review things not to miss Minor Injury Clinic for Kids

• Started April 2006 • Referral based clinic • Non-surgical follow-up for all city ER departments • Referrals from family MD’s and Pediatricians offices • Orthotechs, Ortho, Plastics, Physio, medical equipment, MRI • 2 y.o. fell on out stretched arm • 10 days post injury Buckle Fracture

• MOI – FOOSH • Occurs in kids because bones are “soft” • Most commonly seen in distal radius • May be very subtle on AP • Pay close attention to lateral • Often associated with ulnar styloid fracture Radial Buckle treatment

• Very stable fracture • Initial back slab for 5-10 days • Cast for 2 weeks • Removable cast for 2-3 weeks 4 weeks post injury • Young child Foosh injury • Tender distal radius Salter-Harris Type I Radius

• Common Fracture in Kids • Diagnosed Clinically • X-ray most often normal • NOT a radiologic diagnosis SH-Type I Radius Treatment

• Below Elbow Back slab – 5-10 days • BE cast x 2 weeks • Removable Cast x 2 weeks Salter Harris Classification

• 8 y.o. fell off bike - forearm pain Monteggio Fracture

• Fracture of ulna with ant dislocation of radial head • Suspect when ulna fractured and radius not • Usually 7-10 y.o. Monteggio fracture radialcapatellar line

• Line drawn through the radius should pass through the capitellum in all planes Monteggio fracture radialcapatellar line Elbow Injuries

• More difficult due to multiple ossification centers Elbow Injuries Ossification Centers

Capitalum

Radial Head

medial epicondyle

Trochlea

Olecronon

Lateral Epicondyle Elbow Injuries Ossification Centers

• Order of Occurrence • CRMTOL • 1,3,5,7,9,11 years (guide) • Medial epicondyle ossifies last • 4 y.o. Fell onto his elbow 10 days post injury Supracondylar Fractures

• Most common pediatric elbow fracture (60%) with the average age of 6.7 years and rarely seen after age 15 years • 95% are extension type with posterior displacement of distal fragment • Type I fractures - Undisplaced • Type II fractures - Displaced with posterior cortex still intact • Type III fractures - Displaced with both anterior and posterior cortex disrupted Supracondylar Fractures What to look for on X-ray

• Fat pads – if posterior seen with no obvious fracture 75% will have a fracture identified if x-ray’d in 3 weeks

Anterior Fat pad

Posterior fat pad Supracondylar Fractures What to look for on X-ray • Anterior Humeral Line – should go through middle 1/3 of capitalum in undisplaced fracture. May be more anterior if younger child (due to incomplete ossification of capitalum)

Type II supraconcylar fracture with posterior displacement of distal humerus • 3 y.o. fell directly onto elbow

26 days later 4 y.o. Fell and not using arm well 4 weeks later What are you going to do next? 1. X-ray Elbow 2. Examine Child 3. Manipulate Elbow 4. Above Elbow Backslab Pulled Elbow

• Examine child – should be no swelling, no focal tenderness, pain with supination and pronation • Manipulation Pulled Elbow

• 1- 4 years of age • Annular ligament slips on to head of radius and may tear • No history of trauma • No physical signs other than decreased ROM Pulled Elbow Pulled Elbow Treatment

• History/Physical consistant • No x-ray needed • Manipulation of arm • No reduction – x-ray then backslab Pulled Elbow - Manipulaton Pulled Elbow – f/u

Clavicle Fractures

1 week post injury

5 weeks post injury Clavicle fractures

4 weeks post injury in 3y.o Clavicle Fracture

• Consider surgery in older kids with overlap more than 2 cm • Sling • Figure 8 • No contact 8-12 weeks • No need for re-x-ray unless early return to play considered 14y.o. checked and slid into boards diagnosed with AC separation

6 days post - tender mid to lateral 3.5 weeks post injury • 12 y.o male twisted right ankle while running • Most common – inversion or eversion? • Inversion injury – most common associated injuries • Ligamentous injury – ATFL, CFL, PTFL • Fibula Fracture – Salter Harris type 1 • Fracture base of 5th Metatarsal

