Here are images of the Salter-Harris fracture classification:Type I: A fracture through the growth plate only. The epiphysis is separated from the metaphysis. Type II: A fracture that extends from the growth plate into the metaphysis. This is the most common type.Type III: A fracture that extends from the growth plate into the epiphysis. Type IV: A fracture that extends through the metaphysis into the epiphysis. Type V: A crush injury or compression injury of the entire growth plate.I have removed the images due to copyright. Let me know if you would like me to describe the images in more detail
1. The document discusses pediatric orthopedic emergencies, focusing on the unique aspects of pediatric musculoskeletal injuries compared to adults.
2. Key differences include the pediatric skeleton being less dense, more porous, and still growing, making children more prone to certain injury patterns like plastic deformity fractures.
3. The document reviews mechanisms of injury, uniquely pediatric fractures, and the initial approach to pediatric orthopedic trauma, emphasizing immobilization and careful evaluation for other injuries.
Similaire à Here are images of the Salter-Harris fracture classification:Type I: A fracture through the growth plate only. The epiphysis is separated from the metaphysis. Type II: A fracture that extends from the growth plate into the metaphysis. This is the most common type.Type III: A fracture that extends from the growth plate into the epiphysis. Type IV: A fracture that extends through the metaphysis into the epiphysis. Type V: A crush injury or compression injury of the entire growth plate.I have removed the images due to copyright. Let me know if you would like me to describe the images in more detail
Similaire à Here are images of the Salter-Harris fracture classification:Type I: A fracture through the growth plate only. The epiphysis is separated from the metaphysis. Type II: A fracture that extends from the growth plate into the metaphysis. This is the most common type.Type III: A fracture that extends from the growth plate into the epiphysis. Type IV: A fracture that extends through the metaphysis into the epiphysis. Type V: A crush injury or compression injury of the entire growth plate.I have removed the images due to copyright. Let me know if you would like me to describe the images in more detail (20)
Here are images of the Salter-Harris fracture classification:Type I: A fracture through the growth plate only. The epiphysis is separated from the metaphysis. Type II: A fracture that extends from the growth plate into the metaphysis. This is the most common type.Type III: A fracture that extends from the growth plate into the epiphysis. Type IV: A fracture that extends through the metaphysis into the epiphysis. Type V: A crush injury or compression injury of the entire growth plate.I have removed the images due to copyright. Let me know if you would like me to describe the images in more detail
1. Project: Ghana Emergency Medicine Collaborative
Document Title: Pediatric Orthopedic Emergencies
Author(s): Stuart A Bradin, DO, FAAP, FACEP
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2
3. Pediatric Orthopedic
Emergencies
Stuart A Bradin, DO, FAAP, FACEP
Assistant Professor of Pediatrics and
Emergency Medicine
University of Michigan Health System
Richard
Masoner,
Flickr
Derrick Mealiffe, Wikimedia Commons
Wikimedia Commons
3
4. Objectives
1. Introduction of most common pediatric
orthopedic injuries
2. Understand physiologic differences between
adult and pediatric musculoskeletal system
3. Introduction of orthopedic injuries unique to
pediatrics
4. Discussion of initial evaluation and
management of common pediatric orthopedic
injuries
4
5. Introduction
nn Children experience diverse array of illnesses andChildren experience diverse array of illnesses and
injuriesinjuries
nn Many unique to pediatricsMany unique to pediatrics
nn 1/3 of all ED patients annually are children1/3 of all ED patients annually are children (Annals of Emergency(Annals of Emergency
Medicine, 1990)Medicine, 1990)
nn PrePre--hospital setting, 10% ambulance runs are forhospital setting, 10% ambulance runs are for
pediatric patientspediatric patients ((KallsenKallsen GW, inGW, in DieckermanDieckerman RA, 1991)RA, 1991)
nn Trauma represents majority of pediatric transportsTrauma represents majority of pediatric transports
(50(50--65%)65%)
nn Age dependentAge dependent
nn Injuries are most common reason pediatric patientsInjuries are most common reason pediatric patients
present to the EDpresent to the ED
5
6. Introduction
Ø Represent 10-15% of ED visits
Ø 70% related to falls in younger children
Ø In the multi- trauma patient, > 50% will
have at least 1 musculoskeletal injury
Ø Injury patterns in pediatrics differ greatly
from adults
Ø Recognizing and understanding these
differences critical to appropriate diagnosis
and care
6
7. Pediatrics
nn Prehospital providers often have:Prehospital providers often have:
–– Limited pediatric patient contactsLimited pediatric patient contacts
–– Limited knowledge, training, andLimited knowledge, training, and
experience specifically directed towardsexperience specifically directed towards
pediatricspediatrics
nn Many other healthcare providers areMany other healthcare providers are
similarly affectedsimilarly affected
nn Children are not little adults!!!Children are not little adults!!!
