Paediatric Orthopaedic Emergencies

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Paediatric Orthopaedic Emergencies

• Kelly Millar

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Overview

• Traumatic Emergencies
• Fractures
• Dislocations
• Medical Emergencies
• Infectious
• Developmental

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Developing Bone - Anatomy

• Epiphysis
• Physis
• Metaphysis
• Diaphysis

E
P
M
D
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The Developing Bone

• Blood supply
• Epi / Meta arteries
• Infancy transphyseal
• Physis
• Multiple zones
• Rapidly dividing
• Not yet calcified

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The Developing Bone

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

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Pediatric Fractures

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

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Growth Plate Injuries
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Upper Limb Fractures
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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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???
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Physeal Injuries of the Radius

• Usually Salter I or II
• Usually displaced posteriorly (colles-type)
• Smiths-type less common
• Complications uncommon

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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

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Metaphyseal Injuries of the Radius

• Buckle fractures
• Greenstick
• Complete

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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

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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
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Does this need a reduction?What is acceptable
angulation in the distal radius?
12 yo male
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Distal Forearm - Greenstick Complete

• Reduction?
• Radial or ulnar angulation
• Rotational deformity
• Infants gt30º angulation
• Children gt15º angulation
• Peripubertal need 2-3 yrs growth to remodel
• Practically, most of us are more aggressive

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How about this midshaft ?What is acceptable
angulation in a midshaft ?
8 yo female
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Midshaft Radius/Ulna Injuries

• Reduction?
• Any radial / ulnar angulation
• Any rotational deformity
• Infants gt25º
• Children gt10º
• Peripubertal need 2-3 years to remodel
• Acceptable displacement?
• If young, as much as 90

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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

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What about Bayoneted ?

• When can you give them a go?

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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

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• Is this a problem?

2 yo male
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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

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Ouch !!! Whats This?
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Galeazzi Fracture

• Radial fracture distal radio-ulnar dislocation
• Rare in kids
• Always call ortho!

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Elbow

• Supracondylar
• Lateral condyle
• Medial epicondyle
• Proximal radius

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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

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Ossification Centers - CRITOE
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Ossification Centers - CRITOE
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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

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Elbow X-ray Is it Adequate?
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• 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!

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Fat Pads - Elbow Effusion
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• 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

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Anterior Humeral Line
Should pass through the middle third of the
capitellum in the lateral view
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Radial Line
Should bisect the radius in ALL views
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Whats this?
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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

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Type I
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Type II
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Type III
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Supracondylar Fracture Management

• Type I
• Backslab at 90º, ortho in 1 week
• Type II
• If mild angulation (lt10º) and no rotation, may
  attempt closed reduction by flexing at elbow,
  then placing in backslab at 90º
• When to call ortho
• All type IIIs, any rotation, type II with
  angulation or failed reduction, neurovascular
  compromise

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• What are the common complications of
  supracondylar fractures?

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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, Volkmanns ischemic contract.

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Whats this?
47
Lateral Condyle Fracture

• 15 of elbow s
• Usually Salter-Harris IV
• Peak age 4-10 years
• If displaced lt2mm, backslab at 90º, early ortho
  f/u as inherently unstable
• If displaced gt2mm, pinned

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Lateral Condyle Fracture
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Whats This?
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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 lt 4mm backslab
• If displacement gt 5 mm - pinned

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Medial Epicondyle Fractures

• Difficult to identify in young children (so much
  cartilage)
• NORMAL ?
• Ossification centre should follow smooth contour

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Medial Epicondyle Fracture
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Whats this?
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Proximal Radius Fractures

• Most common in ages 8 - 12
• Usually involve the metaphysis or the physis, and
  not the radial head
• Management?
• lt 15 angulation - posterior slab, F/U with ortho
• 15-30º - posterior slab early to ortho
• gt 30 angulation call ortho for reduction

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Proximal Radius
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Whats this?
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Monteggia Fracture
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Monteggia

• Ulnar fracture proximal radial dislocation
• "Monteggia equivalent" with plastic deformation
  of the ulna occurs in 17
• 8--17 associated neurologic deficits (usually
  posterior interosseous branch of the radial nerve
• Management call ortho!

