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Peds Injuries Jeremy Onnen M.D.

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What is the most common

complication caused by treatment in the ED/Urgent care?

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Distal Femoral Epiphysis Fx S A L T R

I II III IV V

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Distal Femoral Physeal Fractures

• direct blow mechanism

• Salter I or II common

• check neurologic / vascular status – Less common

than w/ tibial injury

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Distal Femoral Physeal Fractures

• high rate of premature growth arrest rare < 2 yo 80% 2 - 11 yo 50% > 11 yo

• angular deformity • leg length discrepancy

• F/U 6 mo – XR other side; & reg

intervals until maturity

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Distal Femur Physeal Bar

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Case 1 • 15yo male c/o R knee pain for 4-5

months, but unable to bear weight since 3 days due to a stumble from a horse.

• PMHx: healthy, non-obese. • FHx: negative • X-rays??

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Case 1:Presenting radiographs

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Case 1: “In-situ” screw fixation

• Extremity positioned on a fracture table with internal rotation, moderate traction, and neutral abduction

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Case 1: 3 mos f/u

• Back to full activities (roping and riding) with only occasional limp and R hip pain

• PEx: – Foot progression angle:

R-30°ER, L-10°ER – PROM: FF- 90°(115°), IR -

15°(35°) – Obligate ER w/ FF R hip

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SCFE

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Case 2

• 15yo fell while skateboarding over weekend. Was seen by orthopaedist. He had walked into office with limp. A “pinning” was scheduled for later in the week, but when pt was walking to surgi-center, fell off curb and could no longer walk.

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Case 2 • Reduced on fx table

and single screw inserted.

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Case 2 • 4 months post-op

began to develop stiffness and pain.

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Diaphyseal Femur Fractures

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Patellar Sleeve Fracture • 8-12 year old • Inferior pole sleeve of

cartilage may displace • May have small ossified

portion • <2mm displaced, intact

extensor mechanism- treat non-operatively

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Patella Fractures • Tension Band or

screw if large enough • Consider excising

small marginal frag’s • Good PPx • Complications:

– Alta – ext lag – quad muscle

atrophy

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Proximal Tibial Physeal Fractures

• Usually Salter II fractures. • Occasionally Salter I or IV

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Proximal Tibial Physeal Fx • Post displaced epiphysis

or metaphysis can cause vasc inj

• HYPEREXTENSION • Exploration or

arteriography if ischemic or diminished pulse after Fx reduction

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Principles of Distal Tibial Growth

• Distal tibia ossific nucleus – Appears => 2 – 3 y/o – Fuses:

• Girls => 15 y/o • Boys => 17 y/o

• Fuses central to medial and then lateral over 18 months!

• Distal fibula ossific nucleus – Appear => 2 y/o ; fused => 20 y/o

• Secondary ossification centers

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Triplane Fractures

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Tibial Diaphyseal Fractures

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OSSIFICATION • 1. CAPITELLUM

(6 mo. - 2 yrs.) • 2. MED.

EPICONDYLE (5 - 9 yrs.)

• 3. TROCHLEA (7 -13 yrs.)

• 4. LAT. EPICONDYLE (8 - 13 YRS.)

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Septic hip • Most common in 1st

decade • Difficult to diagnose

– If in doubt -> admit and observe

• Serious sequelae

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Septic hip • Differential diagnosis

– “the limping child” – Inflammatory and

infectious • Osteomyelitis • Diskitis • Transient synovitis • JRA • Psoas abscess • Pyogenic sacroiliitis • Lyme arthritis

– Trauma/fracture – Anatomic

• DDH • Coxa vara • Perthes disease • SCFE • Chondrolysis • OCD • LLD

– Neoplasms • Leukemia • Osteoid osteoma

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• Kocher et al. JBJS-A Dec 1999

– Retrospective review of 186 patients

• Kocher criteria – Fever (greater than 38.5 degrees celsius) – Non-weight-bearing – ESR (greater than 40 mm/hr) – WBC count (greater than 12,000)

• Probability of septic arthritis

– 0 predictors – 0.2 % – 1 predictor – 3 % – 2 predictors – 40 % – 3 predictors – 93 % – 4 predictors – 99 %

Septic hip

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Septic hip • Modified Kocher criteria • Caird et al. JBJS-A June 2006

– Includes CRP – Prospective study of 53 patients

• Probability of septic arthritis

– 0 predictors – 17 % – 1 predictor – 37 % – 2 predictors – 62 % – 3 predictors – 83 % – 4 predictors – 93 % – 5 predictors – 98 %

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Septic hip

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Septic hip • Etiology

– Hematogenous spread – Direct seeding of

synovium – Metaphyseal

osteomyelitis then enters the joint

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Septic hip • Workup

– X-rays – Blood cultures – CRP – ESR – CBC with

differential – Ultrasound – Aspiration

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Septic hip • Aspiration

– Definitive Dx – Cloudy appearance – WBC count between

80,000 – 200, 000 • >75% polys

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• Treatment – Standard is I & D

• Approach depends on preference – IV abx followed by Oral abx – Serial CRPs

Septic hip

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Case ?

• 10 yo male playing basketball had large Center fall into his leg.

• Minimally displaced midshaft tibia fracture. Placed into a splint and instructed to go home. Still in severe pain.

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• He has Anxiety • He has needed increased Analgesia • He has become aggitated.

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Compartment Syndrome – Injury

• Can occur at any site where muscle is contained in a closed fascial space

• common areas are lower leg, forearm, foot, hand, gluteal region and thigh

• Develops when pressure in the osteofascial compartment causes ishemia and necrosis

• Ischemia can be caused by swelling or constricting dressings

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Compartment Syndrome

• end stage is an ischemic Volkmann’s contracture

– Assessment • High risk:

– tibia or forearm fractures – crush injuries – tight dressings or casts – difficult to assess in the patient with altered

mental status

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Compartment Syndrome

• Signs and Symptoms – pain out of proportion to injury – pain with passive stretching – paresthesia – decreased sensation or functional loss – tense swelling – weakness or paralysis and loss of pulse are

late signs

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Compartment Syndrome

– Diagnosis is clinical • based on history of injury, physical exam • intracompartmental pressures are

helpful – Tissue pressures greater that 35 to 45 mm

Hg or within 30 mmHg of diastolic pressure are suggestive of compartment syndrome

• Management consists of loosening of tight dressings,

splints, casts • If no improvement, then fasciotomy is required

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