Pediatric Orthopedics in the ED
Common presentations, common fractures, and common
sense treatments.
James Thorburn
Overview
Housekeeping - terms and unique
physiology of children
General Approach
Upper body (limbs) injuries - FOOSH
Lower body - Approach to limping child
What’s the difference?
Periosteum is thicker, stronger, and more
biologically active
More plastic deformities
GROWTH PLATES !!
Ligaments stronger than bones
Ortho talk
Fracture description
Buckle Fracture (#)
Greenstick #
Salter Harris
Initial Approach
ABC’s - just like everything else
Quick assessment for:
Neurovascular compromise (NVI)
Open #
Bleeding - femur and pelvis (C’s)
History
Mechanism of injury - important
time
exact location of pain
other associated symptoms
“SAMPLE”
Pain Control!
May be nervous about “medicating”
kids. DON’T BE!
Pain in kids can be difficult to interpret
Pain scales
Mechanism of injury
Clinical exam
Pain meds
Ibuprofen (advil): 10 mg/kg per dose
Acetaminophen (tylenol): 15 mg/kg per
dose
Narcotics:
Fentanyl - IV, or intranasal (12mcg/kg)
Morphine - 0.1mg/kg SQ, 0.1-0.5/kg
PO
SPLINT!
Don’t be me
back slab!
FOOSH
Examine clavicle to wrist!
Clavicle #
Elbow #
Forearm #
Quick and Dirty NV exam
Colour, cap refill, pulses, swelling.
Nerves (3) motor and sensory
Radial - Thumbs up, 1st dorsal web
space
Median - Fist, pinch, palmar distal
2/3 digits
Ulnar - Peace, distal pinky
(palmar)
Case
13 year old, fall off scooter
SAMPLE hx
Quick physical
Fentanyl 1.5mcg/kg x 40kg =
60 mcg intranasal
Place backslab
X-rays.
Clavicle #
Majority in the middle 1/3
Sling for support (if old
enough)
Elbow #
No one likes elbows
ROM important
NV exam quite
important
supracondylar # most
common
Possible #s
Supracondylar
Medial/lateral condylar
Radial head # (older kids)
Olecranon #
X-ray approach
5 things to look at, and won’t miss
Fat pads
Anterior humeral line
Hourglass sign
Proximal radial line
Ossification centres
Fat Pads
Capitellum is key
Hourglass
Ossification - CRITOE
Supracondylar # management
Pain management
Non-displaced - back slab and “U” slab
and follow up with ortho
displaced - consult ortho from
department
compartment syndrome!
Not Sure? No prob!
++ pain
Posterior fat pad/ anterior sail sign
Back slab and follow up for R/A!!
Pulled Elbow
Commonly in 9 month - 3 years old (may
be older)
Subluxation of radial head
Mech: axial tension on pronated,
extended elbow
Minimal swelling, not using arm,
holding in pronation
Management
X-ray? not usually necessary
Reduction
Hyperpronation
Supination and flexion
Can’t reduce?
Consider x-ray
try both techniques
immobilize? sling?
Arrange follow up
Monteggia
Galeazzi #
Management of buckle and
greenstick #
Casting vs splinting
Dr. Boutis
Either for 3 weeks
Approach to the limping child
Differential is huge!!
History is important
Don’t ignore caregiver
Estimate of 25% no diagnosis
Differential - categories
Traumatic vs non-traumatic
Traumatic
Cause may be obvious - #!!!
Beware occult # - sprains/strains not as
common in kids
Buckle #
Greenstick #
Toddlers #
Toddlers #
May have a history of fall/trauma, but
may not
9 months - 3 years
Range of sx - subtle to obvious
high index of suspicion needed.
Management
If obvious - classic teaching long leg
splint with ortho f/u
discuss with family pros/cons of
immobilization if not obvious
Usually splinted 5-6 weeks
Don’t be afraid of follow up!!
No trauma?
Think articular vs systemic
important questions:
Fever?
Rash?
Preceding illness?
Constitutional symptoms?
GI sx?
Ddx Articular
Transient synovitis
Septic Arthritis
Legg-Calve-Perthes
SCFE
JRA
Reactive arthritis
Ddx Extraarticular
Malignancy
Testicular torsion
Sickle cell crisis
Rheum / vasculitis
Transient synovitis vs Septic
DO NOT want to miss septic arthritis
can be difficult to tell the difference
combination of hx, pe, and investigations
can help
Transient Synovitis
Self limited inflammation of synovial
lining (resolve 3-10 days)
classically viral prodrome, but not
necessary
Septic Arthritis
Danger to life and limb!!
History clues
Just how sick is the child?
History
Fever - how long? how high? toxic?
Persistence of non-weight baring?
Viral prodrome?
Physical
Consider early NSAID - may help exam
Vitals and Appearance
gentle log roll - may be tolerated in T.S.
but not S.A.
Importance of serial examination
Labs
Kocher Criteria
Non-weight baring affected side
ESR >40
Fever
WBC >12
Kocher Criteria
Good guide to “rule in” in high pretest
probability
Kocher et all, 2004
Sawyer and Kapoor, 2009
Negative predictive value if no fever
and CRP<2
Ultrasound
Can look for effusion
Can be present in both
Management
If concern of septic arthritis, prompt
Ortho consult.
Await joint aspiration to start antibiotics
If ortho not promptly available, take
blood cultures and start antibiotics.
Conclusion
Manage Pain!
Occult #s!!
Elbows
X-ray findings
Limp
Traumatic vs Atraumatic
Intraarticular vs Extraarticular