1. The document discusses pediatric orthopedic emergencies, focusing on the unique aspects of pediatric musculoskeletal injuries compared to adults. 2. Key differences include the pediatric skeleton being less dense, more porous, and still growing, making children more prone to certain injury patterns like plastic deformity fractures. 3. The document reviews mechanisms of injury, uniquely pediatric fractures, and the initial approach to pediatric orthopedic trauma, emphasizing immobilization and careful evaluation for other injuries.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: Pediatric Orthopedic Emergencies
Author(s): Stuart A Bradin, DO, FAAP, FACEP
License: Unless otherwise noted, this material is made available under the
terms of the Creative Commons Attribution Share Alike-3.0 License:
http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your
ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly
shareable version. The citation key on the following slide provides information about how you may share and
adapt this material.
Copyright holders of content included in this material should contact open.michigan@umich.edu with any
questions, corrections, or clarification regarding the use of content.
For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use.
Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis
or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please
speak to your physician if you have questions about your medical condition.
Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
1

2. Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Use + Share + Adapt
Make Your Own Assessment
Creative Commons – Attribution License
Creative Commons – Attribution Share Alike License
Creative Commons – Attribution Noncommercial License
Creative Commons – Attribution Noncommercial Share Alike License
GNU – Free Documentation License
Creative Commons – Zero Waiver
Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in
your jurisdiction may differ
Public Domain – Expired: Works that are no longer protected due to an expired copyright term.
Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)
Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.
Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your
jurisdiction may differ
Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that
your use of the content is Fair.
To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
{ Content the copyright holder, author, or law permits you to use, share and adapt. }
{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }
{ Content Open.Michigan has used under a Fair Use determination. }
2

3. Pediatric Orthopedic
Emergencies
Stuart A Bradin, DO, FAAP, FACEP
Assistant Professor of Pediatrics and
Emergency Medicine
University of Michigan Health System
Richard
Masoner,
Flickr
Derrick Mealiffe, Wikimedia Commons
Wikimedia Commons
3

4. Objectives
1. Introduction of most common pediatric
orthopedic injuries
2. Understand physiologic differences between
adult and pediatric musculoskeletal system
3. Introduction of orthopedic injuries unique to
pediatrics
4. Discussion of initial evaluation and
management of common pediatric orthopedic
injuries
4

5. Introduction
nn Children experience diverse array of illnesses andChildren experience diverse array of illnesses and
injuriesinjuries
nn Many unique to pediatricsMany unique to pediatrics
nn 1/3 of all ED patients annually are children1/3 of all ED patients annually are children (Annals of Emergency(Annals of Emergency
Medicine, 1990)Medicine, 1990)
nn PrePre--hospital setting, 10% ambulance runs are forhospital setting, 10% ambulance runs are for
pediatric patientspediatric patients ((KallsenKallsen GW, inGW, in DieckermanDieckerman RA, 1991)RA, 1991)
nn Trauma represents majority of pediatric transportsTrauma represents majority of pediatric transports
(50(50--65%)65%)
nn Age dependentAge dependent
nn Injuries are most common reason pediatric patientsInjuries are most common reason pediatric patients
present to the EDpresent to the ED
5

6. Introduction
Ø Represent 10-15% of ED visits
Ø 70% related to falls in younger children
Ø In the multi- trauma patient, > 50% will
have at least 1 musculoskeletal injury
Ø Injury patterns in pediatrics differ greatly
from adults
Ø Recognizing and understanding these
differences critical to appropriate diagnosis
and care
6

7. Pediatrics
nn Prehospital providers often have:Prehospital providers often have:
–– Limited pediatric patient contactsLimited pediatric patient contacts
–– Limited knowledge, training, andLimited knowledge, training, and
experience specifically directed towardsexperience specifically directed towards
pediatricspediatrics
nn Many other healthcare providers areMany other healthcare providers are
similarly affectedsimilarly affected
nn Children are not little adults!!!Children are not little adults!!!
7

8. Pediatric Trauma
Ø Distinguished from that in adults by
differences:
1. mechanisms of injury
2. fracture patterns
3. multiple acceptable treatment options
4. associated systems injuries
5. mortality in pediatric polytrauma
6. residual morbidity
8

