 |
|
|
 |
| Common Disorders | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Trauma Remarkable gains in injury control have been made over the last 2 decades. Pediatric unintentional injury mortality has fallen by 45.3% between 1979 and 1996, with the largest decreases in children between 5 to 9 years of age. This progress can be attributed to an increasingly scientific approach to injury causation and more effective prevention programs. Despite these enormous gains trauma remain the leading cause of death among children older than 1 year and exceeds all other causes of death combined. Each year, approximately 20,000 children and teenagers die as a result of injury and an estimated 50,000 children acquire permanent disabilities. Moreover, for every child who dies from an injury, 40 others are hospitalized and 1120 are treated in emergency departments. Each year, one in every four children suffers injuries that require medical attention. Skeletal trauma accounts for 10% to 15% of all pediatric injuries. To effectively care for this immense patient population, primary care and emergency room physicians need to have a solid understanding of the guidelines for pediatric orthopedic trauma evaluation, treatment, and referral. Caring for an injured child in an acute setting requires specific pediatric knowledge, meticulous attention to detail, and precise management. Evaluation should be performed by emergency room physicians specialized in pediatrics or trauma surgeons who are familiar with tenets of modern pediatric trauma care (This is a very strong statement and impossible to fulfill.). Once airway, breathing, and circulation have been addressed, a meticulous secondary survey evaluating for musculoskeletal injury should be performed. Careful evaluation of every extremity is essential. First inspect and palpate for gross deformity or tenderness. Then carefully assess for presence of distal pulses and nerve function. Adequate documentation of the neurovascular exam before and after manipulation is essential. Evaluate for compartment syndrome in all extremities even if no gross deformity exists. If compartment syndrome is suspected due to physical findings, fracture patterns, or a history of crush injury, than serial exams must be performed over 12 to 24 hours. Splint fractured limbs to reduce ongoing hemorrhages. Initial splints should be radiolucent or easy removable so they do not sacrifice the quality of screening radiographs. A high suspicion for abuse is required. Abuse is responsible for a staggering percentage of pediatric injuries. Spiral fractures, corner fracture, multiple fractures of different stages of healing, fracture patterns inconsistent with the history, unwitnessed fractures, and suspicious skin lesions are all red flags that warrant a complete skeletal survey. Keep in mind that there is no pathognomonic fracture for child abuse. Radiographs should always include the joint above and below the injury. If the fracture is in a region where ossification is not complete than contra-lateral radiographs are may be useful. This is especially true for pediatric elbow fractures. CT scans are useful for articular fractures that are difficult to delineate on plain radiographs or complex physeal fracture as seen in the distal tibia. The biomechanics surrounding the growth plates differentiates pediatric fracture patterns from adult fractures. A solid understanding of the Salter-Harris classification system is essential to diagnosis and treat pediatric fractures and effectively communicate with consulting orthopedic surgeons (Rememvber, these are pediatricians reading this. They don't want to know about SH classification. They do need to know when to refer to specialists. You should include a paragraph about when to consult a specialist. ? open fxs, compartment syndrome dislocations, neurovascular injury, etc.),.
Injuries to the Clavicle The clavicle is one of the most commonly fractured bones in children. These tend to occur in the region of the middle of the clavicle. The majority can be managed with a sling for 2-3 weeks . by then there is sufficient healing that the child should be able to support his own arm comfortably. The purpose of the sling is for comfort, not to reduce the ends of the fractured bones. These injuries have a tremendous capacity to remodel and reform a nearly normal bone.. Surgical intervention is reserved for rare open fractures, severe tenting of the skin, neurovascular compromise, or symptomatic non-union.
Injuries to the pediatric elbow are extremely common, representing ~9% of all fractures in children. Because they can be difficult to diagnose and have the potential for significant complications, they remain a challenge in pediatric orthopedic trauma. A careful neurovascular exam must be performed and documented before and after any manipulation. Initial radiographs should include true anteroposterior and lateral radiographs. Occaisionally comparison views are helpful to differentiate normal anatomy from injury. Because the fracture line can be difficult to view on plain radiographs, anterior and posterior fat pad signs on radiographs and the clinical exam play an important role in the diagnosis. Figure 1 shows the frequencies of different elbow fractures, peak incidence, and need for surgery.
