Orthopedic Emergencies: Expert Management for the Emergency Physician 1st Ed.

Chapter 7. Pediatric orthopedic emergencies

Nathan W. Mick and Amy E. Valasek

Orthopedic Emergencies, ed. Michael C. Bond, Andrew D. Perron, and Michael K. Abraham. Published by Cambridge University Press. © Cambridge University Press 2013.

Key facts

·        Pediatric bones are more flexible than adults, leading to unique fracture patterns such as:

o   Buckle fractures

o   Greenstick fractures

o   Plastic deformation

·        Because of the high metabolic turnover for pediatric bones, closed reduction and casting is the treatment of choice for most pediatric fractures

·        Transient synovitis is an inflammation of the hip joint that typically follows a viral upper respiratory infection (URI) and is characterized by hip pain and a limp

·        Transient synovitis is typically self-limited and treated with non-steroidal anti-inflammatory medication (NSAIDs), though excluding a bacterial infection is critical to avoid significant morbidity

·        Slipped capital femoral epiphysis (SCFE) occurs in obese pre-pubescent children. Pain may be indolent in cases of chronic SCFE, though acute worsening of pain is seen after relatively minor trauma in some cases

·        SCFE presents bilaterally in a significant proportion of cases, even if only one side is symptomatic

Unique features of pediatric fractures

General principles

·        Bones in children remodel at a more rapid rate than adults, making closed reduction a viable treatment modality for many fractures that would require operative repair in adults

·        Bones in children are more flexible, leading to unique fracture patterns such as buckle and greenstick fractures that are not seen in adults

·        Injury to growth plates can result in significant morbidity

Buckle fractures

·        Buckle or torus fractures typically occur at the metaphyseal diaphyseal junction and result from a “crumpling” of the more porous metaphysis (see Figure 7.1)

·        Typical locations for buckle fractures include the distal radius, distal tibia, distal fibula and distal femur

·        A fall on to an outstretched arm or leg is a common mechanism of injury

·        Treatment involves splinting or casting for 4 weeks and outpatient orthopedic follow-up. Some centers will immobilize for even shorter periods with similar results

·        Prognosis is excellent

Pearl: Buckle fractures can be adequately treated with splinting or casting for 4 weeks with excellent prognosis.



Figure 7.1 Buckle fracture of the distal radius (arrows).

Greenstick fractures

·        Greenstick fractures commonly occur after a fall on to an outstretched arm or jumping on to a leg (see Figure 7.2)

·        Because of the flexibility of pediatric bones, one cortex breaks while the other remains intact, similar to trying to break a piece of green wood

·        Treatment of greenstick fractures involves closed reduction and splinting or casting

·        Prognosis is excellent, provided acceptable closed reduction is achieved



Figure 7.2 A: shows the Greenstick fracture of the forearm (arrow). B: shows the impressive bowing that can occur (arrow).

Plastic deformation

·        Occurs after a longitudinal force is applied to growing bone, such as the force that occurs with a fall onto an outstretched arm

·        The bone bends and microscopic fractures occur which result in a bend but no visible fracture line on plain radiographs

·        Typically occurs in the radius, ulna or fibula

·        If the deformity is less than 20°, the bone often remodels and closed reduction is not needed

·        Greater degrees of deformity require attempts at closed reduction

·        Casting is the treatment of choice and these injuries rarely need operative repair

Growth plate injury

Key facts

·        The Salter–Harris classification system is used to describe fractures involving the growth plate. The higher the classification, the higher the likelihood that the patient will have growth abnormalities such as growth arrest, malunion, growth disturbance with angulation, or growth acceleration

·        Growth plate injuries account for 20% of all pediatric fractures

Pearl: Salter–Harris Type I and V injuries can appear the same on plain radiographs. Comparison views of the contralateral leg can help distinguish the two, though the provider should always assume it is the more serious (Type V) injury.

Description

·        Injury to the growth physis or physeal plate

·        The most commonly affected bones are the long bones of growing children specifically distal radius, distal tibia, phalanges, and proximal humerus

·        Sites which show the most growth disturbance when injured are the distal femur and distal tibia

Epidemiology

·        Younger children have a higher risk of serious sequela from a physeal injury because they have more potential growth remaining

Incidence

·        Males are affected twice as often as females

·        Accounts for 20% of all pediatric fractures

Prevalence

·        Occurs most frequently in girls aged 11–12 years and boys aged 12–14 years, when growth is most rapid

Etiology

·        Trauma, infection, tumors, drugs (steroids, testosterone, estrogen)