9. Common Pediatric Mechanisms of Injury
Ø Pedestrian struck by vehicle
Ø Fall from low heights
Ø Non accidental injury in infant/ toddler
Ø Power tools/ lawn mower injuries
Ø Vehicle operator and falls from heights
(teens)
9

10. Mechanisms of Pediatric Injury
Waddell’s Triad
William Murphy, Flickr
Rhymeswithbombs, Fllickr
10

11. Mechanisms of Pediatric Injury
PMcM, Liftarm, Wikimedia Commons
11

12. Non accidental Injury
Ø Close to 1% all children victims of abuse
Ø 1/3 of these kids will be reinjured
Ø 1-5% of these kids will die if returned to original
environment
Ø Abuse is 2nd leading cause of death infants and children
Ø Majority < 1 year of age
Ø Must have high index of suspicion
Ø Risk factors: parental substance abuse
young parent
child < 3 yrs old
premature
disability
12

13. Non accidental Trauma
History
- what is mechanism
- is story plausible
- who witnessed event
- time from injury to tx
- who has access to pt
- inconsistent stories
Physical Exam
- serious injury can
exist despite no
outward signs
- patterns of bruising/
unexpected areas
- burns/ scars
- May require opthy
exam/ CT scan
(Shaken Baby)
13

14. Orthopedic injuries in Non accidental
Trauma
Ø Seen 30-50% children
Ø Injuries highly specific for abuse
include:
- corner or bucket handle
fractures
- scapular fractures
- posterior rib fractures
- old fractures
- multiple fractures of different
ages
- spinous process fractures
Ø Spiral fractures are not
pathognomonic for abuse
Melimama, Wikimedia Commons
14

15. Orthopedic injuries and Abuse
Source Undetermined
Source: RadiologyAssistant.nl
15

16. Bucket handle fracture
Source Undetermined
16

17. Corner Fracture
Source Undetermined
Source Undetermined
17

18. Posterior rib fractures
Source Undetermined 18

19. Posterior Rib fractures
Source Undetermined
19

20. Healing Fracture
Source Undetermined
20

21. Other Injuries Associated with Pediatric
Non-accidental Trauma
Source Undetermined
Source Undetermined
Source UndeterminedSource Undetermined 21

22. Physiologic Differences in Child
Ø Periosteum thicker and
stronger
Ø Bone more porous
Ø Higher incidence of plastic
deformities
Ø Less ligament injury/
dislocation
Ø Remodeling is extensive
Ø 15% childhood fractures
involve growth plate
Ø Radiographic evaluation
more difficult due to
growth plates
Ø Kids do stupid things!
Clappstar, Flickr
Edwin Dalorzo, Flickr
Bread for the World, Flickr
Elizabeth Buie, Flickr
22

23. Pediatric Musculoskeletal System
Ø Pediatric skeleton less densely
calcified than adult
Ø Composed higher percentage of
cartilage
Ø Bones are lighter and more porous
Ø More porous= more pliableà
less strengthà increase fractures
Ø Actively growing structure:
- long bones contain growth plates/
physes
- end of bones contain epiphysis
Ø Bones of child surrounded by thick and
active periosteum
Ø Ligaments and periosteum stronger
than bone itselfà
- physis is weak link
- fractures more common than
sprains
Ø Response to trauma age dependent
Source: Wikimedia Commons
23

24. Uniquely Pediatric Fractures
Ø Physeal or Salter- Harris Fractures
Ø Plastic deformity fractures:
1. Buckle or torus fracture
2. Greenstick fracture
3. Bowing or bending fracture
Ø Avulsion fractures
Ø Toddler’s Fracture
24

25. Buckle Fracture
Ø Secondary to
compression
Ø Usually metaphysis
Ø Stable fracture
Ø May be very subtle
Ø Quite common
Ø Requires splint and
ortho follow up
Source Undetermined
25

26. Buckle Fracture
Source: Medscape
26

27. Greenstick Fracture
Ø Most common fracture
pattern in children
Ø Incomplete fracture at
metaphyseal-
diaphyseal junction
Ø Angulation and
rotation common
Ø 1 cortex remains
intact
Ø Often must complete
fx to achieve union
Source Undetermined
27

