1/16/2018 Pediatric Orthopedics Alexander Rogers, MD Associate Professor Emergency Medicine and Pediatrics Michigan Medicine/University of Michigan Disclosures I have no conflicts of interest to disclose I will not be talking about off label use of medications 1 1/16/2018 Scope of the problem • In 2010, analysis of National data showed more than 7.5 million pediatric ED visits for injuries and poisoning – the top visit category – (Wier LM, Yu H, Owens PL, Washington R. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006-2013 Jun) • Immaturity of pediatric skeletal structures leads to different fracture patterns than adults, with different short and long term risks Learning goals • Review common pediatric specific injuries • Recognize when we need to intervene • Cover some non-traumatic presentations 2 1/16/2018 Pediatric Musculoskeletal System • Pediatric skeleton less densely calcified than adult • Bones are lighter and more porous • More porous= more pliableless strength increase fractures • Actively growing structure: – long bones contain growth plates/physes – end of bones contain epiphysis Pediatric Musculoskeletal System • Bones of child surrounded by thick and active periosteum • Ligaments and periosteum stronger than bone itself – physis is weak link – fractures more common than sprains in younger children • Response to trauma age dependent 3 1/16/2018 Salter-Harris Classification • SH I – fracture through physis – may be displaced • SH II- through physis and metaphysis • SH III – through physis and epiphysis • SH IV – through metaphysis, physis and epiphysis • SH V – crush to physis In general – higher grade Associated with higher risk of growth abnormality 5 yo upper extremity injury (or ‘why I work in Pediatrics’) • Doctor: What brings you in today? • Patient: I jumped off a chair and hurt my arm • Doctor: oh, why did you jump off the chair? • Patient: I was trying to fly • Doctor: Did you? • Patient: A little bit! 4 1/16/2018 Distal Forearm fractures • Common fracture type • 2 view radiographs key • Acute reduction can avoid the OR • Reduce if > 15-20 degrees angulated • If not reduced acutely – end up needing OR for pinning Distal Radius and Forearm fractures Orthop Rev (Pavia). 2014 Apr 22; 6(2): 5325. • Multiple recommendations regarding acceptable alignment parameters • Younger age have more remodeling potential • Age > 9 higher risk • after skeletal maturity tx as adult • Distal fractures remodel better • If initial reduction is not adequate – these are difficult to manage in the office* *A friendly plug from my orthopedic colleagues 5 1/16/2018 Forearm fracture variants • 6 yo with fall from the monkey bars • Pain in mid-forearm • Subtle swelling/deformity Bowing fracture • Plastic deformity of long bone (in this case the ulna) • If > 20 degrees of deformity can prevent remodeling of the other bone • Increased need to reduce if > 10 yo • Reduce with either weights or slow, constant traction 6 1/16/2018 Forearm fracture variants • 5 yo FOOSH • Still using affected arm, but decreased • Pain with supination • No swelling or deformity Buckle/Taurus fracture • Distal Radius most common but can be any bone • Can usually treat with prefabricated splints – and your patients will thank you for it!* *Williams KG et al. A randomized controlled trial of cast versus splint for distal radial buckle fracture: an evaluation of satisfaction, convenience, and preference. Pediatr Emerg Care. 2013 May;29(5):555-9. 7 1/16/2018 Forearm Fracture variants • 9 yo fall from a giant yoga ball that was next to a tree at family camp Monteggia Fracture • Monteggia fracture- dislocations consist of a fracture of the ulnar shaft with associated dislocation of the radial head. The ulnar fracture is usually obvious, whereas the radial head dislocation can be overlooked 8 1/16/2018 Monteggia Fracture Monteggia Fracture • Ulnar fracture + radial head dislocation • Uncommon (2% all elbow fx’s)– but peak age 4-10 • Can be easily missed- must have films of both elbow and forearm • Isolated ulna fractures rare • If unrecognized and not reduced, can lead to permanent disability • Closed reduction possible in children, less likely with increased age Galleazzi Fracture • Classic: - Fx distal 1/3 radius - dislocation of distal ulna • Disruption of radioulnar joint • Peak age 9-12 years • Suspect in angulated distal radius fractures • Difficult to recognize MUGR fractures… Monteggia has fractured Ulna • Requires ortho consult in ED and reduction Galeazzi has fractured Radius 9 1/16/2018 Pediatric Elbow • 6 ossification centers around the elbow joint • C= Capitellum ( 1 yr) • R = Radial head ( 3-5 yrs) • I = Internal/ medial epicondyle- (4-6 yrs) on ulnar side of elbow • T = Trochlea (6-8 yrs) • O = Olecranon (8- 10 yrs) • E= External/ lateral epicondyle ( 10-12 yrs) – due to anatomical position lateral epicondyle on radial side of elbow Elbow Fractures and Anatomic Landmarks • Anterior Fat