Pediatric Orthopedic Emergencies Tracy Merrill MD

1. Pediatric Orthopedic Emergencies Tracy Merrill MD Division of Pediatric Emergency Medicine Children’s Healthcare of Atlanta at Egleston and Emory University School of Medicine Use * † ‡ if there are authors other than our group, using * to demark us, if its only us take out *

2. The Limping Child • 4 year old child presents to the emergency department with a chief complaint of limping for two days • No report of trauma • Afebrile • No additional systemic symptoms • PMH negative for joint problems or chronic disease • Nontender to palpation and no pain with passive ROM but limps when bears weight • Differential? • Workup?

3. Transient Synovitis - Definition • Also known as “irritable hip” or “toxic synovitis” • The #1 cause of acute hip pain in children • Benign self limited disease of uncertain etiology most commonly affecting the hip joint • Usually occurs in children age 3 to 10 years • 4 cases in adults have been reported • Almost always unilateral • Causes pain and limitation of the movement of the hip, with or without an effusion • Pain is the worst when walking, usually presents with a limp or refusal to bear weight

4. Transient Synovitis – Etiology, Treatment • Due to transient sterile inflammation of the synovium of the hip • No clear precipitants, ?post viral • Sudden onset, gradual resolution • Self limited, usually lasts 4-7 days • Treated with OTC analgesics: ibuprofen and tylenol • Study done showed ibuprofen decreased median duration of symptoms from 4.5 days to 2 days • No residual long term deficits • Most important thing to do is distinguish it from septic arthritis

5. Septic Arthritis - Definition • Results from bacterial invasion of the joint space • Can occur at any age but 50% of cases reported occur in children under the age of 3 years • Acute onset • Usually monoarticular • Usually the large peripheral joints • Organisms can invade the joint by three possible mechanisms: • Usually through hematogenous seeding • Adjacent osteomyelitis • Direct inoculation from a penetrating wound

6. Septic Arthritis - Bugs • Staphylococcus aureus • Streptococcus • GBS • S pneumoniae • S pyogenes • Neisseria gonorrhoeae • Haemophilus influenzae

7. Septic Arthritis - Presentation • Most commonly involves the hip joint “septic coxitis” • Symptoms include: • Fever • Joint pain • Limp and an inability to bear weight • Pain with active or passive range of motion • Joint swelling, effusion, warmth, tenderness • The patient holds their leg in a flexed, abducted, externally rotated position

8. Septic Arthritis - Presentation • May be extremely difficult to diagnose in infants and nonverbal children • Fever, irritability, and decreased po intake may be your only clues • May fuss more when handled due to movement of the affected extremity • May have decreased movement of an extremity • Predisposing factors include recent URI or otitis, skin or soft tissue infections, traumatic puncture wounds, femoral venipunctures, underlying chronic disease, or immunosuppression

9. Septic Arthritis - Differential • Differential can include: • Transient synovitis • Viral arthritis • Traumatic arthritis • Periarticular cellulitis • Osteomyelitis • JRA • Acute rheumatic fever (JONES criteria) • Lyme disease • Post-infectious reactive arthritis • Oncologic process (eg. leukemia, osteosarcoma)

10. Septic Arthritis - Diagnosis • Laboratory: • CBC with diff shows elevated white count with a left shift • Blood cultures are positive 40-50% of the time • CRP elevated • ESR elevated • Joint aspiration shows elevated WBC’s 10,000-250,000 (normal is less than 200), >75% segs, and decreased glucose • Imaging: • Plain films may show a displacement or blurring of periarticular fat pads as well as an increased hip joint space • MRI

11. Septic Arthritis - Diagnosis • Study done by Jung, et al. (2003*) found five predictors that correlated with a high probability of septic arthritis to help distinguish from transient synovitis whose presentation can be similar • Temperature >37 degrees Celsius (37.7 vs. 36.6) • WBC >11,000/mL (18.2 vs. 8.2) • CRP >1mg/dL (10.1 vs. 0.66) • ESR >20mm/h (79.2 vs. 20.3) • Joint space difference >2mm between the affected and unaffected sides (difference of 4.0mm vs. 1.2mm) • No significant difference found in platelet count

12. Septic Arthritis - Treatment • Treatment: • Prompt orthopedic consultation • Surgical debridement of the hip through arthrotomy • Hospitalization until fever defervescence and signs of clinical improvement post operatively • Intravenous antibiotics for 4 weeks • Usually requires central line placement for home administration of antibiotics