28. Greenstick and Bending Fracture
Source: Medscape
28

29. Bowing Fracture
Ø Forces on bone stops
short of fracture
Ø Persistent plastic
deformity can result
Ø Little remodeling
Ø Forearm, fibula
common
Ø Functional and
cosmetic deficits
Ø Requires ortho
referral
Source Undetermined
Source Undetermined
29

30. Physeal Fractures
Ø 18-30% of pediatric
fractures
Ø Common adolescence
Ø Peak 11-12 yrs
Ø Usually upper extremity
injury
Ø Physis = weak area
Ø Salter- Harris
Classification
Ø Salter Harris type 2 most
common
Source Undetermined
30

31. Salter-Harris Classification
• SH I - through physis
• SH II - through physis &
metaphysis
• SH III - through physis &
epiphysis
• SH IV - through
metaphysis, physis &
epiphysis
• SH V - crush injury to
entire physis Source Undetermined
31

32. Salter- Harris Fractures
Image Removed (Salter
Harris Fracture
Classification)
Source Undetermined
32

33. Salter- Harris 1 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
33

34. Salter- Harris Type 2 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
34

35. Salter- Harris Type 3 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
35

36. Salter Harris Type 4 Fracture
Source Undetermined
Lena Carleton, University of
Michigan
36

37. Salter-Harris Type 5 Fracture
Source Undetermined
Source Undetermined
Lena Carleton, University of
Michigan
37

38. Case
Ø 18 mth old brought in by mom because she
won’t bear wt on R leg. No fever. No recent
illnesses. No witnessed trauma.
Ø Exam: afebrile, non toxic appearing
no gross deformity, swelling,
redness / warmth, bruising
Draws leg up when standing
Cries when you try to move lower R
leg
No rash/ petechiae
Mom and baby good rapport, eye contact
What do you think is going on?
What do you want to do?
Jocelyndale, Flickr
38

39. Toddler’s Fracture
Ø Hairline, non
displaced spiral or
oblique fracture tibia
Ø Typically kids < 4 yrs
Ø Minor force- usually
fall
Ø Subtle findings
Ø Does not = abuse
Source: Medscape
39

40. Toddler’s Fractures
Source Undetermined
Source Undetermined
Source Undetermined 40

41. What’s Your Diagnosis?
15 year old baseball player
Rounding 3rd base, acute pain in hip while
running
Pain is sharp, felt “ pop”
Finished game but has pain walking
Exam benign except pinpoint tenderness at
AIIS, worse w/ abduction of hip
41

42. Avulsion Fracture of the Pelvis
Ø Intense muscular
contraction
Ø Subsequent shearing
of secondary
ossification center
Ø Pelvis, tibia tubercle,
phalanges
Ø Require conservative
care
Ø Adolescent -14-18 yrs
Ø 90% Male
Ø 80% sports related
Source Undetermined
42

43. Initial Approach to Orthopedic Trauma
Ø ABC’s
Ø Evaluate involved limb for:
- neurovascular compromise
- open vs closed fracture
- compartment syndrome
Ø Evaluate for fx’s at increased risk for significant bleeding/
hemodynamic instability ( pelvic/ femur fractures)
Ø Search for associated injuries
Ø Pain control
Ø Immobilization
Ø Xray evaluation
Ø Miscellaneous: last meal, allergies/ meds, last period if
female 43

44. Fracture Treatment in Children:
General Principles
Ø Children heal faster than adults
Ø Require less immobilization time
Ø Stiffness of adjacent joints less likely
Ø Vast majority- tx’d closed methods
Ø Exceptions: open fractures
Salter Harris type III- IV injury
multi-system trauma
Ø If any concern re: displacementà keep NPO
Ø Any swollen elbow is displaced supracondylar fx until
proven otherwise
Ø Analgesia ( morphine 0.1 mg/kg IV), then Xrays
44

45. Radiographic Evaluation
Ø Point tenderness
Ø Large amount of swelling
Ø Severe pain
Ø Persistent symptoms after 3-5 days
Ø High risk mechanism
Ø Must include joint above and below
Ø Comparison views?
Ø All unstable and deformed fractures must be
immobilized prior to transfer to radiology
45

