Fracturas óseas en pediatría Walter F. Lambert, MD University of Miami Child Protection Team.
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Transcript of Fracturas óseas en pediatría Walter F. Lambert, MD University of Miami Child Protection Team.
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Fracturas óseasFracturas óseasen pediatríaen pediatría
Walter F. Lambert, MDWalter F. Lambert, MDUniversity of Miami Child Protection TeamUniversity of Miami Child Protection Team
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Partes del huesoPartes del hueso
Epiphysis = End of the bone where growth occurs
Metaphysis = Flaring part of bone near the end
Diaphysis = Shaft, the long part of the bone
Periosteum = Tough membrane covering bone, which helps repair fractures
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Indicadores de MaltratoIndicadores de Maltrato Comportamentales
– Padres: Inapropiado, hostil, inmaduro, psicopático, adicto– Niño: Aislado, tímido, explosivo, agresivo
Historia– Discrepancia entre historia y hallazgos– Historias que varían de una entrevista a la próxima o entre personas– Historia inapropiada para la edad, actividad y herida– Falta de preocupación de la herida por el padre/la madre– Antepasados de maltrato, heridas no tratadas, o herman@s maltratados– Visitas en horas raras
El Examen – Heridas múltiples en varias etapas de sanar– Evidencia del castigo físico (moretones en patron)– Heridas no relacionadas– Herida fueras de proporción al accidente alegado– Trauma de la genitales o enfermedades transmitidas sexualmente – Fracturas que surgían abuso
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Heridas del esqueletoHeridas del esqueleto
Cualquier herida del esqueleto puede ser accidente o infligida.
Un historia detallada en el contexto del nivel de desarrollo y condiciones medicas del niñ@ .
Caídas y heridas son común y usualmente de poco importancia.
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Evaluación de fracturas Evaluación de fracturas Fractura: tipo localización: asís o periferia; simétrico o asimétrico cantidad de fractura(s) edad de fractura(s) otras heridas Esqueleto configuración de los huesos y esqueleto densidad de los huesos presencia de otros signos (Wormian bones) Niño edad y nivel de desarrollo presencia/ausencia de una patología Historia detalles de la historia (evento presenciado o no)
biomecánica de la fractura
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Household InjuryHousehold Injury
Warrington: Accidents and resulting injuries in premoblie infants. Arch Dis Child 2001; 85: 104-7– >11,466 infants <6 mo: 3357 (22%) involved in
household fall; 53% from beds & 12% from arms. – Only 14% reported visible injuries, of which 56% were
bruises; 97% of involved the head. – 21 falls (<1%) resulted in any serious injury (defined as
concussion or fracture)– (A burn/scald occurred in 172 cases (1.5%); hot drinks
and water & radiators, cookers, and hot food.)
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Heridas normales en la infanciaHeridas normales en la infancia
Lyons: Falling out of bed: a relatively benign occurrence. Pediatrics 1993; 92:125-7– 207 caídas desde 25-54 pulgadas (63-138 cm) in
niños hospitalizados < 6 años de edad– 2 fracturas (parietal & clavicula)
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Injuries Resulting from Short Vertical Injuries Resulting from Short Vertical FallsFalls
Rarely Life-ThreateningRarely Life-Threatening Series of 167 children less than 10 months old who fell
from heights of < 48 inches inches Results
– 85% suffered minor or no injury
– 15% suffered long bone or skull fractures The only 2 infants with intracranial hemorrhage were
discovered to be victims of abuse No child suffered an intracranial hemorrhage from
falling off a bed or being dropped
Tarantino CA et. al. Short Vertical Falls in Infants. Pediatric Emergency Care 15:5, 1999.
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Injuries Resulting from Falling Down Injuries Resulting from Falling Down
StairsStairs Rarely SeriousRarely Serious Joffe and Ludwig reviewed 363
consecutive pediatric patients seen in the ED who had fallen down stairs
Most injuries were minor Only 3% were injured sufficiently
to be admitted to the hospital No patient had life-threatening
injuries, and none required intensive care
Joffe M and Ludwig S. Stairway Injuries in Children. Pediatrics 82:457, 1988.
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Types of Long Bone FracturesTypes of Long Bone FracturesMedical TerminologyMedical Terminology
Mercier, LR. Practical Orthopedics, 4th edition. Mosby, 1995.
Comminuted = Shattered, broken in several pieces
Transverse = Broken straight across
Oblique = Broken at an angle
Spiral = Broken as with a circular force
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Diagnosis diferencial de fracturas Diagnosis diferencial de fracturas y reacción del periostioy reacción del periostio
Trauma
trauma en el parto
accidente
no-accidental negligecia
infligido
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Diagnosis diferencial de Diagnosis diferencial de fracturas y reacción del periostiofracturas y reacción del periostio
Anomalías de la formación del colágeno osteogenesis imperfecta deficiencia de cobre síndrome de Menkes Defectos congénitos basados en minerales enfermedad metabólica del hueso del prematuro raquítica resistente a la vitamina D malabsorbtion Defectos adquiridos basados en minerales raquítica por desnutrición uso de diuréticos o glucocorticiodes intoxicación (plomo, etc.) condiciones de desuso Reacción del periostio del recien nacido y infamia temprana
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Diagnosis diferencial radiológico,Diagnosis diferencial radiológico,no fracturasno fracturas
Sífilis congénitaOsteomielitis Artritis sépticaAnemia falciformeDeficiencia de vitamina C (escorbuto)Hipervitaminosis ALeucemia, neuroblastoma, osteoma
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Skeletal InjuriesSkeletal Injuries Degrees of Specificity for AbuseDegrees of Specificity for Abuse
High specificity High specificity
Moderate specificityModerate specificity
Low specificityLow specificityKleinman, Paul. Diagnostic Imaging of Child Abuse. Williams and Wilkins, 1998, page 9.