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Whats this?
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Proximal Humeral Fractures

• Proximal humeral physis
• Usually SH type I or II
• potential for remodelling
• Age 1-5
• 70º angulation, 100 displacement
• Age 5-12
• 50º angulation, 50 displacement
• Age gt12
• 30 displacement

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Proximal Humeral Fractures

• Management
• Sugar tong splint sling, f/u ortho

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Clavicle

• 1015 of all pediatric s
• 90 middle third
• Sling
• Pain management
• Warn parents about the bump
• F/U fam doc in 6-8 weeks

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Sling vs Figure of 8

• Treatment of clavicular fractures.
  Figure-of-eight bandage versus a simple sling.
  Andersen K. Jensen PO. Lauritzen J. Acta
  Orthopaedica Scandinavica. 58(1)71-4, 1987
• RCT
• 79 pts
• figure-of-eight bandage vs simple sling
• simple sling caused less discomfort and perhaps
  fewer complications than figure-of-eight
• The functional and cosmetic results of the two
  methods of treatment were identical and alignment
  of the healed fractures was unchanged from the
  initial displacement

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Proximal / Distal Clavicle Fractures

• Proximal clavicle s (lt2)
• Usually involve growth plate SH I or II
• If clavicle displaced posteriorly, may get
  tracheo-esophageal compression if so talk to
  ortho and get CT
• Distal clavicle s
• Usually involve growth plate SH I or II
• Often difficult to distinguish from AC sep
• Ortho f/u if grossly unstable

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Lower Limb Fractures
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Distal Fibula Salter I
9 yo boy
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Distal Fibula Salter I

• Clinical diagnosis
• Widening on x-ray often not appreciated
• If unsure, posterior slab, f/u 1 week for
  reassessment
• If fairly sure, below-knee cast for 3 weeks
  (walking cast OK)

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Adolescent Ankle
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Whats this?
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Tillaux Fracture

• Often caused by low-energy trauma
• Forced external rotation of the foot or medial
  rotation of the leg on the fixed foot
• Stress placed on anterior tibiofibular ligament
• Avulsion

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Tillaux Fracture

• Fracture of the antero-lateral tibial epiphysis
• Salter III injury
• Low threshold for CT
• Call ortho
• Closed reduction may be attempted will accept
  max of 2mm displacement

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Whats this?
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Triplane Fracture

• Talk to ortho
• Often need CT
• Closed reduction in 30-50

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• 20 mo
• Playing with sibs in bedroom
• Found crying
• Refusing to walk
• Whats this?

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Toddlers Fracture

• Common
• Low energy mechanism
• Spiral fracture of tibia often subtle
• Above knee cast 3 weeks

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Tib / Fib Shaft Fractures

• If minimally displaced, attempt closed reduction
• Non-displaced and successfully reduced are
  placed in above-knee cast, f/u ortho 1 week
• For significant displacement, or involvement of
  the proximal physis or metaphysis d/w ortho

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Whats this?
80
Tibial Spine Fracture

• Ages 8 to 14 (often bicycle-related)
• Usually the anterior intercondylar eminence
• Anterior spine fracture is analogous to an ACL
  injury in the skeletally mature
• If non-displaced - immobilize (Zimmer) early
  ortho F/U
• May be more extensive than appears on x-ray
  (ortho has low threshold for CT)
• If displaced d/w ortho

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Femur Fractures

• Consider femoral block
• Bucks traction
• All admit to ortho
• Thinks abuse in young kids!