46. What Does Ortho Need to Know?
Ø Age and sex of patient
Ø Mechanism of injury
Ø Bone or bones involved in
injury
Ø Type of fracture
Ø Neurovascular status of the
extremity
Ø Presence and amount of
displacement
Ø Presence and estimate of
angulation
Ø Open or closed fracture
Mike Blyth, Flickr
46

47. Description of Injury-Location
Source Undetermined
Humerus Radius Femur Tibia
Gray’s Anatomy,
Wikimedia Commons
Gray’s Anatomy
Wikimedia Commons
Gray’s Anatomy
Wikimedia Commons
Gray’s Anatomy
Wikimedia Commons
47

48. Fracture Description
Ø Fracture pattern:
spiral ( twisting)
oblique
(bending)
transverse
(direct)
Ø Displacement
Ø Angulation
Ø Communition
Source: http://askabiologist.asu.edu/how-bone-breaks
48

49. Fracture Types
Source Undetermined
Lena Carleton, University of Michigan
49

50. Fracture Types and Description
Source Undetermined
Source Undetermined
50

51. Open Fractures
Xy01, Wikimedia Commons
Saltanat enli, Wikimedia Commons 51

52. Open Fractures
• IV antibiotics, tetanus
prophylaxis
– Cefazolin &
Gentamicin
– TdaP
• Emergent irrigation &
debridement
– 6-8 hrs
• NPO
Bobjgalindo, Wikimedia Commons
Saltanat, Wikimedia Commons
52

53. Pediatric Extremity Injuries Requiring
Emergent Orthopedic Evaluation
Ø Femur Fractures
Ø Pelvic fractures
Ø Open fractures
Ø Spinal fractures
Ø Complete fracture of long bones of lower
extremities
Ø Neurovascular compromise
Ø Dislocation of large joint
Ø Fractures with significant displacement
Ø Fractures involving large joint
53

54. Injuries to the Upper Extremity
Ø Clavicle
Ø Shoulder
Ø Humerus
Ø Elbow
Ø Forearm
Ø Wrist and hand
54

55. Clavicle Fracture
Ø Most common childhood
fracture
Ø Direct trauma and indirect
forces
Ø > 50% kids less than 10
yrs of age
Ø Symptoms:
- point tenderness/ pain
- decreased mobility
- unnoticed until “lump”
noted as callus forms
Ø Sling or sling and swathe
Ø Pain control
Ø Ortho follow up 2-3 weeks
Source Undetermined
Source Undetermined
Wikimedia Commons
55

56. Shoulder dislocation
Source Undetermined
Source Undetermined Source Undetermined
56

57. Humerus Fracture
Ø Proximal
- 80% growth
- Adolescent
- non union unlikely
- consult ortho:
> 50 degrees
angulation
NV compromise
- sling & swathe
Ø Shaft
- less common
- spiral fx < 3 yrs
consider abuse
- look for radial
nerve
injury
- sling & swathe
Source Undetermined
Source Undetermined
57

58. Elbow Anatomy
Source Undetermined
58

59. Elbow Fractures and Anatomic
Landmarks
• Anterior Fat Pad
– May be normal if
“adherent” to bone
• Posterior Fat Pad
– Always abnormal if
visible
Source Undetermined 59

60. Radiograph Anatomy and Landmarks
• Anterior Humeral
Line
– drawn along the
anterior humeral
cortex
– should pass
through the middle
1/3 of the
capitellum
Source Undetermined
60

61. Anatomy and Landmarks
• Radiocapitellar line
– should intersect the
middle 1/3 of the
capitellum
– Radial head
dislocation
• Make it a habit to
evaluate this line on
every pediatric
elbow film
Source Undetermined
61

62. Radiocapitellar Line
What kind of fracture is
this?
• Monteggia Fracture
• Ulnar fracture w/
Radial Head
Dislocation
Source Undetermined
62

63. Supracondylar Fracture
Ø Fall on outstretched arm
Ø Hyperextension
Ø Common elbow fracture
Ø Complications:
- NV compromise
- compartment syndrome
Ø Graded 1- 3
Ø Management dependent
upon type of injury
( splint or OR for repair)
Ø Ortho needs to see all
elbow fractures
Source Undetermined
Source Undetermined 63

