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Episode 35 - Pediatric Orthopedics - Emergencymedicinecases.Com EPISODE 35 - PEDIATRIC ORTHOPEDICS - EMERGENCYMEDICINECASES.COM KNEE INJURIES: Check the X-ray for a Segond fracture, a vertically oriented In general, children’s ligaments are avulsion fracture off the lateral stronger than their bones, thus proximal tibia. This is highly fractures are more likely than associated with ACL and meniscal sprains. Have a low threshold for tears. (See page 4 for a picture.) imaging if suspicious. Management of ACL tears: The same ACL-injury mechanism (sudden deceleration - pain management in acute phase of distal leg with forward and (NSAIDs, tylenol, morphine) rotatory movement) will cause a - short term immobilization (splint EPISODE 35: tibial spine fracture in a as needed, +/-crutches), but PEDIATRIC ORTHOPEDICS younger child, and an ACL tear in atrophy of quadriceps occurs WITH DR. SANJAY MEHTA & a teenager or adult. (See page 4 for quickly, so start range of motion in DR. JONATHAN PIRIE a photo of a tibial spine fracture.) 2–3 days. Some experts Patellar subluxations: the child Lachman test for ACL tear recommend weight bearing as may feel a “pop”, from the kneecap involves pulling the proximal tibia tolerated immediately. subluxing, and feel unstable on the anteriorly while holding the knee in - Surgical repair is delayed until leg. First time patella dislocations flexion. It has good sensitivity (>80% range of motion has recovered. and non-displaced fractures do and specificity of 95%) (1). The Refer to outpatient orthopedics. need knee immobilization, pivot shift test (valgus force and with weight bearing as tolerated. internal rotation to extended leg, Displaced fractures or fractures with which is then flexed to feel Additional X-ray views: an impaired extensor mechanism subluxation) is also sensitive for ACL - patellar injury requires a “skyline need urgent orthopedic tear. Always do a straight leg view” (views patella with knee in consultation. raise to rule out extensor flexion) to detect fractures Remember kids with knee mechanism rupture. - tibial spine and tibial plateau pain can be having pain from Click for a Youtube video fractures are best seen on a a source in the hip, so always demonstrating these tests. “tunnel view” examine the hip as well. Non-accidental trauma Do the Ottawa Knee Rules Apply to Kids? Some fractures *always* raise suspicion of non-accidental trauma (i.e. posterior rib fractures). OKR state that a standard knee series is indicated if: However non-accidental trauma can result in any type • age >55 years (this won’t apply to kids...) or of fracture pattern. Always remember to be systematic • isolated tenderness of patella or when taking histories, and document carefully! • tenderness at head of fibula or Clues for non-accidental trauma (3): • inability to flex knee to 90˚ or 1) Delay in presentation, • inability to bear weight immediately after injury AND in the ED for 4 steps (limping is accepted) 2) Vague or inconsistent explanation of mechanism, Multicenter studies show these rules are 100% sensitive in 3) Mechanism described that is inconsistent with injury, children for clinically significant fractures and 4) Injury inconsistent with developmental stage of child. capable of reducing radiographs by 31%. (2). APPROACH TO THE Ultrasound? Presence of an SLIPPED CAPITAL CHILD WITH A LIMP: effusion can support a diagnosis, but FEMORAL EPIPHYSES: cannot rule out septic arthritis. 1)Rule out septic arthritis SCFE is easy to miss! This can Treatment: in patients you suspect 2)Look for fractures, which can be present subtly, with pain that radiates septic arthritis, usually you can wait very subtle, and ask about trauma into the thigh or knee. Typical patients to start empiric IV antibiotics until are older children, overweight, but 3)Look for clues of systemic illnesses after the joint can be aspirated. also skeletally immature. such as a rash, fever, bruising However, if there will be a significant On exam, pain is usually greatest with Assess the persistence of the limp delay, start antibiotics first. internal rotation of the hip, and they from the history and observations of LEG-CALVE-PERTHES: can present with the hip held in the child. Give analgesia, which LCP is avascular necrosis of external rotation. can help improve the physical exam. femoral head, typically in a child Get x-rays of both hips, Use distraction and observation of aged 4–10. It can present insidiously, including frog’s-leg view in the child at play to complete a full or may follow a hip injury. The initial addition to standard views. Look for physical examination (4). x-ray can be normal, or show a very Kline’s line, the line from the SEPTIC ARTHRITIS vs. subtle change in appearance of the external part of femoral neck, which TRANSIENT SYNOVITIS? femoral head. Speak to radiology to should intersect part of the femoral