Pad – May be normal • Posterior far pad – Always abnormal if visible – Treat a posterior fat pad as an occult fracture even if the rest of the structures are normal 10 1/16/2018 Radiography and Anatomic Landmarks • Anterior humeral line – Follow anterior humeral cortex – Should pass through the middle 1/3 of the capitellum – Note the visible posterior fat pad! Radiography and Anatomic Landmarks • Radiocapitellar line (need a good lateral film!) – Should intersect the middle 1/3 of the capitellum – If not – think radial head dislocation/Monteggia fracture Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 41196 11 1/16/2018 Supracondylar fractures • Fall on outstretched arm with hyperextension • Neuropraxia • Absent pulse in 7-12% • Volkmann contraction with brachial artery compression after repair Supracondylar types Type 1 Type 2 Type 3 • Abnormal fat pad • Posterior cortex • Both cortices • Posterior splint intact disrupted • Pain control • Posterior splint • Check pulse and • Outpatient ortho • Pain control nerve function! for casting • Operative repair – • Posterior splint in vs outpatient • Pain control • Urgent/emergent OR 12 1/16/2018 Supracondylar Reduction • If pulseless extremity and delay in transport to definite care, consider closed reduction • Traction • ‘Milking’ of displaced portion • Hyperflexion of elbow • Follow by documentation of pulses and splinting • Do not delay transport for reduction if pulses are thready but capillary refill is adequate – closed reduction is a last resort as often slips! Heading down… 13 1/16/2018 Lower Extremity Injuries/Kids who won’t walk Limping Teenager • 14 yo male with 1 month hx of limp and progressive knee pain • No known trauma • 100 kg male • Pain with internal rotation of hip 14 1/16/2018 Slipped Capital Femoral Epiphesis • 14 yo male with 1 month hx of limp and progressive knee pain • No known trauma • 100 kg male • Pain with internal • Slipped Capital Femoral Epiphysis rotation of hip (SCFE) • Male>Female, African American, obese • Often present as knee pain • AP, Frog leg view of both hips • Urgent operative repair • Worsening slip can lead to AVN Family Case Study • 18 month old male being swung in circle by father (me) and swings free • Fall approximately 8 inches with rotational torque • Won’t bear weight • No deformity noted • Mother of child (my wife) not happy 15 1/16/2018 Toddler’s Fracture • Nondisplaced spiral fracture of tibial shaft • Ambulatory children < 3 yo • Can occur with low energy mechanism • Up to 40% of initial films are negative (? US dx) • Pain control and casting – sometimes empiric – for 3 weeks • Casting preferable to splinting (kids escape splints) Hip pain and fever • 3 year old male with recent fall off bike • URI one week ago • Now with fever, unwilling to bear weight • Complains of pain with movement of the right hip 16 1/16/2018 Hip Septic Arthritis vs. Transient Synovitis • Both can cause patients to be unwilling to bear weight and have pain with hip movement • Risk factors in order of importance – Fever (38.5) > CRP (>2.0) > ESR(>40) > refusal to bear weight > WBC (>12) Caird et al. The Journal of Bone & Joint Surgery. 88(6):1251–1257, JUN 2006 Non-accidental trauma • Close to 1% all children victims of abuse • 1/3 of these kids will be reinjured • 1-5% of these kids will die if returned to original environment • Abuse is 2nd leading cause of death infants and children • Risk factors*: – child < 4 years of age (majority are < 2) – parental substance abuse – young parents, single parents, large # children – Nonbiological, transient caregivers in the home – disability *https://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html 17 1/16/2018 Orthopedic injuries and abuse Fractures associated with NAT • Bucket handle and corner fractures are considered Classic Metaphyseal Lesions • Torsional force applied to immature bone • Highly suspicious and should prompt a skeletal survey if < 2 (NOT a babygram), 3200 and NAT workup or transfer to appropriate facility 18 1/16/2018 Fractures associated with NAT • Posterior rib fractures – often found in contiguous ribs and different stages of healing if repetitive trauma • Compressive force applied to sternum and costovertebral junction during violent shaking • Highly suspicious and should prompt a skeletal survey if < 2 (NOT a babygram), 3200 and NAT workup or transfer to appropriate facility Acknowledgements • Thanks to… • Stuart Bradin, MD – Pediatric Emergency • Ramon Sanchez, MD – Pediatric Radiology • Matthew Abbott, MD – Pediatric Orthopedics • Michelle Caird, MD – Pediatric Orthopedics • Marco Rogers – my son who had the Toddler’s fracture 19 1/16/2018 Thank you to MCEP!!!! Questions? Fractures that only need a sling… • Humerus fractures with < 50 degree angulation in younger kids • Clavicle fractures – even with significant displacement in kids < 10 years old • Kids approaching skeletal maturity can consider outpatient surgery 20.