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Especificidad baja para for AbusoEspecificidad baja para for Abuso
fractura de la claviculafractura de un hueso largofractura del cranio en linia
(especialmente parietal)
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Especificidad ModeradaEspecificidad Moderada
fracturas multiple(especialmente bilateral)Fracturas de edades differentesseparationes epiphysealfracturas del cuerpo vertebral body y
suluxacionesfracturas digitalesfracturas del cranio complejas
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Especificad AltaEspecificad Alta
Lesiones de la metafases Fracturas de las costillas posterioresFractura de la escapulaFractura del proceso espinoso de la vértebraFractura del esternon
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Fracturas del cráneoFracturas del cráneo
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Fracturas de la Fracturas de la costillascostillas
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Dynamics of Posterior Rib Dynamics of Posterior Rib FracturesFractures
Newsletter of the American Academy of Pediatrics Section on Chld Abuse, Volume 9:1, 1997.
They’re No Accident
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Fracturas de las costillasFracturas de las costillas
Bulloch: Cause & clinical characteristics of rib fractures in infants. Pediatrics 2000; 105(4):E48 – Todos niñ@s < 1 año ingresados con fracturas de las
costillas durante 3 años– 39 niñ@s; 32 (82%) abusivo– 3: accidente; 1: trauma asociado con el parto;
3: fragilidad de los huesos (OI, raquítica, prematuro)
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Does Cardiopulmonary Resuscitation Does Cardiopulmonary Resuscitation Cause Rib Fractures?Cause Rib Fractures?
Feldman and Brewer studied 113 children including Feldman and Brewer studied 113 children including 41 victims of abuse, 50 who had received CPR, and 41 victims of abuse, 50 who had received CPR, and 22 with known rib fractures22 with known rib fractures– 48 % of rib fractures were due to abuse48 % of rib fractures were due to abuse– No rib fractures were due to CPRNo rib fractures were due to CPR
Spevak et al found Spevak et al found no rib fracturesno rib fractures on postmortem on postmortem radiographs of 91 infants who had undergone CPR.radiographs of 91 infants who had undergone CPR.
Pediatrics 73:339, March 1984
JAMA 272:617, August 1994
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Posterior Rib FracturesPosterior Rib FracturesHighly Specific for AbuseHighly Specific for Abuse
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HighHigh Specificity for Abuse Specificity for Abuse
Metaphyseal lesions
Posterior rib fractures
Scapular fractures
Spinous process fractures
Sternal fractures
Kleinman, Paul. Diagnostic Imaging in Child Abuse, 2nd Edition. Williams and Wilkins, 1998, page 9.
Fractures Rarely Seen in Other Circumstances
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Lesiones de la metaphysis clásicaLesiones de la metaphysis clásica Descrito como fractura “de la esquina” o “bucket
handle” Se habia pensado que eara heridas por avulsión Kleinman: Diagnostic Imaging of infant abuse. 2nd
edition, 1998– Estudio estas fracturas en niños abusados en la autopsia
comparando los estudios radiológicas y la histología – En actualidad son una seria de microfracturas en la
spongiosa primaria de la metaphysis– Parecen como “esquina” cuando son visita en tangente y “
bucket handle” cuando vista en angulo
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Baby JBaby J One month old infant
brought to ED with C/O swollen right knee
New boyfriend caring for baby; mom noted swelling shortly after return
X-ray shows chip fracture of distal right femoral metaphysis
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Baby JCBaby JC One month old infant
brought to ED with C/O swollen right knee
New boyfriend caring for baby; mom noted swelling shortly after return
X-ray shows chip fracture of distal right femoral metaphysis
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Baby JCBaby JC
Right Leg Left Leg
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Baby JCBaby JC
9 Days Later
Right Leg Right Leg
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Fracturas Fracturas
Fracturas in niñ@s pequeños, especialmente en lactantes no-móviles, muy frecuentemente son resulto de maltrato.
55-70% de todos fracturas infligidas: < 1 año de edad 80% of fracturas abusivas : <18 meses de edad Trauma de esqueleto oculta y multifocal es en gran
parte limitado a los primer dos años de la vida.
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Protocoló en casos de suspecha Protocoló en casos de suspecha de maltrato con fracturasde maltrato con fracturas
Seria ósea: “obligatorio” < 2 años de edad
(? repetir en 2 semanas) Tomografía del cerebro: < 1 año de edad Scan (medicina nuclear) de los huesos para
areas en cuestión O en niñ@s mayores
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Serie ÓseaSerie Ósea Cráneo-4 vistasTórax (AP y lateral) Costillas bilaterales (vistas oblicuas)Extremidades superiores (incluyendo manos)
bilaterales (AP y lateral)Extremidades inferiores (incluyendo pies) bilaterales (AP y lateral)Pelvis (AP)Espina dorsal (lateral)
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Gracias por la invitaciónGracias por la invitación