Common Pediatric Injuries

Common Pediatric Injuries
Dr. Norman Silver
Medical Director
Minor Injury Clinic for Kids
Pan Am Clinic
Disclosures
• Nothing to Disclose
Objectives
• At the end of this session the attendee
will be able to:
• Recognize and treat common pediatric
injuries
Outline
• Minor Injury Clinic for Kids
• What it is?
• Review of some of the most common
pediatric injuries
• Review things not to miss
Minor Injury Clinic for Kids
• Started April 2006
• Referral based clinic
• Non-surgical follow-up for all city ER
departments
• Referrals from family MD’s and
Pediatricians offices
• Orthotechs, Ortho, Plastics, Physio,
medical equipment, MRI
• 2 y.o. fell on out stretched arm
• 10 days post injury
Buckle Fracture
• MOI – FOOSH
• Occurs in kids because bones are “soft”
• Most commonly seen in distal radius
• May be very subtle on AP
• Pay close attention to lateral
• Often associated with ulnar styloid
fracture
Radial Buckle treatment
• Very stable fracture
• Initial back slab for 5-10 days
• Cast for 2 weeks
• Removable cast for 2-3 weeks
4 weeks post injury
• Young child Foosh injury
• Tender distal radius
Salter-Harris Type I Radius
• Common Fracture in Kids
• Diagnosed Clinically
• X-ray most often normal
• NOT a radiologic diagnosis
SH-Type I Radius Treatment
• Below Elbow Back slab – 5-10 days
• BE cast x 2 weeks
• Removable Cast x 2 weeks
Salter Harris Classification
• 8 y.o. fell off bike - forearm pain
Monteggio Fracture
• Fracture of ulna with ant dislocation of
radial head
• Suspect when ulna fractured and radius
not
• Usually 7-10 y.o.
Monteggio fracture
radialcapatellar line
• Line drawn through the radius should pass through
the capitellum in all planes
Monteggio fracture
radialcapatellar line
Elbow Injuries
• More difficult due to multiple
ossification centers
Elbow Injuries
Ossification Centers
Capitalum
Radial Head
medial epicondyle
Trochlea
Olecronon
Lateral Epicondyle
Elbow Injuries
Ossification Centers
• Order of Occurrence
• CRMTOL
• 1,3,5,7,9,11 years (guide)
• Medial epicondyle ossifies last
• 4 y.o. Fell onto his elbow
10 days post injury
Supracondylar Fractures
• Most common pediatric elbow fracture
(60%) with the average age of 6.7 years
and rarely seen after age 15 years
• 95% are extension type with posterior
displacement of distal fragment
• Type I fractures - Undisplaced
• Type II fractures - Displaced with posterior cortex
still intact
• Type III fractures - Displaced with both anterior
and posterior cortex disrupted
Supracondylar Fractures
What to look for on X-ray
•
Fat pads – if posterior seen with no obvious fracture 75% will have a fracture
identified if x-ray’d in 3 weeks
Anterior
Fat pad
Posterior fat pad
Supracondylar Fractures
What to look for on X-ray
• Anterior Humeral Line – should go through middle 1/3 of capitalum in
undisplaced fracture. May be more anterior if younger child (due to
incomplete ossification of capitalum)
Type II supraconcylar fracture
with posterior displacement of
distal humerus
• 3 y.o. fell directly onto elbow
26 days later
4 y.o. Fell and not using arm well
4 weeks later
What are you going to do
next?
1.
2.
3.
4.
X-ray Elbow
Examine Child
Manipulate Elbow
Above Elbow Backslab
Pulled Elbow
• Examine child – should be no swelling,
no focal tenderness, pain with
supination and pronation
• Manipulation
Pulled Elbow
• 1- 4 years of age
• Annular ligament slips on to head of
radius and may tear
• No history of trauma
• No physical signs other than decreased
ROM
Pulled Elbow
Pulled Elbow Treatment
• History/Physical consistant
• No x-ray needed
• Manipulation of arm
• No reduction – x-ray then backslab
Pulled Elbow - Manipulaton
Pulled Elbow – f/u
Clavicle Fractures
1 week post injury
5 weeks post injury
Clavicle fractures
4 weeks post injury in 3y.o
Clavicle Fracture
• Consider surgery in older kids with
overlap more than 2 cm
• Sling
• Figure 8
• No contact 8-12 weeks
• No need for re-x-ray unless early return
to play considered
14y.o. checked and slid into boards
diagnosed with AC separation
6 days post - tender mid to lateral
3.5 weeks post injury
• 12 y.o male twisted right ankle while
running
• Most common – inversion or eversion?