64. Elbow Fractures in Children
Ø Very common
Ø Radiographic assessment difficult
Ø Requires thorough exam and reassessment
Ø Neurovascular injuries can occur before and after
reduction
Ø Kids will not move elbow if fracture present
Ø Swelling about the elbow is constant feature
- may be minimal if non displaced fx
- may not develop for 12-24 hrs after injury
Ø 60% are supracondylar fractures
Ø May be accompanied by distal radius or forearm fx
64

65. Supracondylar Fractures
• Type 1: Non-displaced
• Type 2: Angulated/displaced fracture with
intact posterior cortex
– Hinged
• Type 3: Complete displacement, with no
contact between fragments
Source Undetermined
Image Removed,
Supracondylar Fracture
65

66. Type 1- Nondisplaced
• Note the non-
displaced fracture
(Red Arrow)
• Note the Posterior
Fat Pad (Yellow
Arrows)
Source Undetermined 66

67. Type 2: Angulated and Displaced
Source Undetermined Source Undetermined
67

68. Type 3 Supracondylar Fracture
Ø High risk for NV
compromise
Ø Significant
associated
swelling
Ø Ortho consult
Ø OR for
percutaneous pin
fixation
Ø Open reduction
may be
necessary
Source Undetermined
Source Undetermined
Source Undetermined
68

69. Type 3: Complete Displacement
Source Undetermined
Image Removed, Bone
Displacement
69

70. Case
Ø 9 yr old falls off slide, landing
on outstretched L arm
Ø Presents to ED due to pain in
forearm and elbow
Ø No hx LOC/ CHI
Ø Benign medical hx
Ø Tender over proximal L
forearm
Ø Decreased ROM forearm and
elbow due to pain, swelling,
guarding
Ø NV intact, good radial pulse,
can wiggle fingers
Ø Cap refill < 2 sec
Ø What do films show?
What do you want to do?
Source Undetermined
Source Undetermined 70

71. Monteggia Fracture
Ø Ulnar fracture + radial
head dislocation
Ø Uncommon in kids (2%
all elbow fx’s)
Ø Can be easily missed-
must have films of both
elbow and forearm
Ø Isolated ulna fractures
rare
Ø If unrecognized and not
reduced, can lead to
permanent disability
Ø Pain control, ortho
consult, OR for repair
Source Undetermined
Source Undetermined
71

72. Galleazzi Fracture
Ø Classic:
- Fx distal 1/3 radius
- dislocation of distal
ulna
Ø Disruption of radioulnar
joint
Ø More common
teenagers and adults
Ø Rare fracture
Ø Suspect in angulated
distal radius fractures
Ø Difficult to recognize
Ø Requires ortho consult
in ED and reduction
Source Undetermined
72

73. Radial Head Subluxation:
Nursemaid’s Elbow
• Nursemaid’s Elbow
• Tractional mechanism
• Unusual > 5 yo
• Holds arm pronated, slightly flexed at
elbow and at side
• No swelling or ecchymosis
• X-rays not necessary
Kevin Harber, Flickr
73

74. Nursemaid’s Elbow
Ø Radial head subluxation due
to annular ligament tear
Ø Typically “ pull” on pronated
forearm
Ø Typical presentation:
-do not appear in pain
-refuse to use arm
-held in pronation and
slightly flexed
-no swelling/ bruising
-may hold wrist to support
extremity
Ø Reduction techniques:
- pressure over radial head
- supination w/ flexion
- pronation w/ flexion
- extension/ hyperpronation
Ø Films only if hx / exam not
consistent
Wikimedia Commons
Sean Dreilinger, Flickr
74

75. Pediatric Forearm Fractures
Ø Approximately 4% children’s
fractures
Ø Most due from fall onto
outstretched hand
Ø ¾ fractures distal
Ø Rare to see isolated ulna
fracture
Ø Neurovascular compromise rare
Ø Remodels well
Ø Ortho consult :
angulation > 10’ midshaft
> 15’ distal
will require procedural sedation
for reduction
Ø Treatment- sugartong or volar
splint
Source Undetermined
Source Undetermined
Source Undetermined
75