Figure 1: Elbow injuries
Representing 41% of elbow injuries and 60% of elbow fractures, supracondylar fractures are common and usually require operative treatment. Peak incidence in children is from 5 to 8 years. Extension type injuries make up 96% of supracondylar fractures. Neurologic deficits are found in 7% to 15% of supracondylar fractures and it is therefore essential to document the neurologic exam before and after manipulation. The anterior interosseous branch of the median nerve is most commonly involved, followed by the radial nerve and ulnar nerve. Most nerve injuries are neuropraxias and do not require treatment. Vascular injury, although less common with an incidence of less than 1%, has higher potential for morbidity. Anterior displacement of the proximal humerus can impinge on or damage the brachial artery. Closed reduction often relieves impingement on the artery and should not be delayed when there are diminished pulses. Prompt orthopedic consultation is critical in this scenario. Management of a pulseless hand that is warm, pink, and has adequate capillary refill is controversial in the orthopedic community but is trending towards nonoperative management. Treatment of uncomplicated supracondylar fractures is based on the degree of displacement. Only a nondisplaced fracture is amenable to nonoperative treatment in a long arm cast with the elbow at 90 degree for 2 to 3 weeks. Displaced fractures are treated surgically with closed reduction and percutaneous pinning followed by casting. Recent studies have shown that two lateral pins are clinically as effective as a medial and lateral cross pins without the added risk of ulnar nerve injury. Postoperatively the patient is observed for 24 to 48 hours to ensure normal vascular flow and rule out a Volkmann's ischemic contracture. More commonly known as ?nursemaid's elbow? these injuries are most common in children from 2 to 4 years of age, but have been encountered in children up to 8 years of age. The injury is caused by longitudinal traction in an extended and pronated arm that leads to tearing of the annular ligament. Interposition of the torn ligament prevents spontaneous reduction. A child with radial head subluxation holds the elbow flexed and the forearm pronated. Pain will be localized to the elbow. Although there are no radiographic findings with radial subluxation, radiographs should be performed to rule out other injuries. Reduction is performed by manually supinating the forearm with the elbow in 60 to 90 degrees of flexion. While holding the arm supinated the elbow is then maximally flexed. During this maneuver the physician's thumb applies pressure over the radial head. A palpable click is often heard with reduction. Immobilization is not necessary and the child may immediately resume use of the arm. Follow up is only needed if the child does not resume normal use of his arm in the following weeks. Recurrence occurs in 5% to 39% of cases, but generally ceases after 5 years of age.
Lateral condyle fractures are common and their outcomes have historically been worse than supracondylar fractures. The combination of the fracture's articular nature, associated growth disturbance, and diagnostic challenge lead to an unacceptably high incidence of malunion and nonunion. Physical exam is often relatively benign and lacks the deformity often seen with supracondylar fractures. Swelling and tenderness are usually limited to the lateral side. If the lateral condyle and capitellum have not ossified then radiographic findings can be subtle. The most important radiographic finding is the relationship between the capitellum and the proximal radius. Contra-lateral radiographs are very important. MRI and arthrograms can be helpful as well. To obtain good treatment results the articular surface must be perfectly reduced. Only when one is confident the fracture is nondisplaced should nonoperative treatment with casting be performed. More often, the fracture is displaced and should be treated with closed reduction with percutaneous pinning in the operating room. Intraoperative arthrogram is valuable to delineate the fracture and ensure anatomic reduction. Delay in diagnosis and improper treatment can lead to nonunion, malunion, or osteonecrosis. All three can cause deformity, the most common and feared being cubitus valgus and associated tardy ulnar nerve palsy. These complications, coupled with the fracture's high prevalence and subtle radiographic findings should keep lateral condyle fractures on the forefront of physician's minds when evaluating elbow injuries in children.