• Inversion injury – most common
associated injuries
• Ligamentous injury – ATFL, CFL, PTFL
• Fibula Fracture – Salter Harris type 1
• Fracture base of 5th Metatarsal
To Irradiate or not to
Irradiate
• 12 y.o. inversion injury to the right foot
• Unable to weight bear
• Tender over distal fibula
• X-ray normal with open physis
SH1 fracture of the Fibula
• Clinical diagnosis based on MOI and
area of tenderness, may be difficult to
localize initially
• BK Backslab
• BK walking cast/walking boot
• Ankle Brace
• Physio
Treatment of Sprains
• Grade 1-2 – functional bracing and
weight bearing as tolerated
• Grade 3
• Backslab – NWB
• NWB/WB cast
• Cast Boot
• Brace – wean but consider keeping for
sports
10 y.o male twisted foot –
tender over 5th MT
3.5 weeks later
Fracture base of 5th MTT
• BK backslab
• BK cast – WB
• Cast boot
• Ankle Brace
• If Jones fracture – NWB cast for longer
• Distal to metatarsal/cuboid junction
• Young child that suddenly stops weight
bearing, otherwise well
• Broad differential but most commonly:
• Toddlers fracture
• Transient synovitis of the hip
4y.o stopped weight bearing
Toddler’s fracture
• Toddler’s
• Twisting injury – may not be observed
• Difficulty or not weight bearing
• Careful physical examination
• 15 percent no x-ray findings initially
• Cast if unsure
6 weeks post injury
Another Example
acute
18 days post injury
And yet again – 4y.o
3.5 weeks later
acute
Transient Synovitis of the
Hip
• Well appearing
• Low-grade fever
• May walk with limp
• Hip Rom restriction
• Mainly internal/external rotation
• Not frozen hip
• ESR/X-ray to R/O other causes
• Direct blow to the knee
Patella Dislocation
• Dislocates laterally
• May relocate spontaneously
• Swelling
• Tender over medial patella/lateral fem
condyle
• DDx – ACL tear if not seen out of
position
Patella dislocation
Reduction
• Extend knee
• Gentle pressure on lateral patella
Post reduction
• Removable brace
• G2 ROM brace
• Physiotherapy
• Knee brace with lateral support for
sports
ACL Tear
• History most important
• Twist on a straight knee/landing from jump
• Pop felt
• Immediate swelling
• Knee dislocated or completely gave way
• Beware misdiagnosed as patella dislocation
• Physical
• Swelling
• Lachman/Anterior drawer
Lachman
Anterior drawer
ACL Tear
• Investigations
• X-ray
• MRI
• Treatment
• Physiotherapy
• Surgery
• 13y.o. Female felt pain in hip 3 weeks ago
• Seen at walk-in – using crutches since
• x-ray showed “subluxable hip” – MRI
booked but not for 2 more weeks
• Pushed today – felt pop – now very
painful hip
Slipped capital Femoral Epiphysis
• Instability of the Femoral Epiphysis
• Femoral head slips posterior and inferior
• 10-16 years of age
• 20% bilateral at presentation
• Additional 20-40% will become bilateral
within 18 months
• Increase risk with obesity
SCFE - presentation
• Hip or Knee pain
• Generally hip externally rotated
• Antalgic gait or unable to bear weight
• Decrease ROM esp. – internal rotation
• X-ray – AP and Frog leg
• MRI, CT, Bone Scan can be used to
confirm suspicious cases
Klein’s line – should go
through the femoral epiphysis –
otherwise slipped
SCFE – Treatment
• Orthopaedic Consult – Urgent
• 12 year old soccer player with knee pain
for 6 months
• Worse last few weeks
• Hurts near the end of the game
• Sometimes limps after the game and the
next day
• Tender over Tibial tuberosity
Osgood-Schlatter Disease
Osgood Schlatter Disease
• Ice, Rest, nsaids
• Patella tendon straps, knee brace
• Physio
• Occasional immobilization
• May completely avulse fragment
Summary
• Minor injury for kids
• Buckle fractures/SH1 radius/SH class
• Supracondylar #, pulled elbow
• Clavicle #
• Ankle – SH1 fibula, Sprain, 5th MTT
• NWB – toddler #, Transient Synovitis
• Patella dislocation/ACL
• SCFE
• Osgood Schlatter
Questions??