Salter–Harris classification

·        Five total patterns of physis fractures. Types III to V are at highest risk for growth plate damage

o   Type I: Split parallel through the physis

o   Type II: Split through physis and exits through the metaphysis

o   Type III: Intra-articular fracture through the epiphysis and exits through physis

o   Type IV: Intra-articular fracture through the epiphysis that exits through metaphysis and physis

o   Type V: Crush injury to the physis

Physical examination

·        Evaluate the limb for open wounds, swelling, crepitus, and neurovascular status

Tests

·        Plain radiographs: AP, lateral, and oblique

·        CT scan: May be necessary to evaluate complicated fracture patterns

·        MRI: Best method to establish injury to the growth plate since it can visualize the cartilage of the growth plate as separate and distinct from bone

Treatment

·        Ice, immobilization

·        Pain medication

·        Monitor for compartment syndrome as appropriate

·        Splint non-displaced fractures

·        Displaced fractures should be reduced under procedural sedation, hematoma block, or general anesthesia. The fracture is then splinted and alignment is rechecked with repeat plain radiographs

Follow-up

·        Patients should be seen by orthopedics in 3 to 5 days, and the splint is usually maintained for 1–2 weeks, until swelling has resolved

Surgery

·        If closed reduction is not possible or fractures become unstable, the fracture will need to be reduced in the operating room and stabilized by percutaneous pins or internal hardware

Prognosis

·        The higher Salter–Harris classification correlates with higher incidence of growth abnormality such as growth arrest, malunion, growth disturbance with angulation, or growth acceleration. The closer the child is to skeletal maturity, the less likely growth abnormality will result

·        A bony bar can be resected or a corrective osteotomy done surgically to restore angulation or length deformity. Another simple option is to stop the growth in the contralateral growth plate to maintain symmetry

Monitoring

·        Monitored for 6 to 12 months after injury to ensure normal growth

Osgood–Schlatter disease

Key facts

·        A traction apophysitis of the tibial tuberosity

·        Treatment is supportive with rest, ice, pain control, and patellar strap

Description

·        Osgood–Schlatter disease is a traction apophysitis of the tibial tuberosity caused by repetitive strain by the quadriceps tendon.

Epidemiology

Incidence

·        Males are affected twice as often as females

·        Bilateral presentations are seen in 25–50% of patients

·        Commonly seen in patients who participate in running, jumping, and squatting activities

Prevalence

·        Frequent in girls aged 8–12 years and boys aged 10–15 years when growth is most rapid

Etiology

·        Repetitive traction of the patellar tendon from the tibia tubercle from running, jumping, rapid growth, and overuse

Intrinsic risk factors

·        Tight rectus femoris, tight hamstrings, patella alta, and external tibial rotation

Physical examination

·        May note tenderness to palpation directly over the tibial tuberosity with no or trace swelling at the insertion site

·        Testing of the quadriceps muscle will elicit full strength but will cause pain at the site. If strength of resisted leg extension is weak and there is swelling at the tibial tuberosity, consider that there may be a tibial tubercle avulsion fracture

·        Deep squats will elicit pain

·        Evaluate foot alignment for pathology which may stress the knee such as over-pronation or pes planus

Tests

·        Radiographs are not required. If radiographs are done, the lateral knee view may demonstrate sclerosis at the tubercle

Treatment

·        Rest or activity modification

·        Ice

·        Possible short course of anti-inflammatory medication

·        Eccentric stretching and strengthening the quadriceps and hamstrings

·        Patellar strap bracing

·        Foot inserts if indicated by clinical examination

Follow-up

·        Follow-up with primary care physician if pain progresses, limp, swelling develops or inability to walk

Prognosis

·        Favorable, but will be exacerbated during times of rapid growth or activity

·        Many will have prominence of the tibial tuberosity into adulthood. May have persistent pain with kneeling as an adult, which may represent presence of residual ossicles and warrant surgical removal

Pearl: If initial presentation includes swelling, inability to actively extend the knee, decreased strength with knee extension, inability to walk, obtain radiograph to evaluate for avulsion fraction of the tibial epiphysis.

