Pediatric Orthopedic Trauma: An Overview

1. Pediatric Orthopedic Trauma: An Overview Ahmed Bazzi, D.O. Fellow, Pediatric Orthopaedic Surgery March 22, 2013

2. Few Orthopedic Emergencies to Discuss • Compartment Syndrome • Open Fractures • Common pediatric fractures and peri-operative management • Nursing Management of the Ortho pt • C-spine clearance Scope of our discussion

3. Compartment syndrome • Open fractures • Spinal injury & fxs • CaudaEquina Syndrome • Joint Dislocations Orthopedic Emergencies

4. Increased pressure in osseofascial compartments • Decreased perfusion of tissues • Cellular anoxia and subsequent cell death Compartment Syndrome

5. Risk factors: • Fracture • Tibia • Calcaneus • Crush injuries of foot • Corrective osteotomies • Traction • Bleeding disorders • anticoagulants • Burns • 3rd degree circumferential • Tight dressings Compartment Syndrome

6. Diagnosis • At risk patient • Physical exam • 7 P’s • PAIN • Paresthesias • Pressure • Pulselessness • Pallor • Paralysis • poikilothermia Compartment Syndrome

7. Timing • Mean 7h post injury • May be up to 4 days post injury Compartment Syndrome McQueen et al, JBJS 1996

8. Equivocal patient • Obtunded, etc • Pressure monitor Compartment Syndrome

9. Treatment: • Split/remove casts/occlusive dressings • Fasciotomy • Wound vacuum • Repeat debridement • Delayed wound closure Compartment Syndrome

10. When to release? • Clinical situation • Within 30mmHg of diastolic pressure Compartment Syndrome

11. “Compound” fractures • Bone through skin • Treatment goals: • Prevent infection • Unite fracture • Restore function Open Fractures

12. Assessment • Mechanism of injury • Degree of contamination • Soft tissue involvement Open Fractures

13. Classification • Type I • Less than 1cm open • Type II • More than 1cm • Type IIIa • Extensive soft tissue damage • Type IIIb • Requires skin coverage • Type IIIC • Requires vascular repair Open Fractures Gustilo et al J Trauma, 1984

14. Initial cultures offer no benefit • Therapeutic antibiotics • Ancef/gentamycin • Within 3h of injury • Bead pouch • 3 days Open Fractures

15. Irrigation • Surgical débridement • Fixation • Splinting/casting • Intramedullary nailing • Ex fix • plating Open Fractures

16. Elbow Fxs • Femur Fxs • Tibia Fxs • The Poly-Trauma pt Common Fxs on In-patient Ward

17. SupracondylarHumerusFx

18. Injury force • Hyperextension + Olecranon fulcrum • Posterior displacement in 97% • Rotational component allows tilting • Heralds instability, typically varus • Gartland Classification • Type 1: minimal displacement • Type 2: extension deformity • Type 3: complete displacement SupracondylarHumerusFxs

19. Important to document NV exam SupracondylarHumerusFxs

20. Surgical Tx of SupracondylarHumerusFxs

21. Proximal Femur Development • Ossification • Proximal femur (wk 7 in utero) • Proximal femur epiphysis (4-8 mos) • Greater trochanter (4 years) • Physeal closure • Proximal femoral epiphysis (18 yr) • Trochantericapophysis (16-18 yr) Pediatric Femur Fractures

22. Peds Hip Fxs

23. Medial and lateral femoral circumflex artery Ligamentumteres vessels Blood Supply to the Hip

24. Rare (<1% pediatric fractures) • Mechanism: • Usually high energy injury (MVC) • Pathologic (tumor, cyst) • Stress fx • Present with hip/groin pain and limited WB • LE may appear shortened, ER. Incidence

25. Treatment

26. Femur Fxs: Shaft

27. 1.6% pediatric fractures • M > F (2.6 : 1) • Bimodal age distribution • 2 to 4 yrs • Adolescence • More common in summer • Consider abuse • Schwend et al. 9% of cases due to abuse Femoral Diaphyseal Fractures

28. Mechanism: • Young children: Low energy falls, twisting. Abuse. • Adolescent: High energy (MVC, ped struck) • Pathologic fractures • Clinical exam: • Thigh pain, swelling, ecchymosis with limited ROM • Full trauma evaluation • Neurovascular exam Femoral Diaphyseal Fractures