76. Carpal Bone Fractures-Scaphoid Fracture
Ø Rare fx
Ø Teenager or adolescent
Ø Hard to diagnose- not
easily seen on film
Ø Heals poorly
Ø Concern avascular
necrosis
Ø Typical mechanism: fall
hyperextended wrist
Ø Snuffbox pain
Ø Treat: thumb spica splint
Source Undetermined
Amada44,
Wikimedia Commons
76

77. Metacarpal Fracture-Boxer’s Fracture
Source Undetermined Hellerhoff, Wikimedia Commons
77

78. Boxer’s Fracture
Ø Uncommon injury
Ø Adolescent boy
Ø Mechanism of injury= direct
blow/ strike object w/ closed
fist
Ø Fracture 4th or 5th
metacarpal
Ø Be wary of infection
Ø Look for rotational defects
Ø Never acceptable in fx of
mcp or phalanges
Ø Reduce if angulation > 30’
Ø Ulnar gutter splint Bobjgalindo, Wikimedia Commons
78

79. Injuries to Lower Extremities
Ø Hip dislocations and femoral neck fx’s due to high
energy impact
Ø Major trauma
Ø Care and resuscitate child before addressing orthopedic
injury
Ø Single ring fx of pelvic ring = STABLE
superior and inferior rami fx
symphysis pubis fx
Ø Double breaks in pelvic ring = UNSTABLE
high incidence GU, abdominal, vascular injuries
life threatening hemorrhage
79

80. Hip Anatomy
Source Undetermined
80

81. Bad or Really Bad?
Ø 4 yr old, previously healthy
Ø Febrile, R leg pain x 1 night
Ø Slipped and fell earlier but
able to walk immediately
Ø Temp 40.7, HR 160
Ø Uncomfortable, non toxic
Ø Refuses to wt bear at all
Ø R leg held externally rotated
and abducted
Ø ROM severely limited due to
pain
Ø What is going on ?
Ø What do you want to do?
The U.S. Army, Flickr
81

82. What Now?
Ø WBC 21.7, 85
seg, 4 bands
Ø CRP 8.2
Ø ESR 48
Ø What do films
show?
Source Undetermined
82

83. Septic Arthritis
Ø Peak age < 3 yrs
Ø Usually single joint
Ø Most common: hip, knee, shoulder, elbow
Ø Hematogenous seeding bacteria to joint
Ø Direct spread from adjacent osteomyelitis or trauma
Ø Staph Aureus most common pathogen
Ø Neonate: Staph aureus
Group B Strep
Gram negative bacilli
Ø Toddler: Staph aureus
Group A streptococcus
S. pneumoniae
Ø Sexually active teen: Neisseria gonorrhoeae
83

84. Septic Arthritis
Ø Non specific findings neonate
Ø Older kids more localized pain,
fever, decreased ROM
Ø Septic hip- classically- leg
held:
Externally rotated ,flexed,
abducted
Ø Delay in diagnosis/ tx results
rapid cartilage destruction,
ischemia, avascular necrosis
Ø Film frequently normal w/
acute septic arthritis
Ø U/S- highly sensitive for
detection effusion
Ø Lack of effusion does not
exclude infection
Source Undetermined
84

85. Hip Effusion
Source Undetermined Source Undetermined
85

86. Septic Arthritis
Ø Labs include : elevated ESR and CRP
Ø WBC may be normal or elevated
Ø Blood cx + < 50% cases
Ø Caird, et al ( J Bone Joint Surg, 2006) –
Fever, elevated ESR and CRP best predictor
septic joint
Ø True orthopedic emergency
Ø Arthrocentesis for diagnosis, OR, antibiotics 4-6
wks
86

87. Case
Ø 14 yr old male with 3 mth
hx limp and R knee pain
Ø Wt 100 kg
Ø Limps, has pain with
ROM R hip
Ø Internal rotation and
flexion of hip most limited
Ø No warmth, redness,
afebrile
Ø What is going on?
What do you want to do?
Source Undetermined
Source Undetermined
87

88. Slipped Capital Femoral Epiphysis
Ø Etiology unknown
Ø Male > Female ( 2:1)
Ø Obese
Ø African American, 8-15 yrs of age ( time of growth spurt)
Ø Almost all cases present w/ chronic hip or knee pain
Ø Limitation of hip:
internal rotation
abduction
flexion
Ø Must consider in any preadolescent or adolescent with knee
pain
Ø Must get AP, frog leg views pelvis, both hips
need comparison – slip may be subtle
10-25 % cases bilateral
88