13. Septic Arthritis - Treatment • Antibiotic Therapy • <2 months of age: oxacillin or nafcillin plus gentamicin for Gram negatives • 2 months to 3 years: ampicillin-sulbactam or ceftriaxone • >3years: oxacillin, nafcillin, or ceftriaxone • Adjust based on gram stain and culture results • Consider Clinda or Vanc if suspect MRSA

14. Septic Arthritis - Outcomes • Complications • Osteomyelitis, osteonecrosis • Avascular necrosis due to the pressure on blood vessels and cartilage in the femoral head area • Epiphyseal separation • Pathologic dislocation • Growth arrest and subsequent leg length discrepancies up to several inches • Sepsis

15. Septic Arthritis - Outcomes • Prognosis • Joint destruction can occur within days leading to longterm disability, residual deformity, arthritis, and decreased range of motion • Prior to the discovery of antibiotics, pediatric mortality rates averaged 50% • If diagnosed early before changes seen on plain films, have an improved prognosis • Note that joint destruction as a result of gonococcal infection is uncommon

16. SCFE: Slipped Capital Femoral Epiphysis • An acquired growth plate injury • The separation of the proximal femoral epiphyses from the metaphysis at the level of the growth plate • Most commonly occurs in adolescents and preadolescents who are vulnerable to slippage due to widened and weakened growth plates during periods of rapid growth • Occurs in 2-10 per 100,000 adolescents in the US • Peak age is 10-13 in females and 12-16 in males • Rarely occurs after menarche • More common in males, male to female ratio is 2.5 : 1.6 • More common in Pacific Islanders and African Americans

17. SCFE - Etiology • The epiphysis is located at the top of the femur and is connected to the metaphysis via the physis or growth plate • The head of the femur stays within the acetabulum while the femur slips • Occurs when the shearing stress exerted onto the femoral head is greater than the resistance provided by the physis • Occurs in the hypertrophic zone, the weakest zone of the physis

18. SCFE - Risk Factors • Obesity resulting in mechanical overload of an immature growth plate, 81% of cases are in children over the 95th percentile for BMI • Local trauma • Hypothyroidism • Panhypopituitarism • Growth hormone administration • Renal osteodystrophy • Previous radiation therapy

19. SCFE - Presentation • Limp • Hip, groin, thigh, or knee pain • Hip pain often referred to the knee due to the pathways of the obturator and femoral nerves • 15% of patients report pain only in the distal thigh and medial knee • If stable, can still bear weight • As the slip progresses, eventually get external rotation of the toes when walking • Decreased range of motion of the hip • If chronic or unrecognized, may develop atrophy of the thigh and gluteal muscles • A stable chronic slip may suddenly worsen and become unstable with what seems like minor trauma

20. SCFE - Diagnosis • Radiography: bilateral A/P and frog leg x-rays of the hips • “Ice cream falling off the cone” the femoral head is the ice cream that falls off the femur which is the cone

21. SCFE – Grades of severity

22. SCFE - Treatment • Screw fixation under fluoro to prevent further slippage • Strict non weight bearing leading up to surgery and then partial for 6-8 weeks after surgery • Never attempt to reduce the slip during surgery or will increase the risk of avascular necrosis • For severe slips, a corrective osteotomy may be required

23. SCFE - Treatment • Technically only need fixation until the growth plate fuses but would be too invasive to remove the screw, so they are usually left in unless complications develop • Some will do prophylactic pinning of the contra- lateral hip if at high risk for a bilateral slip • Casting or bracing not required postop • Sports restrictions for 3-6 months

24. SCFE - Complications • Avascular necrosis: altered blood supply to the proximal femoral head and physis leading to bone death, most commonly occurs in severe or unstable slips, can lead to rapid hip deterioration and severe progressive arthritis • Chondrolysis: necrosis of the articular cartilage, can progress to severe pain, decreased range of motion, and contracture of the hip

25. SCFE - Prognosis • Occurs bilaterally in 25-40% of cases • Most contralateral slips occur within 6-12 months of the index case • Most stable or chronic SCFE’s are treated effectively with minimal complications, makes up >90% of all slips • The more severe the slippage, the more altered are the mechanics of hip movement, and the sooner the hip wears down, leading to premature arthritis • The most severe cases may eventually require total hip replacements

26. Legg-Calve Perthes Disease • Aseptic necrosis of the femoral head and neck • Results from a disruption of the blood supply • Onset usually between the ages of 4-8 years • Male to female ratio of 5:1 • Bilateral in 10% of cases • Present with a limp • Pain may refer to the knee, medial thigh, or groin along the distribution of the obturator nerve • Exam reveals limited hip abduction and medial rotation • More advanced cases may show leg length shortening or thigh muscle atrophy