7
8. Pediatric Trauma
Ø Distinguished from that in adults by
differences:
1. mechanisms of injury
2. fracture patterns
3. multiple acceptable treatment options
4. associated systems injuries
5. mortality in pediatric polytrauma
6. residual morbidity
8
9. Common Pediatric Mechanisms of Injury
Ø Pedestrian struck by vehicle
Ø Fall from low heights
Ø Non accidental injury in infant/ toddler
Ø Power tools/ lawn mower injuries
Ø Vehicle operator and falls from heights
(teens)
9
10. Mechanisms of Pediatric Injury
Waddell’s Triad
William Murphy, Flickr
Rhymeswithbombs, Fllickr
10
12. Non accidental Injury
Ø Close to 1% all children victims of abuse
Ø 1/3 of these kids will be reinjured
Ø 1-5% of these kids will die if returned to original
environment
Ø Abuse is 2nd leading cause of death infants and children
Ø Majority < 1 year of age
Ø Must have high index of suspicion
Ø Risk factors: parental substance abuse
young parent
child < 3 yrs old
premature
disability
12
13. Non accidental Trauma
History
- what is mechanism
- is story plausible
- who witnessed event
- time from injury to tx
- who has access to pt
- inconsistent stories
Physical Exam
- serious injury can
exist despite no
outward signs
- patterns of bruising/
unexpected areas
- burns/ scars
- May require opthy
exam/ CT scan
(Shaken Baby)
13
14. Orthopedic injuries in Non accidental
Trauma
Ø Seen 30-50% children
Ø Injuries highly specific for abuse
include:
- corner or bucket handle
fractures
- scapular fractures
- posterior rib fractures
- old fractures
- multiple fractures of different
ages
- spinous process fractures
Ø Spiral fractures are not
pathognomonic for abuse
Melimama, Wikimedia Commons
14
21. Other Injuries Associated with Pediatric
Non-accidental Trauma
Source Undetermined
Source Undetermined
Source UndeterminedSource Undetermined 21
22. Physiologic Differences in Child
Ø Periosteum thicker and
stronger
Ø Bone more porous
Ø Higher incidence of plastic
deformities
Ø Less ligament injury/
dislocation
Ø Remodeling is extensive
Ø 15% childhood fractures
involve growth plate
Ø Radiographic evaluation
more difficult due to
growth plates
Ø Kids do stupid things!