carefully review the images, and head. (See page 4 for an X-ray with Transient synovitis of the hip is a self- follow with a bone scan or MRI if Kline’s line.) As it slips, the femoral limited inflammation of the synovial very suspicious. head becomes medial to that line. lining. It is often preceded by a viral Compare both sides, but remember infection, and should resolve in 3–10 OCCULT FRACTURES: SCFE can be bilateral. days. However, concurrent illness can A commonly missed occult fracture is make diagnosis challenging. the Toddler’s fracture (spiral If suspicious, call orthopedics—these Pay attention to vital signs, general fracture in children 9 months to 3 cases need surgical management and SCFE will worsen if patients continue appearance (well or unwell years, usually of distal tibia - see page appearing) and symptom progression. 4 for an example). It can present with to weight bear. The Kocher criteria for predicting subtle findings. Pain with ankle TIPS FOR FRACTURE septic arthritis gives increasing dorsiflxion or calf rotation should PAIN MANAGEMENT: probability for each of the following raise suspicion. Oblique views can - Use age-appropriate pain scores. criteria met (5): help reveal the fracture (7). - Start with ibuprofen/tylenol. 1) non-weight-bearing on affect side Toddler’s fractures need an above -Add oral narcotics, or IV if planning knee immobilizing splint with 2) ESR > 40 mm/hr a reduction. Consider intranasal slight flexion, with orthopedic 3) fever fentanyl, or intranasal ketamine. follow-up. However, if nothing is seen 4) WBC >12,000 on the X-ray and symptoms are very -Morphine (0.2 mg/kg up to 5mg per The Kocher rule is helpful to rule-in mild, consider follow up without a dose, with instructions about side higher pre-test probability patients. cast, after discussion about pros/cons effects) may be used in addition to Fever is probably the best criteria. with parents. Ultrasound may help, ibuprofen/tylenol for severe pain What about CRP? Lack of fever when clinical suspicion is high but X- after discharge. and a CRP<2.0 has a good predictive rays appear normal. Codeine is not recommended, value for ruling out septic arthritis (6) Avulsion fractures and bowing due to variations in its when pretest probability is low. aka greenstick fractures, are metabolism, and adverse side also frequently missed on plain X-ray. effects. ANKLE FRACTURES: minimal splinting (12). Minimally- Immobilizing supracondylar angulated transverse fractures can also Salter Harris (SH) fractures around the fractures: Cast in a non- growth plate (mnemonic SALTR): be treated similarly. circumferential sugar-tong and I – S = Slip. Fracture of the cartilage of the *acceptable degrees vary, but only dorsal gutter splint, to ensure stabilization physis (growth plate) and volar angulation is acceptable! of the distal humerus, with space to II – A = Above. Fracture above physis. swell (to minimize compartment FALL ON OUTSTRETCHED III – L = Lower. Fracture below the physis syndrome risk). in the epiphysis. HAND (FOOSH): IV – T = Through. Fracture is through the Pulled elbow: If mechanism or metaphysis, physis, and epiphysis. Examine entire limb, up to the clavicle, history is unclear, then consider an V – R = Rammed. The physis has been and examine the joint above and below X-ray. For a clear “pulled” elbow, crushed/heavily damaged. the painful site for a second fracture. the hyperpronation method is very Ottawa Ankle Rules is highly Supracondylar fractures are the (~95% effective)(13) and may be sensitivity for ankle fractures (7), most common elbow fractures. more comfortable. (See page 4). except SH-1. MRI evidence suggests Mechanism is usually a fall, and elbow SH-1 fractures are similar to a sprain, extension is typically limited. On and do well when treated as such (8). imaging, look for fat pads, and assess References: Non-displaced SH-II lateral malleolar adequacy of the X-ray (see the hourglass and anterior humoral line 1) Scholten RJ et al. J Fam Pract fractures heal as well in an ankle 2003;52:689. (see page 4). stirrup brace as in a cast or boot, but 2) Bulloch B et al. Ann Emerg Med. patients prefer an ankle brace, and Assess the radiocapitellar line (for 2003;42:48. mobilize earlier (9). radial head dislocations). Review each 3) Horsley L. Am Fam Physician. 2008;77:1461. ossification center, which appear TILLAUX FRACTURES: 4) Luhmann SJ et al. J Bone Joint Surg-Am. approx. every 2 years from age 2–3 2004:86;956. Tillaux fracture (see pic on page 4) (see page 4 for mnemonic), to rule out 5) Kocher et al. J Bone Joint Surg-Am. is an intra-articular SH-3 with avulsion 2004:86;1629. an avulsion fracture masquerading as an of the anterolateral tibial epiphysis. 6) Sawyer JR and Kapoor M. Am Fam ossification center. Physician. 2009;79:215. Often from a low energy mechanism, in 7) Boutis K et al. Lancet.2001;358:2118.
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