89. Slipped Capital Femoral Epiphysis
Source Undetermined
Source Undetermined
89

90. Treatment of SCFE
Ø Strict non wt bearing
Ø Goal: prevent further
slippage
Ø Ortho evaluation
urgently
Ø Screw placement/
pinning
Ø Complications:
opposite side SCFE
avascular necrosis
degenerative changes
Source Undetermined
Source Undetermined
90

91. Femur Fractures
Source Undetermined
Source Undetermined
Source Undetermined
91

92. Patellar dislocations
Hellerhoff, Wikimedia Commons The Marines
92

93. Anatomy of the Knee
Mysid, Wikimedia Commons
93

94. Fractures of the Knee
Image Removed
© Christy Krames
Classification of Knee
Fractures
Source Undetermined
Source Undetermined
Source Undetermined
94

95. This can’t be good…
Ø 16 yr old female
soccer player
Ø Planted leg, felt “pop”
Ø Immediate pain
Ø Quite swollen
Ø Hard to weight bear
Ø What does film show?
Source Undetermined
95

96. Segond Fracture
Ø Lateral capsule
sign
Ø Avulsion fx
lateral aspect
proximal tibia
Ø Pathognominic
for intra-articular
injury
Ø >70% ACL tear
Source Undetermined
96

97. Knee Sprain
Ø ACL- basketball, soccer, football,
volleyball
Ø > 70% occur w/o contact
Ø Rare < 11 yrs age
Ø 1/ 100 high school aged kids
Ø Girls higher incidence (2-8 x boy similar
sports)
Ø Typical hx: twisting injury
painful pop
immediate swelling
feeling instability
inability to weightbear
Ø Physical exam: hemarthrosis
limited ROM
Lachman Test
sportEx journals, Flickr
Lam, et al.,
Wikimedia Commons
97

98. Mechanism and Anatomy of
Ankle Injuries
Gray’s Anatomy,
Wikimedia Commons
Image Removed-
Mechanism of Ankle
Injury
98

99. Who Gets Films?
Image Removed
Gray’s Anatomy,
Wikimedia Commons
99

100. Triplanar Fracture
Ø Unusual fracture
Ø Combination SH 2 and
SH 3 fx of distal tibia
Ø Associated fibular fx
common
Ø Most common 12-15
yrs of age
Ø Unstable fracture
Ø Require Ortho consult
Ø Growth plate damage
potentially significant
Ø Anatomic reduction
essential
Source Undetermined Source Undetermined
Source Undetermined
100

101. Splinting Pointers:
- Use the appropriate size and shape
- Pad all bony prominences, especially elbow, ankle, and heels
- Wrap somewhat loosely
- Splint in position of
Kinds of Splints:
1. Volar Splint
2. Thumb Spica Splint
3. Ulnar Gutter Splint
4. Sugar Tong Splint
5. Posterior Short-Leg Splint
6. Stirrup Splint
7. Medial-Lateral Long-Leg Splint
8. Posterior Long Leg Splint
Splinting
101

102. Distal Forearm Splints
Ø Buckle fx
Ø Forearm
fracture
Sugar Tong Splint
handarmdoc, flickr
Volar Splint
Matanya, Wikimedia Commons
102

103. Thumb Spica Splint
Ø 1st metacarpal fx
Ø Thumb fx
Ø Scaphoid fx
Ø Lunate fx
handarmdoc, flickr
103

104. Ulnar Gutter Splint
Ø Fx involving 4th and
5th MCP joint
Ø Boxer’s Fracture
handarmdoc, flickr
104

105. Posterior Long Arm Splint
Ø Proximal Forearm Fx
Ø Elbow Fx
Ø Distal Humerus Fx
Matanya, Wikimedia Commons
105

106. Posterior Short Leg Splint
Ø Ankle fx
Ø Ankle sprain
Ø Foot Fx
Posterior Short-Leg Splint Stirrup Splint
Gray’s Anatomy, Wikimedia Commons
106