Clappstar, Flickr
Edwin Dalorzo, Flickr
Bread for the World, Flickr
Elizabeth Buie, Flickr
22
23. Pediatric Musculoskeletal System
Ø Pediatric skeleton less densely
calcified than adult
Ø Composed higher percentage of
cartilage
Ø Bones are lighter and more porous
Ø More porous= more pliableà
less strengthà increase fractures
Ø Actively growing structure:
- long bones contain growth plates/
physes
- end of bones contain epiphysis
Ø Bones of child surrounded by thick and
active periosteum
Ø Ligaments and periosteum stronger
than bone itselfà
- physis is weak link
- fractures more common than
sprains
Ø Response to trauma age dependent
Source: Wikimedia Commons
23
25. Buckle Fracture
Ø Secondary to
compression
Ø Usually metaphysis
Ø Stable fracture
Ø May be very subtle
Ø Quite common
Ø Requires splint and
ortho follow up
Source Undetermined
25
27. Greenstick Fracture
Ø Most common fracture
pattern in children
Ø Incomplete fracture at
metaphyseal-
diaphyseal junction
Ø Angulation and
rotation common
Ø 1 cortex remains
intact
Ø Often must complete
fx to achieve union
Source Undetermined
27
29. Bowing Fracture
Ø Forces on bone stops
short of fracture
Ø Persistent plastic
deformity can result
Ø Little remodeling
Ø Forearm, fibula
common
Ø Functional and
cosmetic deficits
Ø Requires ortho
referral
Source Undetermined
Source Undetermined
29
30. Physeal Fractures
Ø 18-30% of pediatric
fractures
Ø Common adolescence
Ø Peak 11-12 yrs
Ø Usually upper extremity
injury
Ø Physis = weak area
Ø Salter- Harris
Classification
Ø Salter Harris type 2 most
common
Source Undetermined
30
31. Salter-Harris Classification
• SH I - through physis
• SH II - through physis &
metaphysis
• SH III - through physis &
epiphysis
• SH IV - through
metaphysis, physis &
epiphysis
• SH V - crush injury to
entire physis Source Undetermined
31
33. Salter- Harris 1 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
33
34. Salter- Harris Type 2 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
34
35. Salter- Harris Type 3 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
35
36. Salter Harris Type 4 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
36
37. Salter-Harris Type 5 Fracture
Source Undetermined
Source Undetermined
Lena Carleton, University of
Michigan
37
38. Case
Ø 18 mth old brought in by mom because she
won’t bear wt on R leg. No fever. No recent
illnesses. No witnessed trauma.
Ø Exam: afebrile, non toxic appearing
no gross deformity, swelling,
redness / warmth, bruising
Draws leg up when standing
Cries when you try to move lower R
leg
No rash/ petechiae
Mom and baby good rapport, eye contact
What do you think is going on?
What do you want to do?
Jocelyndale, Flickr
38
39. Toddler’s Fracture
Ø Hairline, non
displaced spiral or
oblique fracture tibia
Ø Typically kids < 4 yrs
Ø Minor force- usually
fall
Ø Subtle findings
Ø Does not = abuse
Source: Medscape
39
41. What’s Your Diagnosis?
15 year old baseball player
Rounding 3rd base, acute pain in hip while
running
Pain is sharp, felt “ pop”
Finished game but has pain walking
Exam benign except pinpoint tenderness at
AIIS, worse w/ abduction of hip
41
42. Avulsion Fracture of the Pelvis
Ø Intense muscular
contraction
Ø Subsequent shearing
of secondary
ossification center
Ø Pelvis, tibia tubercle,
phalanges
Ø Require conservative
care
Ø Adolescent -14-18 yrs
Ø 90% Male
Ø 80% sports related
Source Undetermined
42
43. Initial Approach to Orthopedic Trauma
Ø ABC’s
Ø Evaluate involved limb for:
- neurovascular compromise
- open vs closed fracture
- compartment syndrome
Ø Evaluate for fx’s at increased risk for significant bleeding/
hemodynamic instability ( pelvic/ femur fractures)
Ø Search for associated injuries
Ø Pain control
Ø Immobilization
Ø Xray evaluation
Ø Miscellaneous: last meal, allergies/ meds, last period if
female 43
44. Fracture Treatment in Children:
General Principles
Ø Children heal faster than adults
Ø Require less immobilization time
Ø Stiffness of adjacent joints less likely
Ø Vast majority- tx’d closed methods
Ø Exceptions: open fractures
Salter Harris type III- IV injury
multi-system trauma
Ø If any concern re: displacementà keep NPO
Ø Any swollen elbow is displaced supracondylar fx until
proven otherwise
Ø Analgesia ( morphine 0.1 mg/kg IV), then Xrays
44
45. Radiographic Evaluation
Ø Point tenderness
Ø Large amount of swelling
Ø Severe pain
Ø Persistent symptoms after 3-5 days
Ø High risk mechanism
Ø Must include joint above and below
Ø Comparison views?