To Irradiate or not to Irradiate • 12 y.o. inversion injury to the right foot • Unable to weight bear • Tender over distal fibula • X-ray normal with open physis

SH1 fracture of the Fibula

• Clinical diagnosis based on MOI and area of tenderness, may be difficult to localize initially • BK Backslab • BK walking cast/walking boot • Ankle Brace • Physio

Treatment of Sprains

• Grade 1-2 – functional bracing and weight bearing as tolerated • Grade 3 • Backslab – NWB • NWB/WB cast • Cast Boot • Brace – wean but consider keeping for sports 10 y.o male twisted foot – tender over 5th MT 3.5 weeks later Fracture base of 5th MTT

• BK backslab • BK cast – WB • Cast boot • Ankle Brace • If Jones fracture – NWB cast for longer • Distal to metatarsal/cuboid junction

• Young child that suddenly stops weight bearing, otherwise well • Broad differential but most commonly: • Toddlers fracture • Transient synovitis of the hip 4y.o stopped weight bearing Toddler’s fracture

• Toddler’s • Twisting injury – may not be observed • Difficulty or not weight bearing • Careful physical examination • 15 percent no x-ray findings initially • Cast if unsure 6 weeks post injury Another Example

acute 18 days post injury And yet again – 4y.o

3.5 weeks later acute Transient Synovitis of the Hip • Well appearing • Low-grade fever • May walk with limp • Hip Rom restriction • Mainly internal/external rotation • Not frozen hip • ESR/X-ray to R/O other causes • Direct blow to the knee Patella Dislocation

• Dislocates laterally • May relocate spontaneously • Swelling • Tender over medial patella/lateral fem condyle • DDx – ACL tear if not seen out of position Patella dislocation Reduction • Extend knee • Gentle pressure on lateral patella Post reduction

• Removable brace • G2 ROM brace • Physiotherapy • Knee brace with lateral support for sports ACL Tear

• History most important • Twist on a straight knee/landing from jump • Pop felt • Immediate swelling • Knee dislocated or completely gave way • Beware misdiagnosed as patella dislocation • Physical • Swelling • Lachman/Anterior drawer Lachman

Anterior drawer ACL Tear

• Investigations • X-ray • MRI • Treatment • Physiotherapy • Surgery • 13y.o. Female felt pain in hip 3 weeks ago • Seen at walk-in – using crutches since • x-ray showed “subluxable hip” – MRI booked but not for 2 more weeks • Pushed today – felt pop – now very painful hip

Slipped capital Femoral Epiphysis

• Instability of the Femoral Epiphysis • Femoral head slips posterior and inferior • 10-16 years of age • 20% bilateral at presentation • Additional 20-40% will become bilateral within 18 months • Increase risk with obesity SCFE - presentation

• Hip or Knee pain • Generally hip externally rotated • Antalgic gait or unable to bear weight • Decrease ROM esp. – internal rotation • X-ray – AP and Frog leg • MRI, CT, Bone Scan can be used to confirm suspicious cases Klein’s line – should go through the femoral epiphysis – otherwise slipped SCFE – Treatment

• Orthopaedic Consult – Urgent • 12 year old soccer player with knee pain for 6 months • Worse last few weeks • Hurts near the end of the game • Sometimes limps after the game and the next day • Tender over Tibial tuberosity Osgood-Schlatter Disease Osgood Schlatter Disease

• Ice, Rest, nsaids • Patella tendon straps, knee brace • Physio • Occasional immobilization • May completely avulse fragment Summary • Minor injury for kids • Buckle fractures/SH1 radius/SH class • Supracondylar #, pulled elbow • Clavicle # • Ankle – SH1 fibula, Sprain, 5th MTT • NWB – toddler #, Transient Synovitis • Patella dislocation/ACL • SCFE • Osgood Schlatter Questions??