27. Legg-Calve-Perthes Disease • The exact cause is unknown but can be related to anything that may damage the blood supply to the hip:

28. Legg-Calve-Perthes Disease • Radiographs show: • Smaller denser femoral head • Relative osteopenia of the adjacent proximal femur and pelvis • Widened joint space • Subchondral lucent area • Irregular physeal plate, fragmented in later stages • Blurred and lucent metaphysis • Confirm with MRI or bone scan

29. Legg-Calve-Perthes Disease • A temporary condition • Occurs in 4 phases: • 1. From several months up to one year, blood supply is absent, portions of the bone die, the femoral head collapses and looses it’s shape • 2. From one to three years, the dead cells are replaced with new bone cells • 3. Also from one to three years, the femoral head begins to remodel and obtain its shape again • 4. Completion of the healing process

30. Legg-Calve-Perthes Disease • Treatment: • Rest, often with the aid of crutches, wheelchair • Activity restrictions • NSAIDS • Traction, casting, or bracing to hold the femoral head in the hip socket to preserve the round shape of the femoral head during remodeling • Surgery to secure the femoral head in the hip socket • Physical therapy to keep the hip muscles strong and maintain range of motion • Complications: • Limited hip motion • Leg length differences • Arthritis long term

31. Osgood-Schlatter Disease • Tibial tubercle apophysitis • Due to traction of the patellar ligament on the tibial tuberosity • An overuse syndrome • Occurs most frequently in boys age 11-15 years who are active in sports • Pain to palpation of the tibial tubercle, pain with quadriceps contraction • May have overlying soft tissue swelling • Radiographs are either normal or may show an irregular tibial tubercle with or without fragmentation • Often mistaken for avulsion fractures

32. Osgood-Schlatter Disease • Self limited • Cured by fusion of the tubercle • Treatment is limitation of physical activity to the point of pain tolerance and RICE • Rest • Ice • Compression with ace wrap or neoprene sleeve • Elevate • NSAIDS may help with acute pain exacerbations

33. Osteomyelitis - Definition • An infection of the bone • 90% of cases involve a single bone • Pathogens can spread to the bone from the blood stream from distant infections, from direct penetration from trauma, or from spread from overlying soft tissue infections • Long bones of the lower extremity are the most commonly affected from hematogenous seeding • Usually beneath the epiphyseal plates in the rapid growth areas • Up to 25% may occur in short or nontubular bones

34. Osteomyelitis - Bugs • Staphylococcus aureus is the number one cause in any age group! 70-90% of cases! • Haemophilus influenzae • GBS and enteric rods in neonates • Salmonella in sickle cell patients • Pseudomonas aeruginosa in foot punctures

35. Osteomyelitis - Presentation • Symptoms: • Limp • Difficulty bearing weight • Bone pain, gradual onset, constant • Infants are usually fussy, febrile, and may not be moving all extremities equally • Fever over 38.5 C in up to 80% of patients • Physical Exam: • Point tenderness on exam • Local erythema and edema once purulent material has ruptured through the bone cortex

36. Osteomyelitis

37. Osteomyelitis - Diagnosis • Laboratory • White blood cell count is normal in up to two thirds of cases! • An elevated ESR is more sensitive, elevated in up to 90% of cases, peaks at day 3-5 of treatment, normalizes by 3 weeks • CRP is best for monitoring response to treatment, elevated in up to 98% of cases, peaks at day 2 of treatment, normalizes in as little as one week in uncomplicated cases • Blood culture yields an organism in 30-50% of cases • Bone aspiration for gram stain and culture yields an organism in 50-70% of cases

38. Osteomyelitis - Diagnosis • Radiographs may be normal early in the course but as bony destruction occurs, may see periosteal reactions (in 3-10 days) or lytic lesions (in 10-12 days) • Technetium-99 bone scan will show areas of increased blood flow due to inflammation, sensitivity >90% (note: your bone scan won’t be affected by needle aspiration) • If have a poor treatment response, consider MRI which can aid in finding drainable subperiosteal abscesses • If have a pelvic osteomyelitis, consider MRI early in the course of evaluation due to an increased occurrence of abscesses in these cases, or can use MRI to replace bone scan in the diagnosis of these cases