Ø All unstable and deformed fractures must be
immobilized prior to transfer to radiology
45
46. What Does Ortho Need to Know?
Ø Age and sex of patient
Ø Mechanism of injury
Ø Bone or bones involved in
injury
Ø Type of fracture
Ø Neurovascular status of the
extremity
Ø Presence and amount of
displacement
Ø Presence and estimate of
angulation
Ø Open or closed fracture
Mike Blyth, Flickr
46
53. Pediatric Extremity Injuries Requiring
Emergent Orthopedic Evaluation
Ø Femur Fractures
Ø Pelvic fractures
Ø Open fractures
Ø Spinal fractures
Ø Complete fracture of long bones of lower
extremities
Ø Neurovascular compromise
Ø Dislocation of large joint
Ø Fractures with significant displacement
Ø Fractures involving large joint
53
54. Injuries to the Upper Extremity
Ø Clavicle
Ø Shoulder
Ø Humerus
Ø Elbow
Ø Forearm
Ø Wrist and hand
54
55. Clavicle Fracture
Ø Most common childhood
fracture
Ø Direct trauma and indirect
forces
Ø > 50% kids less than 10
yrs of age
Ø Symptoms:
- point tenderness/ pain
- decreased mobility
- unnoticed until “lump”
noted as callus forms
Ø Sling or sling and swathe
Ø Pain control
Ø Ortho follow up 2-3 weeks
Source Undetermined
Source Undetermined
Wikimedia Commons
55
59. Elbow Fractures and Anatomic
Landmarks
• Anterior Fat Pad
– May be normal if
“adherent” to bone
• Posterior Fat Pad
– Always abnormal if
visible
Source Undetermined 59
60. Radiograph Anatomy and Landmarks
• Anterior Humeral
Line
– drawn along the
anterior humeral
cortex
– should pass
through the middle
1/3 of the
capitellum
Source Undetermined
60
61. Anatomy and Landmarks
• Radiocapitellar line
– should intersect the
middle 1/3 of the
capitellum
– Radial head
dislocation
• Make it a habit to
evaluate this line on
every pediatric
elbow film
Source Undetermined
61
62. Radiocapitellar Line
What kind of fracture is
this?
• Monteggia Fracture
• Ulnar fracture w/
Radial Head
Dislocation
Source Undetermined
62
63. Supracondylar Fracture
Ø Fall on outstretched arm
Ø Hyperextension
Ø Common elbow fracture
Ø Complications:
- NV compromise
- compartment syndrome
Ø Graded 1- 3
Ø Management dependent
upon type of injury
( splint or OR for repair)
Ø Ortho needs to see all
elbow fractures
Source Undetermined
Source Undetermined 63
64. Elbow Fractures in Children
Ø Very common
Ø Radiographic assessment difficult
Ø Requires thorough exam and reassessment
Ø Neurovascular injuries can occur before and after
reduction
Ø Kids will not move elbow if fracture present
Ø Swelling about the elbow is constant feature
- may be minimal if non displaced fx
- may not develop for 12-24 hrs after injury
Ø 60% are supracondylar fractures
Ø May be accompanied by distal radius or forearm fx
64
65. Supracondylar Fractures
• Type 1: Non-displaced
• Type 2: Angulated/displaced fracture with
intact posterior cortex
– Hinged
• Type 3: Complete displacement, with no
contact between fragments
Source Undetermined
Image Removed,
Supracondylar Fracture
65
66. Type 1- Nondisplaced
• Note the non-
displaced fracture
(Red Arrow)
• Note the Posterior
Fat Pad (Yellow
Arrows)
Source Undetermined 66
67. Type 2: Angulated and Displaced
Source Undetermined Source Undetermined
67
68. Type 3 Supracondylar Fracture
Ø High risk for NV
compromise
Ø Significant
associated
swelling
Ø Ortho consult
Ø OR for
percutaneous pin
fixation
Ø Open reduction
may be
necessary
Source Undetermined
Source Undetermined
Source Undetermined
68
69. Type 3: Complete Displacement
Source Undetermined
Image Removed, Bone
Displacement
69
70. Case
Ø 9 yr old falls off slide, landing
on outstretched L arm
Ø Presents to ED due to pain in
forearm and elbow
Ø No hx LOC/ CHI
Ø Benign medical hx
Ø Tender over proximal L
forearm
Ø Decreased ROM forearm and
elbow due to pain, swelling,
guarding
Ø NV intact, good radial pulse,
can wiggle fingers
Ø Cap refill < 2 sec
Ø What do films show?
What do you want to do?
