Trauma-related Pediatric Orthopedic Emergencies...Monteggia’s Fracture • Fracture proximal ulna...
Transcript of Trauma-related Pediatric Orthopedic Emergencies...Monteggia’s Fracture • Fracture proximal ulna...
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Trauma-related Pediatric Orthopedic Emergencies
Javier Gonzalez del Rey, M.D.
Professor Pediatrics Cincinnati Children’s Hospital Medical Center
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Room # 10 …7 month old “sick since birth”…
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Room # 11…5 y/o Fell off Monkey Bars…Complaining about Elbow
Pain..
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Same…However…What else is wrong?
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Elbow Injuries - Radiographic Evaluation
• Fat pads • Anterior humeral line
middle 1/3 capitellum • Radiocapitellar line
center capitellum all views • Hour Glass Sign • Radial Head • Ossification centers
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Elbow Fractures … Management?
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Room # 12…3 y/o Playing with his brother comes running to his mother
crying and holding the arm in the following position...
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Subluxed Radial Head Nursemaid’s Elbow
• Pull on pronated forearm
• Rare after age 5 yr. • Annular ligament is torn
and some fibers roll over the radial head
• Presentation – Arm in pronation – Elbow slight flexion – No swelling
• Rarely associated with fracture
• Reduction techniques – Supination with flexion – Pronation with flexion – Extension hyperpronation
• Radiographic evaluation not necessary
• Give time to child after reduction and reevaluate for pain
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Room # 13…Time to “show off”…7 y/o fell off tree ..arrives to ED by EMS...
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Forearm Fractures
• Proximal – Olecranon – Radial Head – Monteggia’s
• Distal – Torus – Greenstick – Salter Harris I-IV – Galeazzi’s – Colles’ – Smith’s – Barton’s – Hutchinson’s
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Monteggia’s Fracture
• Fracture proximal ulna with radial head dislocation
• 2% of elbow fx • Caveat - isolated fx of ulna,
expect to find radius injury • Orthopedic referral -
reduction of radial head & ulnar fracture
• Don’t miss - permanent disability
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Galeazzi’s Fracture
• Fracture of radial shaft, usually at junction middle/distal thirds with disruption of radioulnar joint
• More common teenagers & adults
• Suspect in angulated fractured distal radius
• Orthopedic consult
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And you will use the following splint...
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Room # 14…10 y/o Complaining of Pain …Right there after a fall...
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Carpal Bone Fractures Scaphoid (Navicular)
• Largely cartilaginous in childhood - rare fracture • Scaphoid - most commonly fractured • Examination in ulnar deviation of wrist • Most pediatric scaphoid fracture diagnosed at time
of injury heal without complication • The more proximal the fracture line > chance of
avascular necrosis
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And you will use the following splint...
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Metacarpal Fractures
• Uncommon - Mechanism of injury - direct blow • P.E. - flexed fingers should all point the same direction • Most common fracture - 5th MC boxer’s
– Splint with 45-90 degree flexion MCP, mild wrist extension with 15 if < 30 degrees angulation
• Referral – all intra-articular 1st MC or oblique shaft – MC 1,2,3 if > 20 degree – 4th 5th angulated > 30 degrees
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Rotational Deformities • Never acceptable in fracture of metacarpal or
phalanges (little remodeling)
• Acceptance of angulation deformities in metacarpal or phangeal fractures is dependent on the degree of angulation and bony mobility
• Angulation is unacceptable in stationary bone (ie. 2nd or 3rd metacarpal)
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Phalangeal Fractures - Treatment • Middle phalanx -
– less frequent than proximal – SH I or II and not angulated (refer others) – finger splint or buddy tape
• Distal phalanx - SH I or II, not angulated – bulky dressing, splint or buddy tape
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Interphalangeal Dislocations & Tendon Injuries
• Uncommon in young children - common in adolescents
• Radiographic evaluation prior to manipulation to rule out concomitant fractures
• Perform reduction under digital block or nitrous sedation
• May require orthopedic referral • Post reduction films and splints for 3 weeks
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Tendon Injuries - Finger
• Mallet finger (baseball finger) • Boutonniere finger • Jersey finger • Gamekeeper’s Thumb (skier’s)
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Room # 15…5 y/o Fell off his bike (this one was wearing his helmet!)…pale
and “lethargic”…HR 135 ...your diagnosis is?
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Room # 16…15 y/o AA female complaining of Left Knee Pain …seen by PMD…Knee X-Rays are negative
… Presents to your ED …so??
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Room # 17…2 y/o ….(Get it = a 2 y/o)…Refusing to Walk … No Hx of
trauma or Fever...
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Fractures of the Tibia and Fibula
• Tibial and fibular shaft fractures are the most common fractures of the lower extremity in children
• Toddler’s Fracture – Acute gait disturbance - refusal to walk – History of minor accident (or no Hx.) – Subtle physical findings – Spiral or oblique fracture of distal tibia – Splint or short leg cast
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Room # 18…16 y/o Presents to ED with pain, edema @ ankle … not able
to walk … Your diagnosis …
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Next Step ...