Child abuse/non-accidental trauma

Epidemiology

·        Infants and children with disabilities are at higher risk

·        In more than 80% of cases the parent or primary guardian is the abuser

·        History given is inconsistent with the mechanism of injury

Risk factors

·        Domestic violence

·        Maternal depression

·        Drug and alcohol abuse

·        Premature birth

·        Unrealistic expectations for the child

Signs and symptoms

·        Description of the mechanism does not match the injury

·        Child is developmentally unable to sustain such an injury

·        Soft-tissue injuries are common and consider abuse if bruises, ecchymosis, and soft-tissue injuries are on the face, cheeks, back, neck or if the child is not cruising yet. The child might also have bruises in clusters or patterned marks

Fractures highly suspicious of abuse

·        Rib fractures, especially posterior

·        Metaphyseal or “bucket handle” fractures

·        Scapular fractures

·        Spinous process fractures

·        Sternal fractures

Fractures moderately suspicious of abuse

·        Long-bone transverse or spiral fractures of the diaphysis of the femur, humerus, tibia

·        Multiple bilateral fractures

·        Different stages of healing with multiple fractures

·        Epiphyseal separations

·        Vertebral body separation

·        Complex skull fractures

·        Pelvis fractures

Diagnosis

·        Maintain high index of suspicion when history does not explain injury

·        Conduct careful examination of the skin

Tests

·        Skeletal survey for all children less than 2 years of age

1. Skull AP and lateral view

2. Chest AP including clavicles

3. Right and left oblique of the chest

4. AP of abdomen to include pelvis and hips

5. Lateral spine to include cervical, thoracic, and lumbar vertebrae

6. AP spine to include cervical, thoracic, and lumbar vertebrae

7. AP bilateral humerus

8. AP bilateral forearms

9. AP bilateral femurs

10. AP bilateral tibia and fibula

11. Posterior view of the hands

12. Dorsoplantar view of the feet

·        Head computed tomography for any child less than 1 year with suspicion of abuse or greater than 1 year with concerning signs of head trauma

Treatment

·        Treat each fracture as clinically indicated

·        Report abuse to the appropriate state child protection authority

Prognosis

·        Children who are victims of abuse without proper intervention are likely to sustain more repeated episodes.

·        Twenty percent of the fatalities related to abuse had contact with the health care community within one month of death

Spinal cord injury without radiographic abnormality (SCIWORA)

Key facts

·        A traumatic injury to the spinal cord that is not evident on plain radiographs or CT

·        Most often occurs in children less than 8 years old

Description

·        A traumatic injury to the spinal cord that causes neural damage without evidence of radiographic injury on plain radiographs or CT. The increasing elasticity of the spine, shape of the vertebral bodies, facet alignment, and level of maximum flexion in the cervical spine place the pediatric spine at risk because of its hypermobility and malleability. This term was coined before the widespread availability of MRI. With this imaging modality, these patients will have abnormalities that can be visualized

Epidemiology

·        Most often presents in children less than 8 years of age

·        Responsible for approximately 5% of all spinal cord injuries in children

·        Three critical features:

1. May have a delay in diagnosis because of transient paresthesia

2. Progressive latent paralysis can present up to 4 days after the injury

3. Recurrent episodes may occur without proper immobilization

Initial evaluation

·        Immobilize in hard collar and place on spine board

·        Document neurologic defects on examination

·        Obtain AP, lateral, and odontoid plain radiographs or CT of cervical spine to exclude fracture or dislocation

Test

·        If CT of the cervical spine is normal yet neurologic deficits persist, the patient should have an MRI of the cervical spine

Treatment

·        Immediate consultation with neurosurgery

·        Cervical stabilization in hard collar

·        Strict bed rest with logroll as necessary

·        Methylprednisone load within 8 hours of injury if advised by your local neurosurgical consultant

Transient synovitis

Clinical presentation

·        Inflammatory condition of the hip typically following a viral upper respiratory illness

·        Occurs most commonly in children ages 3–8 years and presents with hip pain and a limp with varying degrees of limitation of range of motion at the hip

·        Low-grade fevers may occur though high fever should raise concern for a bacterial infection of the hip

·        Affected individuals are typically non-toxic in appearance

·        May be bilateral in up to 5% of cases

Diagnostic testing

·        Diagnosis is clinical

·        It is important to differentiate transient synovitis from septic arthritis or Lyme arthritis

·        Afebrile children who can bear weight, even if limping, can be managed expectantly

·        If the child is febrile, further testing is indicated including CBC, ESR, CRP and blood cultures

·        Fever > 38.5° C in the past week, ESR > 40 mm/hr, a WBC count > 12,000 cells/mm3 and a CRP > 2 mg/dL are all risk factors for bacterial illness

·        Lyme titers may be useful in endemic areas

·        Ultrasound should be used to evaluate for an effusion if there is a clinical concern for bacterial infection. The presence of an effusion does not rule in or rule out transient synovitis, but can predict whether you will be able to obtain fluid for analysis

·        A bone scan can be used for evaluation if there is concern about osteomyelitis

Pearl: Ultrasound may reveal fluid in cases of transient synovitis and up to a quarter of patients will have bilateral effusions, even if only one side is symptomatic.