Source Undetermined
Source Undetermined 70
71. Monteggia Fracture
Ø Ulnar fracture + radial
head dislocation
Ø Uncommon in kids (2%
all elbow fx’s)
Ø Can be easily missed-
must have films of both
elbow and forearm
Ø Isolated ulna fractures
rare
Ø If unrecognized and not
reduced, can lead to
permanent disability
Ø Pain control, ortho
consult, OR for repair
Source Undetermined
Source Undetermined
71
72. Galleazzi Fracture
Ø Classic:
- Fx distal 1/3 radius
- dislocation of distal
ulna
Ø Disruption of radioulnar
joint
Ø More common
teenagers and adults
Ø Rare fracture
Ø Suspect in angulated
distal radius fractures
Ø Difficult to recognize
Ø Requires ortho consult
in ED and reduction
Source Undetermined
72
73. Radial Head Subluxation:
Nursemaid’s Elbow
• Nursemaid’s Elbow
• Tractional mechanism
• Unusual > 5 yo
• Holds arm pronated, slightly flexed at
elbow and at side
• No swelling or ecchymosis
• X-rays not necessary
Kevin Harber, Flickr
73
74. Nursemaid’s Elbow
Ø Radial head subluxation due
to annular ligament tear
Ø Typically “ pull” on pronated
forearm
Ø Typical presentation:
-do not appear in pain
-refuse to use arm
-held in pronation and
slightly flexed
-no swelling/ bruising
-may hold wrist to support
extremity
Ø Reduction techniques:
- pressure over radial head
- supination w/ flexion
- pronation w/ flexion
- extension/ hyperpronation
Ø Films only if hx / exam not
consistent
Wikimedia Commons
Sean Dreilinger, Flickr
74
75. Pediatric Forearm Fractures
Ø Approximately 4% children’s
fractures
Ø Most due from fall onto
outstretched hand
Ø ¾ fractures distal
Ø Rare to see isolated ulna
fracture
Ø Neurovascular compromise rare
Ø Remodels well
Ø Ortho consult :
angulation > 10’ midshaft
> 15’ distal
will require procedural sedation
for reduction
Ø Treatment- sugartong or volar
splint
Source Undetermined
Source Undetermined
Source Undetermined
75
76. Carpal Bone Fractures-Scaphoid Fracture
Ø Rare fx
Ø Teenager or adolescent
Ø Hard to diagnose- not
easily seen on film
Ø Heals poorly
Ø Concern avascular
necrosis
Ø Typical mechanism: fall
hyperextended wrist
Ø Snuffbox pain
Ø Treat: thumb spica splint
Source Undetermined
Amada44,
Wikimedia Commons
76
78. Boxer’s Fracture
Ø Uncommon injury
Ø Adolescent boy
Ø Mechanism of injury= direct
blow/ strike object w/ closed
fist
Ø Fracture 4th or 5th
metacarpal
Ø Be wary of infection
Ø Look for rotational defects
Ø Never acceptable in fx of
mcp or phalanges
Ø Reduce if angulation > 30’
Ø Ulnar gutter splint Bobjgalindo, Wikimedia Commons
78
79. Injuries to Lower Extremities
Ø Hip dislocations and femoral neck fx’s due to high
energy impact
Ø Major trauma
Ø Care and resuscitate child before addressing orthopedic
injury
Ø Single ring fx of pelvic ring = STABLE
superior and inferior rami fx
symphysis pubis fx
Ø Double breaks in pelvic ring = UNSTABLE
high incidence GU, abdominal, vascular injuries
life threatening hemorrhage
79
81. Bad or Really Bad?
Ø 4 yr old, previously healthy
Ø Febrile, R leg pain x 1 night
Ø Slipped and fell earlier but
able to walk immediately
Ø Temp 40.7, HR 160
Ø Uncomfortable, non toxic
Ø Refuses to wt bear at all
Ø R leg held externally rotated
and abducted
Ø ROM severely limited due to
pain
Ø What is going on ?
Ø What do you want to do?
The U.S. Army, Flickr
81
82. What Now?
Ø WBC 21.7, 85
seg, 4 bands
Ø CRP 8.2
Ø ESR 48
Ø What do films
show?