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Room # 19…Painful swollen ankle…
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Tillaux Fracture
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Tillaux Fracture
• SH III of the tibia caused by GP closing medial to lateral
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Ankle Fractures
• May have any SH fracture of tibia or fibula • SH I fibula
– common – cast for 2 week intervals
• SH II tibia – Most common tibial fracture – Tibia = higher energy – Treatment
• posterior splint • sugar tong with foot plate
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Tillaux Fracture Triplane
Bimalleolar Trimalleolar
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Ankle Sprains
• Prior to growth plate closure = SH I fracture • Most common = inversion injury • Eversion = higher rate of fractures • Ottawa criteria
– pain in the area of the malleoli – inability to bear weight - immediately & 4 step ED
– bony tenderness distal tibia or fibula
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Sprains - Rehabilitation
Rest Ice Compression Elevation Motion Medication
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Room # 20…The student wants to present a new case …a 1 month old “spitting up”
after 5 formula changes…
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Room # 2 …14 y/o fell at gym practice…
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Initial Approach
• ABC’s • Evaluate involved limp for:
– Neurovascular compromise – Open fractures / compartment syndrome – Fractures with increased risk for significant
bleeding - Pelvic Fractures / Femur Fractures • Consider associated injury • PAIN MANAGEMENT! • Radiographic evaluation
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Initial Approach
• ABC’s • Evaluate involved limp for:
– Neurovascular compromise – Open fractures / compartment syndrome – Fractures with increased risk for significant
bleeding - Pelvic Fractures / Femur Fractures • Consider associated injury • PAIN MANAGEMENT! – Please “splint” • Radiographic evaluation
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Room # 4 …3 y/o presents to PCP’s office refusing to use the right hand and foot….? Hx of a fall…you send
them for X-Rays...
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Radiographic Evaluation
• Should be ordered if: – Point tenderness – Large amount of swelling – Severe pain – Persistent symptoms after 3 - 5 days – High risk mechanism – Pain with axial / transverse loading
• Joint above and below injury • Comparison views
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Room # 5 … Piece of cake …broken leg …need to call Ortho in this great Sunday afternoon…please Describe...
Femur Fx …. Diaphysis Transverse Overriding Shortening
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Radiographic Findings
• Articular • Subcapital • Cervical • Supracondylar • Transcondylar • Intercondylar • Malleolar
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Radiographic Findings
• Spiral • Impacted • Comminuted
• Longitudinal • Transverse • Oblique
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Radiographic Findings
• Displacement • Angulation • Overriding • Shortening • Distraction • Rotation
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Orthopedic Referral
• Open fractures • Neurovascular compromise • Obvious deformity • Significant joint or growth plate involvement • Dislocation of major joints other than the
shoulder • Pelvic fractures or spinal injuries
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Room # 6…typical family of 3 after a soccer practice
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So…this is…a?
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And this is …?
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Fracture Unique to Children
• Greenstick • Torus (buckle) • Bowing • Avulsion • Physeal
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Room # 7 as usual…cousins, relatives and neighbors who heard that everyone is
having a great Sunday at the “all inclusive” ED …
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Room # 7 as usual…cousins, relatives and neighboors who heard that everyone is
having a great Sunday at the “all inclusive” ED …free meals, free soft drinks, movies, toys…and free rides (wheelchairs in the
waiting room)…
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Please tell me what these are...
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Physeal Fractures Salter Harris Classification
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Room # 8…12 y/o Fell of bike…(head is ok - he was not wearing a helmet)…and presents to your Urgent Care with
left shoulder pain…so…what do we do?
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Clavicle Fractures
• Most frequently fractured bone in childhood • Usually result from direct trauma and from direct forces
transmitted by falls onto an outstretched hand • More than 50% in children younger than 10 years of age • Most are greenstick to the midshaft • Typically child complains of shoulder pain or injury is
initially unnoticed until “a lump” appears as the callus forms • Treatment- figure of eight or sling and swath + education
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Room # 9…14 y/o Male presents to your ED with severe left shoulder
pain...
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Next step...
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Shoulder Dislocations
• Shallow joint with wide range of motions • Age adolescent or older • 95% of dislocations are anterior. • Arm is abducted and externally rotated
and then forced posteriorly
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Anterior Dislocations
• Subcoracoid (most common) • Subglenoid • Subclavicular
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Management - Reduction
• Adequate analgesia and muscle relaxation • Several reduction maneuvers:
– Stimson – Scapular rotation prone / sitting – External rotation – Traction counter traction – Eskimo technique
• Immediately immobilize • Post-reduction xray • Orthopedic follow-up
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Stimson…And Scapular Rotations...
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Eskimo….And External Rotation...
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Traction Counter Traction
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In Conclusion...
• ABC’s • Careful history and physical examination • Pain management • Radiographic evaluation - remember SH • Think “fracture” before “sprain” • When in doubt - SPLINT!!
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