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Whats this?
14 yo girl sudden L hip pain while playing soccer
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Pelvic Avulsions

• Most common in athletic adolescents
• Unexpected, explosive muscle contraction
• Example "kicking out" at the end of race
• Athletes most often affected Hurdler, Sprinter
• Symptoms sudden onset of hip pain
• Limp may be present
• Specific apophysis sites of tenderness
• anterior superior iliac spine (sartorius)
• anterior inferior iliac spine (rectus femoris)
• Ischial tuberosity (hamstring)

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Pelvic Avulsions

• Conservative therapy for ASIS or AIIS avulsion
• RICE
• NSAIDs
• Crutch walking as needed
• Return to sport when able to participate without
  pain

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Osgood-Schlatters Disease

• During growth spurt, boys gt girls
• Pain/bony prominence of the tibial tuberosity
• Repeated microevulsion
• Do x-ray to r/o other pathology
• Management rest, stretching
• Pain resolves in 1-2 years (bump does not)

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Osgood-Schlatters Disease
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Dislocations

• Elbow, Shoulder, Patella
• Largely managed as per adults

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Patellar Dislocations

• In young children, recurrent dislocations usually
  associated with patellar/condylar dysplasia or
  neuromuscular disease
• In older children, acute dislocations managed as
  in adults
• Post reduction films with skyline views
• Immobilization

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Whats this?
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Shoulder Dislocation
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Shoulder Dislocations

• Some children with joint laxity will be able to
  voluntarily dislocate their shoulders if
  discouraged from doing so, they will usually grow
  out of it
• Traumatic dislocations require reduction, films
  to r/o and immobilization children with
  traumatic dislocation are at high risk of chronic
  instability (up to 50)

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• Hill-Sachs
• Bankart
• Axillary nerve

HS
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Elbow Dislocations

• Usually in adolescents
• 90 posterior
• Commonly associated fractures
• Medial epicondyle
• Radial head / neck
• Coronoid
• Associated neurovascular injury high (ulnar nerve
  in 10)

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Elbow dislocation
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Medical Emergencies
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Case 1

• 7 yo boy
• Presents with several week hx of limp and R knee
  pain

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Case 1

• R knee exam normal
• R hip painful passive ROM
• Afebrile, otherwise well
• Labs normal

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Case 1
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Legg-Calvé-Perthes Disease

• Epidemiology
• 1 in 3000 children, boys gt girls
• Peak age 4 9 years
• Familial in 20 of cases
• Pathophysiology
• avascular necrosis of femoral head, with
  trabecular collapse and secondary growth
  disturbance and deformity

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Legg-Calvé-Perthes Disease

• Symptoms
• Pain in area of hip or referred to knee
• Signs
• Child walks with a limp
• Decreased hip range of motion
• Imaging
• Order AP and frog leg views of the hips

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Legg-Calvé-Perthes Disease
This is late disease. In early disease, see
widening of articular cartilage (appears as joint
space widening), small dense epiphysis gets
irregular and flattened with time
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Legg-Calvé-Perthes Disease
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Legg-Calvé-Perthes Disease

• Prompt ortho referral
• Difficult management
• Bracing and casting for up to 1-2 years
• Surgery will allow child back to activity in 4-6
  months
• Complications
• Severe degenerative hip disease in some
• Requires hip replacement by middle age in 50
  cases

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Case 2

• 14 yo obese male
• Several month hx of limp and R hip pain
• Worsening having difficulty bending over to tie
  shoes

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Case 2
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Slipped Capital Femoral Epiphysis

• Epidemiology
• Incidence 4 per 100,000
• Adolescents (during growth spurt)
• Blacks gt caucasian
• Obesity is a risk factor
• Tall and slender is a risk factor

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Slipped Capital Femoral Epiphysis

• Pathophysiology
• Shearing displacement through the zone of
  hypertrophic cartilage
• Occurs before the growth plate closes
• During maximal growth spurt
• Males age 13 to 15 years
• Females age 11 to 13 years

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Slipped Capital Femoral Epiphysis

• Classification by duration
• Acute
• Acute on chronic
• Chronic
• Classification by stability
• Stable (able to walk) 90
• Unstable (unable to walk) 10

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Stable SCFE

• Usually a history of intermittent limp and pain
  of several weeks' or months' duration
• Often poorly localized to the thigh, the groin or
  the knee. Hip pain is reported less frequently
• A vague history of antecedent trauma calls
  attention to the limp and pain
• As the epiphysis continues to slip, the child
  loses hip motion, including internal rotation,
  flexion and abduction