Source Undetermined
82
83. Septic Arthritis
Ø Peak age < 3 yrs
Ø Usually single joint
Ø Most common: hip, knee, shoulder, elbow
Ø Hematogenous seeding bacteria to joint
Ø Direct spread from adjacent osteomyelitis or trauma
Ø Staph Aureus most common pathogen
Ø Neonate: Staph aureus
Group B Strep
Gram negative bacilli
Ø Toddler: Staph aureus
Group A streptococcus
S. pneumoniae
Ø Sexually active teen: Neisseria gonorrhoeae
83
84. Septic Arthritis
Ø Non specific findings neonate
Ø Older kids more localized pain,
fever, decreased ROM
Ø Septic hip- classically- leg
held:
Externally rotated ,flexed,
abducted
Ø Delay in diagnosis/ tx results
rapid cartilage destruction,
ischemia, avascular necrosis
Ø Film frequently normal w/
acute septic arthritis
Ø U/S- highly sensitive for
detection effusion
Ø Lack of effusion does not
exclude infection
Source Undetermined
84
86. Septic Arthritis
Ø Labs include : elevated ESR and CRP
Ø WBC may be normal or elevated
Ø Blood cx + < 50% cases
Ø Caird, et al ( J Bone Joint Surg, 2006) –
Fever, elevated ESR and CRP best predictor
septic joint
Ø True orthopedic emergency
Ø Arthrocentesis for diagnosis, OR, antibiotics 4-6
wks
86
87. Case
Ø 14 yr old male with 3 mth
hx limp and R knee pain
Ø Wt 100 kg
Ø Limps, has pain with
ROM R hip
Ø Internal rotation and
flexion of hip most limited
Ø No warmth, redness,
afebrile
Ø What is going on?
What do you want to do?
Source Undetermined
Source Undetermined
87
88. Slipped Capital Femoral Epiphysis
Ø Etiology unknown
Ø Male > Female ( 2:1)
Ø Obese
Ø African American, 8-15 yrs of age ( time of growth spurt)
Ø Almost all cases present w/ chronic hip or knee pain
Ø Limitation of hip:
internal rotation
abduction
flexion
Ø Must consider in any preadolescent or adolescent with knee
pain
Ø Must get AP, frog leg views pelvis, both hips
need comparison – slip may be subtle
10-25 % cases bilateral
88
95. This can’t be good…
Ø 16 yr old female
soccer player
Ø Planted leg, felt “pop”
Ø Immediate pain
Ø Quite swollen
Ø Hard to weight bear
Ø What does film show?
Source Undetermined
95
100. Triplanar Fracture
Ø Unusual fracture
Ø Combination SH 2 and
SH 3 fx of distal tibia
Ø Associated fibular fx
common
Ø Most common 12-15
yrs of age
Ø Unstable fracture
Ø Require Ortho consult
Ø Growth plate damage
potentially significant
Ø Anatomic reduction
essential
Source Undetermined Source Undetermined
Source Undetermined
100
101. Splinting Pointers:
- Use the appropriate size and shape
- Pad all bony prominences, especially elbow, ankle, and heels
- Wrap somewhat loosely
- Splint in position of
Kinds of Splints:
1. Volar Splint
2. Thumb Spica Splint
3. Ulnar Gutter Splint
4. Sugar Tong Splint
5. Posterior Short-Leg Splint
6. Stirrup Splint
7. Medial-Lateral Long-Leg Splint
8. Posterior Long Leg Splint
Splinting
101
103. Thumb Spica Splint
Ø 1st metacarpal fx
Ø Thumb fx
Ø Scaphoid fx
Ø Lunate fx
handarmdoc, flickr
103
104. Ulnar Gutter Splint
Ø Fx involving 4th and
5th MCP joint
Ø Boxer’s Fracture
handarmdoc, flickr
104
105. Posterior Long Arm Splint
Ø Proximal Forearm Fx
Ø Elbow Fx
Ø Distal Humerus Fx
Matanya, Wikimedia Commons
105
106. Posterior Short Leg Splint
Ø Ankle fx
Ø Ankle sprain
Ø Foot Fx
Posterior Short-Leg Splint Stirrup Splint
Gray’s Anatomy, Wikimedia Commons
106
107. Posterior Long Leg Splint
Ø Tibial Fx
Ø Fibular Fx
Ø Distal Femur Fx
Gray’s Anatomy, Wikimedia Commons107
108. Splinting Controversies
Ø Cast vs Splint
Plint AC, Perry JJ, et al (Pediatrics, March 2006)
Children’s Hospital Ottawa, Canada
Kids w/ removable splint for buckle fx wrist :
1. better physical function