Treatment

·        Non-steroidal anti-inflammatory medications such as ibuprofen are the mainstay of therapy

·        Affected children can weight-bear as tolerated

Prognosis

·        Recovery without sequelae is the typical course

·        Pain usually resolves within days

·        Persistent pain despite NSAIDs should raise suspicion for Legg–Calves–Perthes disease or occult infection

Slipped capital femoral epiphysis (SCFE)

Clinical presentation

·        Typically occurs in obese, pre-pubescent patients

·        Presents with hip pain and gait disturbance with no history of discrete trauma

·        Pain may be acute or indolent over the course of weeks to months

·        SCFE is bilateral in up to 40% of cases and often the other side is asymptomatic

·        Obesity is the chief risk factor for SCFE although there are other predisposing conditions including:

o   Renal failure

o   Hypothyroidism

o   Growth hormone deficiency

o   Radiation therapy

Pearl: Patients with SCFE may present with knee or thigh pain and not hip pain and this may lead to delay in diagnosis.

Diagnostic testing

·        Plain radiographs are the initial diagnostic modality of choice and should include the following views:

o   Anteroposterior (AP) view of the pelvis

o   Frog-leg lateral view of the affected hip

o   Obtaining radiographs of the opposite hip should be strongly considered given the incidence of bilateral disease

·        Radiographic findings include widening of the femoral head physis, irregularity or blurring of the physis, or slippage of the epiphysis (the so-called ice cream falling off the cone) (see Figure 7.3)

Pearl: On the AP radiograph, a line drawn along the superior aspect of the femoral neck should intersect the femoral head (Klein’s line, see Figure 7.4). In cases of SCFE, the line will pass superior to the femoral head, indicating slippage.

·        Plain radiographs are the screening test of choice for SCFE. An MRI may be used for patients whose initial radiographs are inconclusive and there is a high degree of suspicion. An MRI is particularly useful early on in the course of the illness



Figure 7.3 Slipped capital femoral epiphysis of the left hip revealing the so-called “ice cream falling off the cone” (arrow).



Figure 7.4 Slipped capital femoral epiphysis showing Klein’s line. A line drawn along the superior aspect of the femoral neck should intersect the epiphysis.

Treatment

·        Patients diagnosed with SCFE should be non-weight-bearing

·        Refer to an orthopedic surgeon

·        Admission to the hospital is generally indicated, particularly in cases of acute slippage or cases of bilateral SCFE

·        Treatment is operative and involves reduction of the slip and pinning (see Figure 7.5)



Figure 7.5 Operative fixation with pinning of a slipped capital femoral epiphysis on the right hip.

Prognosis

·        Up to 50% of patients with unilateral SCFE will eventually slip on the other side so careful follow-up is indicated

·        Most contralateral cases will occur within 1–2 years after initial slip

·        Complications include avascular necrosis of the femoral head and is more common in acute slips and those that are unstable

·        Chronic gait abnormality and leg-length discrepancy are rare but can occur

Selected readings and references

Chasm RM, et al. Pediatric orthopedic emergencies. Emerg Med Clin N Am. 2010;(28):907–26.

Frassica FJ, Sponseller PD, Wilckens JH. The 5-minute Orthopedic Consult. Philadelphia, PA: Lippincott, Williams & Wilkins. 2007.

Gholve P, Scher D, Khakharia S, Widmann R, Green D, et al. Osgood Schlatter syndrome. Curr Opin Pediatrics. 2007;19:44–50.

Jayakumar P, et al. Orthopaedic aspects of paediatric non-accidental injury. J Bone Joint Surg. 2010; 92-B (2):189–95.

Kermond S, Fink M, Graham K, Carlin JB, Barnett P. A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med. 2002;40(3):294.

Kocher MS, Bishop JA, Weed B, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics. 2004;113(4):e322.

Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86-A(8):1629.

Lalaji A, Umans H, Schneider R, et al. MRI features of confirmed “pre-slip” capital femoral epiphysis: a report of two cases. Skeletal Radiol. 2002;31(6):362.

Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. 2004;55:1325–43.

Sarwark JF, LaBella CR, eds. Pediatric Orthopedics and Sports Injuries. Elk Grove Village, IL: American Academy of Pediatrics. 2010.

Sink, E., et al. The role of the orthopaedic surgeon in nonaccidental trauma. Clinical Orthopaedic Relation. 2011;469(3):790–7.

Solan MC, Rees R, Daly K. Current management of torus fractures of the distal radius. Injury 2002;33:503.