39. Osteomyelitis

40. Osteomyelitis

41. Osteomyelitis - Treatment • All cases must be admitted for IV antibiotics • Immediate orthopedic consultation is required for surgical debridement and draining of any subperiosteal abscesses • Total antibiotic course of 3-4 weeks, up to 6 weeks in complicated or extensive cases • Sickle cell patients who may have areas of poorly perfused bone as well as immunocompromised patients require longer treatment duration • Use the max dosage range listed for the antibiotic chosen • IV route until clinical symptoms improved and afebrile for at least 3-5 days • Can then complete treatment course with oral high dose antibiotics

42. Osteomyelitis - Treatment • Antibiotic Therapy: • Anti-staphylococcal penicillins: • Oxacillin (and gentamicin) in neonates • Nafcillin or oxacillin monotherapy in older children • First generation cephalosporins • Ancef (cefazolin) • Clindamycin if suspect MRSA • Vancomycin if clinda resistant or D test positive for inducible clinda resistance • Linezolid as last resort for highly resistant organisms

43. Osteomyelitis - Outcomes • Complications: • Bony and cartilaginous destruction • Growth arrest • Permanent deformity • Sepsis • Chronic or recurring osteomyelitis • Prognosis: • Complications occur in only ~5% of cases, usually when there was a delay in diagnosis or treatment • Recurrences can occur up to 30 years later, usually the same organism, often reactivated by local trauma

44. Compartment Syndrome • Due to an increase in intracompartmental pressure • From anything that decreases compartment size: • Tight closure of fascial defects • Tight dressings or casts • Or from anything that increases comparment components: • Bleeding from fractures or trauma • Increased capillary permeability from burns • Venous obstruction • Muscle hypertrophy • Can result in ischemic muscle necrosis and subsequent contracture and dysfunction

45. Compartment Syndrome • The lower leg is most susceptible due to its small fascial compartments • Irreversible muscle injury may occur in as little as 6 hours from onset of ischemia • Diagnosis “The Five P’s” • Pain out of proportion to the injury, exacerbated by passive stretching of the muscle • Paresthesia • Pallor • Paralysis • Pulselessness

46. Compartment Syndrome • Treatment • Loosen all restrictive dressings or splints • Direct measurement of compartment pressures if pain not immediately relieved • Incisional release or fasciotomy required if any compartment pressures are over 30mmHg

47. Fractures: Definitions • Alignment: refers to angulation or rotation of the fracture fragments in reference to each other • Apposition: refers to the amount of end to end contact between the fractured bone fragments • Avulsion: “chip fracture”, small fracture near a joint that usually has a ligament or tendon attached • Closed: “simple fracture”, no overlying open wound • Open: “compound fracture”, open wound present • Comminuted: multiple fragments • Dislocation: “luxation”, disruption of the continuity of a joint • Displaced: the two bone ends are separated • Epiphyseal: involves the growth plate or epiphysis • Greenstick: incomplete fracture • Impacted: broken ends are driven into each other • Intra-articular: involves the joint surface of a bone

48. Fractures: Definitions • Delayed union: slower than normal healing • Malunion: healing in an unsatisfactory position • Nonunion: failure of bone healing • Occult: can’t see the fracture on the plain films but other positive signs suggest a fracture such as a posterior fat pad on a lateral elbow film • Pathologic: due to an underlying bone weakness, usually cysts, neoplasms, or metabolic bone disease • Stress: occurs when weak bone is stressed normally or when normal bone is stressed excessively, usually in weight bearing bones • Subluxation: partial disruption of a joint, an incomplete dislocation, most common in pediatrics is nursemaid elbow • Torus: “buckle fracture”, caused by compression of the cortex, most commonly occurs in the distal radius

49. Pediatric Fractures • Fractures in children differ from those in adults • Nonunion is rare due to the active periosteum and abundant blood supply surrounding the growing bone • Continued bone growth after the fracture is healed allows for correction of minor deformities • The closer the fracture is to the end of the bone and the younger the patient, the greater the amount of angulation that is acceptable • The distal radius may correct up to 10-15 degrees per year • Side to side apposition is acceptable in long bone fractures in boys under 12yrs and girls under 10yrs

50. Pediatric Fractures • Slight shortening (overlapping of 2 bone ends) is acceptable and may even be desirable in leg fractures due to the acceleration of growth seen after a displaced fracture, the tibia and femur may overgrow up to 1cm • Exceptions: • Rotational malalignment will not correct itself • Angulated midshaft fractures will not realign • Sprains are rare in children under age 12 yrs, if tenderness is present over a growth plate coupled with overlying soft tissue swelling, assume a fracture even if x-rays are negative