2. less difficulties ADL
Ø Cast vs Brace
Boutis K, Willan AR, et al ( Pediatrics, June 2007)
Hospital For Sick Children, Toronto, Canada
Removable ankle brace better than casting for some ankle injuries:
1. isolated low risk ankle fractures
2. Greater proportion in aircast/ braced group returned to
baseline activities at 4 weeks
3. Greater parental and child satisfaction
108
109. NSAIDS and Bone Healing
Ø Controversial in orthopedic world
Ø Delayed healing long bones retrospective animal studies
Ø Prospective human studies ( only 2) inconclusive
Ø No pediatric studies
Ø Ibuprofen much better analgesia than Tylenol or Codeine for
fractures ( Clark EC, et al, Pediatrics March 2007)
Ø Ibuprofen provides analgesia equivalent to acetaminophen-
codeine in the treatment of acute pain in children with extremity
injuries: a randomized clinical trial. (Friday JH, Kanegaye JT, McCaslin I,
Zheng A, Harley JR, Acad Emerg Med. 2009 Aug;16(8):711-6 ).
Ø A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen
With Codeine for Acute Pediatric Arm Fracture Pain. (Drendel AL,
Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK. Ann Emerg Med. 2009
Aug 18. Epub )
109
110. Conclusions
Ø Kids are not little adults
Ø Think about mechanisms of injury
Ø Injuries must correspond to history, exam,
developmental level of the child
Ø Non accidental trauma may be manifested by orthopedic/
extremity injury
Ø Don’t be distracted by the obvious- look and treat life
threatening injuries
Ø Be kind and control a child’s pain
Ø Fractures may not always be seen on initial films and
can be very subtle
Ø Think “ fracture” before sprain
Ø When in doubt, SPLINT!!
Ø Early diagnosis and treatment septic arthritis essential
110
111. Question 1
10 yr old boy presents to ED after
hurting R index finger playing
basketball.
Exam remarkable for swelling and
tenderness of the proximal
interphalangeal joint (PIP)
Film shows fx line through the
growth plate extending into
the metaphysis
This is what type of fracture:
a. Salter Harris- 1
b. Salter-Harris -2
c. Salter –Harris -3
d. Salter- Harris- 4
e. Salter-Harris-5
Source Undetermined
111
112. Question 2
13 yr old boy presents to ED for R thigh pain
that began after falling playing soccer.
After further questioning, he admits he
has had similar pain intermittently past 3
weeks
Exam : R hip externally rotated
pain increase when you attempt to flex
or internally rotate hip
The most likely X ray finding is :
a. Displaced fx of femoral shaft
b. Intertrochanteric fx of femur
c. Avulsion fx of anterior superior iliac
spine (ASIS)
d. Step off between metaphysis and
epiphysis of the femur (SCFE)
Source Undetermined
112
113. Question 3
A 9 yr old girl fell playing soccer and twisted her ankle
She has swelling at the lateral malleolus and is tender over
the distal fibula
Films show soft tissue swelling but no fracture
What is the most appropriate treatment:
a. rest, ice, compression, elevation x 2 days and ambulate
as tolerated
b. Short leg cast or splint, repeat films in 1 week
c. Ace wrap and crutches
d. Ankle CT
113
114. Question 4
14 yr old boy complains of R wrist pain after falling while
skateboarding. He thinks he landed on his R hand when he tried to
brace himself
Exam: mild swelling in wrist
snuff box pain and pain when pressure applied to thumb
pain with supination forearm/ hand
Film negative
What do you want to do:
a. Velcro wrist splint
b. Sugar tong splint
c. Thumb spica
d. Ace wrap
e. Volar splint
114
115. Question 5
What nerve is most commonly injured in a
child with a supracondylar fracture?
a. Median
b. Ulnar
c. Radial
d. Brachial
115