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Unstable SCFE

• Present with extreme pain, often after
  sports-related trauma or a fall with a twisting
  injury
• Most children have no prior history of symptoms.
• Much higher rate of avascular necrosis related to
  disruption of epiphyseal vascularity

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Slipped Capital Femoral Epiphysis

• Presentation
• Hip held in abduction and external rotation
• Limited internal rotation
• Radiology Hip XRay AP frog leg
• Widened epiphyseal plate
• Displacement of femoral head

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SCFE Kleins sign
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Slipped Capital Femoral EpiphysisStable
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Slipped Capital Femoral EpiphysisUnstable
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Often Bilateral careful with weight bearing
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SCFE - Management

• Stable
• Strict non-weight bearing
• Refer to orthopedic surgeon (next 1-2 days)
• Unstable
• Strict non-weight bearing
• Admit to ortho

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Case 3

• 3 yo female
• Refusing to walk today
• Fever 38º
• Tender ROM L hip
• Just getting over URTI
• What should you do?

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Case 3

• WBC 11
• ESR 8
• X-rays normal
• What is the most likely diagnosis?

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Transient Synovitis of the Hip

• Inflammatory arthritis of the hip
• Incidence 3 of kids before age 14
• Most common cause of limp with hip pain lt age 10
• Peak age 3 to 8 years
• Boysgirls 41
• Presentation
• 3-6 days after URTI
• 95 unilateral
• Signs
• Pain in hip, anteromedial thigh and knee
• Reduced hip range of motion

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Transient Synovitis vs Septic Arthritis

• WBC is not statistically different
• ? ESR 90 sensitive in SA but not specific
• Mean ESR
• Transient synovitis 18
• Septic arthritis 55-82
• Kunnamo CRP gt 20 temp gt 38.5
• 100 sensitive, 87 specific for SA
• Del Beccaro ESR gt 20 temp gt 37.5
• 97 sensitive, 53 specific

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Transient Synovitis vs Septic Arthritis
Transient Synovitis Septic Arthritis
Range of Motion gaurded hip rotation pronounced spasm, gaurding, and fixed position
Fever low grade higher
ESR lt15 gt 20
Synovial fluid clear WBC, bacteria
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Transient Synovitis of the Hip

• Imaging
• Hip X-ray
• Bony landmarks normal
• May see widened joint space
• Hip Ultrasound
• Often have joint effusion
• Management
• Rest NSAIDS

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Case 4

• 4 yo
• Fell at pool yesterday injured R leg
• 12 hr hx fever 40 in ER
• Unable to walk
• What do you want to do?

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Case 4

• Severe pain and limited ROM R hip
• WBC 31
• ESR 39
• CRP 29

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Septic Arthritis

• Most common in large joints hip, knee, elbow,
  shoulder
• Presentation
• Infant fever, irritability, sepsis, abnormal
  posture, pseudoparalysis, joint pain
• Child fever, severe pain, muscle spasm
• Organisms staph aureus, strep spp, Neisseria in
  sexually active teens

130
Septic Arthritis - Investigations

• Labs
• WBC unreliable
• CRP and ESR usually elevated
• Imaging
• Plain film to r/o other pathology, may see
  capsular swelling
• Ultrasound hips to detect effusion
• Joint aspiration in ER or u/s guided (hip)

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Septic Arthritis Age Considerations

• less than 3 months up to 60-100 of neonates w/
  septic arthritis have adjacent osteomyelitis
  due to transphyseal blood vessels which disappear
  by age 6 months
• from 6 mo to 2 yrs search for evidence of other
  - 50 of children septic arthritis have evidence
  of an associated infection
• unimmunized meningitis may occur in up to 20 of
  patients w/ septic arthritis due to H flu

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Osteomyelitis

• Acute osteomyelits
• Subacute osteomyelitis
• Chronic osteomyelitis
• Chronic recurrent multifocal osteomyelitis

133
Osteomyelitis

• 75 of osteomyelitis is of hematogenous origin
• In children - metaphysis of long bones most
  common
• Metaphysis has large blood flow and deficient
  phagocytes
• Nutrient arteries are nonanastomosing, any
  blockage can produce tissue necrosis
• Venous sinusoids have slow, turbulent flow
  predisposing to thrombosis.  
• Sludging of blood flow as vessels make sharp
  angles

