Paediatric Orthopaedic Emergencies

1. Paediatric Orthopaedic Emergencies Kelly Millar

2. Overview • Traumatic Emergencies • Fractures • Dislocations • Medical Emergencies • Infectious • Developmental

3. Developing Bone - Anatomy • Epiphysis • Physis • Metaphysis • Diaphysis E P M D

4. The Developing Bone • Blood supply • Epi / Meta arteries • Infancy: transphyseal • Physis • Multiple zones • Rapidly dividing • Not yet calcified

5. The Developing Bone • Thicker periosteum • Bone is more elastic • Allows for unique fracture types • Torus (buckle) • Greenstick • Bowing • Avulsion before tendon rupture

6. Pediatric Fractures • Heal more rapidly than adults • Capable of remodeling deformity • What favors remodeling? • Younger > older • Closer to physis > midshaft • Only angulation in the plane of the adjacent joint will remodel

7. Growth Plate Injuries

8. Upper Limb Fractures

9. Forearm Fractures • Most common site of fracture (50% of all #) • Physeal injuries of the distal radius (+/- ulna) • Metaphyseal fractures radius/ulna • Midshaft radius/ulna • All usually fairly straightforward to identify – the question is which ones can you leave alone, which need reduction, and which need ortho!

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11. Usually Salter I or II Usually displaced posteriorly (colles-type) Smith’s-type less common Complications uncommon Physeal Injuries of the Radius

12. Physeal Injuries of the Radius • Reduction? • Want physeal injuries close to anatomic • Normally have 0-11º volar tilt at distal radius • Want angulation at least neutral and minimum displacement • Needs good molding – about 11% will slip • Call ortho? • Unable to correct dorsal angulation • More than 10% displaced

13. Metaphyseal Injuries of the Radius • Buckle fractures • Greenstick • Complete

14. Buckle vs Greenstick • Be careful !!! • Buckle # • Cortex on opposite side must be unaffected • These are stable fractures • Greenstick # • Cortex # on one side and bent on other • These are unstable – they tend to move back to the position of maximal deformity

15. Distal Forearm - Buckle # • Stable Fractures • Management controversial: • Immobilize? 60% (PEM) 70% (ortho) • Cast? 60% (PEM) 50% (ortho) • Many opt for splint • Who might benefit from cast? More severe buckle, v. young, v. active • How long do we immobilize? 2-3 wks Wrist buckle fractures. A Plint et al. CJEM March 2003

16. Does this need a reduction?What is acceptable angulation in the distal radius? 12 yo male

17. Distal Forearm - Greenstick & Complete # • Reduction? • Radial or ulnar angulation • Rotational deformity • Infants: >30º angulation • Children: >15º angulation • Peripubertal: need 2-3 yrs growth to remodel • Practically, most of us are more aggressive

18. How about this midshaft #?What is acceptable angulation in a midshaft #? 8 yo female

19. Midshaft Radius/Ulna Injuries • Reduction? • Any radial / ulnar angulation • Any rotational deformity • Infants: >25º • Children: >10º • Peripubertal: need 2-3 years to remodel • Acceptable displacement? • If young, as much as 90%

20. Forearm Reductions & Casting • Greenstick #: Many advocate breaking far cortex to prevent recurrence of deformity (but run the risk of bayonet) • Remember that thick periosteum is your friend !! • Good 3 point molding essential • Apply above elbow cast for all reductions

21. What about Bayoneted # ? When can you give them a go?

22. Bayoneted Fractures • Prepubecsent ~ if distal or midshaft, can give it a try ~ often difficult to get ulna back on (most of us discuss the options with the parents) • Peripubertal / Teens • may consider trying metaphyseal # • Midshaft or proximal – refer to ortho

23. Is this a problem? 2 yo male

24. Bowing deformity • These will NOT remodel !! • Must be reduced if visible deformity or restricted ROM – but difficult • If attempting reduction – check for full supination & pronation • Need early ortho f/u

25. Ouch !!! What’s This?

26. Galeazzi Fracture • Radial fracture + distal radio-ulnar dislocation • Rare in kids • Always call ortho!

27. Elbow • Supracondylar # • Lateral condyle # • Medial epicondyle # • Proximal radius #

28. Ossification Centers of The Elbow • C capitellum 2 mo – 2 yrs • R radial head 3 – 6 yrs • I “internal” m. epicondyle 4 – 7 yrs • T trochlea 8 – 10 yrs • O olecranon 8 – 10 yrs • E “external” l. epicondyle 10 – 13 yrs

29. Ossification Centers - CRITOE

30. Ossification Centers - CRITOE

31. Approach to reading the film • Is the film adequate -look for the hourglass • Fat pads • anterior “sail sign” (bulging fat pad) • posterior fat pad (always abnormal) • Anterior humeral line • Radial line

32. Elbow X-ray – Is it Adequate?

33. If you do not have an adequate lateral: • You can miss the fat pad signs • You may miss a fracture! • You cannot count on the anterior humeral line • You may overcall a supracondylar fracture!

34. Fat Pads - Elbow Effusion

35. A flat anterior fat pad is often present in normal children • A bulging anterior fat pad “sail sign” is always abnormal • A visible posterior fat pad is always abnormal

36. Anterior Humeral Line Should pass through the middle third of the capitellum in the lateral view

37. Radial Line Should bisect the radius in ALL views

38. What’s this?

39. Supracondylar Fracture • 75% of elbow #s • 95% due to FOOSH • Classification: • Type 1 – non-displaced / minimally displaced • Type 2 – displaced, but hinged on posterior cortex (may be rotated as well) • Type 3 – completely displaced, posterior cortex disrupted • Beware of compression of medial column

40. Type I

41. Type II

42. Type III

43. Supracondylar Fracture Management • Type I • Backslab at 90º, ortho in 1 week • Type II • If mild angulation (<10º) and no rotation, may attempt closed reduction by flexing at elbow, then placing in backslab at 90º • When to call ortho: • All type III’s, any rotation, type II with ++angulation or failed reduction, neurovascular compromise

44. What are the common complications of supracondylar fractures?

45. Supracondylar Fracture Complications • Very high rate of complications!! • Acutely: • Neurologic injury (8-15%) • Ant interosseuous branch of median n • Radial and ulnar nerves also may be involved • Radial artery (2% overall, 50% in Type III) • Compartment Syndrome • Longer term: • Cubitus varus, Volkmann’s ischemic contract.

46. What’s this?

47. Lateral Condyle Fracture • 15% of elbow #s • Usually Salter-Harris IV • Peak age 4-10 years • If displaced <2mm, backslab at 90º, early ortho f/u as inherently unstable • If displaced >2mm, pinned

48. Lateral Condyle Fracture

49. What’s This?

50. Medial Epicondyle Fracture • Usually seen in adolescent boys • Do not involve the joint surface • Check for ulnar nerve injury • 50% associated with dislocation – • If diplacement < 4mm – backslab • If displacement > 5 mm - pinned