107. Posterior Long Leg Splint
Ø Tibial Fx
Ø Fibular Fx
Ø Distal Femur Fx
Gray’s Anatomy, Wikimedia Commons107

108. Splinting Controversies
Ø Cast vs Splint
Plint AC, Perry JJ, et al (Pediatrics, March 2006)
Children’s Hospital Ottawa, Canada
Kids w/ removable splint for buckle fx wrist :
1. better physical function
2. less difficulties ADL
Ø Cast vs Brace
Boutis K, Willan AR, et al ( Pediatrics, June 2007)
Hospital For Sick Children, Toronto, Canada
Removable ankle brace better than casting for some ankle injuries:
1. isolated low risk ankle fractures
2. Greater proportion in aircast/ braced group returned to
baseline activities at 4 weeks
3. Greater parental and child satisfaction
108

109. NSAIDS and Bone Healing
Ø Controversial in orthopedic world
Ø Delayed healing long bones retrospective animal studies
Ø Prospective human studies ( only 2) inconclusive
Ø No pediatric studies
Ø Ibuprofen much better analgesia than Tylenol or Codeine for
fractures ( Clark EC, et al, Pediatrics March 2007)
Ø Ibuprofen provides analgesia equivalent to acetaminophen-
codeine in the treatment of acute pain in children with extremity
injuries: a randomized clinical trial. (Friday JH, Kanegaye JT, McCaslin I,
Zheng A, Harley JR, Acad Emerg Med. 2009 Aug;16(8):711-6 ).
Ø A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen
With Codeine for Acute Pediatric Arm Fracture Pain. (Drendel AL,
Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK. Ann Emerg Med. 2009
Aug 18. Epub )
109

110. Conclusions
Ø Kids are not little adults
Ø Think about mechanisms of injury
Ø Injuries must correspond to history, exam,
developmental level of the child
Ø Non accidental trauma may be manifested by orthopedic/
extremity injury
Ø Don’t be distracted by the obvious- look and treat life
threatening injuries
Ø Be kind and control a child’s pain
Ø Fractures may not always be seen on initial films and
can be very subtle
Ø Think “ fracture” before sprain
Ø When in doubt, SPLINT!!
Ø Early diagnosis and treatment septic arthritis essential
110

111. Question 1
10 yr old boy presents to ED after
hurting R index finger playing
basketball.
Exam remarkable for swelling and
tenderness of the proximal
interphalangeal joint (PIP)
Film shows fx line through the
growth plate extending into
the metaphysis
This is what type of fracture:
a. Salter Harris- 1
b. Salter-Harris -2
c. Salter –Harris -3
d. Salter- Harris- 4
e. Salter-Harris-5
Source Undetermined
111

112. Question 2
13 yr old boy presents to ED for R thigh pain
that began after falling playing soccer.
After further questioning, he admits he
has had similar pain intermittently past 3
weeks
Exam : R hip externally rotated
pain increase when you attempt to flex
or internally rotate hip
The most likely X ray finding is :
a. Displaced fx of femoral shaft
b. Intertrochanteric fx of femur
c. Avulsion fx of anterior superior iliac
spine (ASIS)
d. Step off between metaphysis and
epiphysis of the femur (SCFE)
Source Undetermined
112

113. Question 3
A 9 yr old girl fell playing soccer and twisted her ankle
She has swelling at the lateral malleolus and is tender over
the distal fibula
Films show soft tissue swelling but no fracture
What is the most appropriate treatment:
a. rest, ice, compression, elevation x 2 days and ambulate
as tolerated
b. Short leg cast or splint, repeat films in 1 week
c. Ace wrap and crutches
d. Ankle CT
113

114. Question 4
14 yr old boy complains of R wrist pain after falling while
skateboarding. He thinks he landed on his R hand when he tried to
brace himself
Exam: mild swelling in wrist
snuff box pain and pain when pressure applied to thumb
pain with supination forearm/ hand
Film negative
What do you want to do:
a. Velcro wrist splint
b. Sugar tong splint
c. Thumb spica
d. Ace wrap
e. Volar splint
114

115. Question 5
What nerve is most commonly injured in a
child with a supracondylar fracture?
a. Median
b. Ulnar
c. Radial
d. Brachial
115

116. Questions?
Ben Pollard
Wikimedia Commons
116