29. Spica Casting • Traction • IM Nail (flexible or rigid) • ORIF • External fixation Treatment Options

30. < 6 months • Possible abuse • Pavlik harness vs. posterior splint • 6 mos to 6 yr • Spica cast (95%) • Traction  cast • Ex-fix • 6 yr to 12 yr • Retrograde flexible IMN • Ex-fix or bridge plating • 12 yr to Adult • IMN • Submuscular plate fixation (supracondylar or subtroch) • Ex-fix Treatment

31. Distal Femur Fx

32. 1 to 6% of all physeal injuries • Most commonly injured physis about the knee • Largest and fastest growing physis • Most (2/3) are Salter-Harris Type II • Mechanism: • Direct trauma • Indirect (varus/valgus/flex/ext) Distal Femur Fractures

33. Type I: Newborns and adolescents. • Type II: Most common. • Type III: Rare. • Type IV: ORIF • Type V: often diagnosed late Salter – Harris Classification

34. Treatment Options

35. Neurovascular injury • Popliteal artery traction injury (<2 %) • Peroneal nerve palsy (3%) • Knee instability (37%) • Growth disturbance • Angular deformity (19%) • Limb length discrepancy (24%) • Contributes nearly 1cm/yr Complications

36. 1% of pediatric trauma • 60% boys • Higher levels - younger children (C1-3) • Adult stability achieved ~ age 8-9 Pediatric C-Spine Clearance

37. C-spine risk factors • 1. Unconscious • 2. Mechanism: high-speed collision, Fall • 3. Neck pain • 4. Focal neck tenderness or inability to assess neck pain secondary to a distracting injury • 5. Abnormal neurologic findings • 6. Transient neurologic symptoms suggestive of SCIWORA (eg, weakness, paresthesias, or lightening/burning sensation down the spine/extremity or related to neck movement) • 7. Neck trauma (eg, ecchymosis, abrasion, deformity, swelling, tenderness) • 8. Substance abuse • 9. Head or face trauma • 10. Inconsolable Pediatric C-Spine Clearance Lee et al, J PedSurg, 2003

38. Immobilization – 20mm pad Pediatric C-Spine Clearance Copley et al, JAAOS, 1993

39. Criteria for imaging: • neck pain • neck tenderness • limitationof neck mobility • history of trauma to neck • abnormal reflexes • abnormal strength • abnormal sensation • abnormal mental status Pediatric C-Spine Clearance Jaffe et al, Ann Emerg Med, 1987

40. Imaging: • AP & lateral c-spine • CT scan in selected patients Pediatric C-Spine Clearance

41. Radiographic interpretation • More than 20% children have normal radiographic anomalies • C2-3 subluxation • Atlanto-dens interval >3mm • Absent lordosis Pediatric C-Spine Clearance

42. SCIWORA – children under 9 • Spinal cord can move 5mm without injury • Traction of 5-6mm causes injury to spinal cord • Symptoms may not present for several days • More severe presentation – worse prognosis Pediatric C-Spine Clearance Elaraky et al, J Neurosurg, 2000

43. When to get CT scan: • plain radiographs do not visualize the c-spine • neck pain or neurologic deficit, normal x-rays • X-rays: no source of soft-tissue swelling Pediatric C-Spine Clearance Woodring et al, J Trauma, 1993

44. Protocol • Initial • Immobilize • ABC’s • Neuro exam • 2° survey, distracting injuries • Radiographs • C1-T1 • alignment Pediatric C-Spine Clearance Lee et al, J PedSurg, 2003 Copley et al, JAAOS, 1993

45. Low suspicion, normal exam: • clearance without radiographs • CT scan for equivocal exam or unconscious pt • MRI for pt with SCIWORA • MRI for unconscious pt with normal CT scan • Can clear unconscious pt with normal xrays, MRI Pediatric C-Spine Clearance

46. Your Importance in the Care of the Orthopedic Patient

47. Check orthopedic frame & traction • Ensure secure nuts and bolts • Ensure weights are not resting on floor • Inspect pin sites • Pin care (50% water, 50% H2O2) • Turn patient as unit, keeping spine aligned Nursing Management - Equipment

48. Suction • Incentive spirometry, assistive coughing Nursing Management - Respiratory

49. Pulm emboli uncommon in children • Fat emboli more common • Long bone fractures in adolescents Nursing Management - Cardiovasc

50. ROM daily • Patient positioning, repositioning • Stretch heel cords Nursing Management - Musculoskeletal