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Osteomyelitis - Epidemiology

• Overall prevalence 1 per 5,000 children
• Neonatal prevalence 1 per 1,000
• Annual incidence in sickle cell patients is
  approximately 0.36
• Prevalence after foot puncture may be as high as
  16 (30-40 in patients with diabetes

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Acute Hematogenous Osteomyelitis - Presentation

• Acute onset
• fever
• bone pain
• decreased function
• Organisms
• staph aureus
• ß-hemolytic strep
• (Salmonella in sickle cell)

137
Acute Hematogenous Osteomyelitis - Investigations

• Labs
• ? WBC not sensitive or specific
• ESR gt 20 90 sensitive, poor specificity
• ? CRP - 98 sensitive (? earlier than ESR)
• Blood culture - in 50 of hematog osteo
• /- joint aspirate to r/o septic arthritis

138
Acute Osteomyelitis - Imaging

• X-ray unhelpful at presentation (until 14-21
  days)
• Bone scan becomes positive on day 2-3
• Sensitivity 84-100, specificity 70-96
• This is your first choice!
• MRI - Studies have shown its superiority
  compared with plain radiography, CT scan, and
  radionuclide scanning
• Sensitivity ranges from 90-100

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Acute Osteomyelitis - MRI
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Acute Hematogenous Osteomyelitis

• Management
• IV antibiotics - penicillinase-resistant
  penicillin and a third-generation cephalosporin
• Consult ortho possible surgery if abscess
  demonstrated
• Sequelae
• Chronic osteomyelitis
• Impaired/accelerated growth
• Septic arthritis (more common in infants)

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Subacute Osteomyelitis

• Largely a pediatric disease
• Incidence 1 per 100,000 per year
• May affect multiple joints (multifocal)
• Metaphysis of tibia and femur most common
• Presentation
• Mild, intermittent pain over several weeks
• Few systemic signs
• Loss of function common (esp. in spine)

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Subacute Osteomyelitis

• Labs WBC, ESR, CRP may be normal
• Radiologic signs usually well established at
  presentation
• 75 metaphyseal (tibia and femur)
• Also occurs in calcaneus
• Bone absorption and sclerosis
• Bone scans are also helpful

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Subacute Osteomyelitis
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Subacute Osteomyelitis

• Organism usually staph aureus, some staph epi
• Management
• IV antibiotics discuss with ortho before
  starting in case biopsy desired (increase yield
  of cultures
• Need for surgical excision of abscess
  contoversial (87 cure rate with A/Bx alone)
• However, may want Bx to r/o tumor and to ID
  organism

145
Chronic Osteomyelitis

• Follows acute osteomyelitis by months years
• In developed countries, usually post-traumatic as
  hematogenous osteo is usually identified and
  treated
• Suspect if chronic pain in site previously
  affected by acute osteo or injury
• Bone scan and referral to ortho/ID

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Chronic Recurrent Multifocal Osteomyelitis

• Disease of children aged 4-15 years
• Recurrent episodes of localized pain and swelling
  involving different sites at different times
• ? Non Infectious!!! Benign and self-limited
• ? Atypical seronegative arthropathy
• Rx NSAIDS (no antibiotics)

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Chronic Recurrent Multifocal Osteomyelitis
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Developmental Dysplasia of the Hip

• Incidence
• Hip instability at birth 1
• Hip dysplasia in infants 0.1 to 0.3
• Girls 9 times more often than boys
• 30 of hip replacements are due to osteoarthritis
  2º to acetabular dysplasia!!!
• Pathophysiology
• Femoral head dislocates from acetabulum
• Usually unilateral, but bilateral is common

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Developmental Dysplasia of the Hip

• Associated Conditions
• Breech presentation in utero
• Congenital torticollis
• Clubfoot
• First degree relative with hip dysplasia

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Developmental Dysplasia of the Hip

• Signs
• Ortolanis Test
• Barlow's Test
• Management
• Dont image in the ER
• Ortho referral if suspicious

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