Medial epicondyle fractures consist of ~8% of all elbow injuries. They are found in older children ages 10 to 14. The medial epicondyle acts as the insertion site for the forearm flexors and the medial collateral ligament. Therefore, when a valgus force is placed on the elbow while the forearm flexors are contracted, an avulsion of the medial epicondyle occurs. If this force is strong enough the elbow will dislocate. Fifty percent of medial epicondyle fractures are associated with elbow dislocations. If there is generalized elbow pain and swelling one should suspect elbow dislocation even if the elbow is reduced on presentation. An isolated medial epicondyle fracture is extra-articular so pain will be localized to the medial elbow and fat pad signs will be absent on radiographs. Ulnar nerve dysfunction is found in 10% to 16% of these fractures so careful neurovascular exam is critical. Most medial epicondyle fractures are minimally or nondisplaced and may be treated with immobilization in a posterior molded splint with the elbow flexed to 90 degree. After 3 to 4 days the splint is discontinued and active range of motion is begun. A sling can be worn for comfort. For displacement medial epicondyle fractures treatment is controversial in the orthopedic community. Absolute indications for operative treatment include an incarcerated irreducible fragment in the elbow joint. Controversial indications for surgery include ulnar nerve dysfunction and elbow instability. Operative treatment includes percutanous pinning or open reduction with screw fixation, depending on the age of the child.
Elbow dislocations are rare and occur in older children as the result of a fall on a hyperextended elbow. Most dislocations are posterolateral. There is a high association with elbow fractures, especially medial epicondyle fractures. A careful neurovascuclar exam must be performed because injury to the brachial artery, median nerve, and less commonly the ulnar nerve can occur. Reduction should be performed in a timely matter under conscious sedation. The maneuver consists of first reducing medial or lateral displacement, then slowly flexing the elbow while longitudinal traction is applied. Gently pronating and supinating the forearm during this maneuver may aid the reduction. Avoid reduction in hyperextension as it is associated with median nerve entrapment. After reduction stability of the elbow should be tested. If stable, immobilize for one week and then begin range of motion exercises. If unstable, immobilize in a position of stability for three weeks and then begin motion exercises making sure to avoid full extension until 6 weeks. The need for surgery is rare, and is reserved for open dislocations, median nerve entrapment, brachial artery injuries, or treatment of an associated fracture.
Radial Head and Neck Fractures In children radial head fractures are rare and usually involve the radial neck or physis. The radial head is rarely involved. Patients typically present with lateral swelling and pain exacerbated by motion, especially supination and pronation. A portion of the radial neck is extra-articular and therefore an effusion and fat pads signs are often absent. A radiograph with the beam directed 40 degree in the proximal direction, known as the Greenspan view, is helpful to visualize the fracture. Nonoperative treatment is indicated for minimally displaced fractures with less than 30 degrees of angulation. If there is 30 to 60 degrees of angulation closed reduction with or without percutaneous pinning should be perfomed in the operating room. If there is greater than 60 degrees of angulation or greater than 4mm of displacement open reduction and internal fixation is indicted. Postoperatively the patient is placed in a long arm cast with the elbow flexed to 90 degree and the forearm pronated for 3 weeks.
Injuries to the Forearm and Wrist Pediatric forearm fractures are very common, comprising 45% of all pediatric fractures. 81% of these fracrtures occur in children who are older than 5, with a peak incidence occurring from 10 to 12 in girls and 12-14 in boys. Fractures of the diaphysis include both bone fractures, and greenstick fractures where one cortex is disrupted but one remains intact. Fractures of the metaphysic include ?torus? (buckle) fractures, and displaced distal radius fractures (e.g., Colle's fracture). Fractures of the distal physis include Salter Harris fracture I-V. Although rare, compartment syndrome should be carefully ruled out in forearm fractures. Pain out portion to the injury and pain with passive extension of the fingers are the most sensitive findings to identify a developing compartment syndrome. Figure 2 shows a breakdown of different forearm and wrist fractures and their frequency.
Figure 2: Forearm and Distal radius
The majority of forearm and wrist fractures are treated nonoperatively with closed reduction under conscious sedation followed by casting. The reduction maneuver and accepted angulation is defined on a case by case basis depending on the age of the patient, the location of the fracture, and the type of deformity(angulation, rotation, bayoneting). The radius and ulna function as a single rotational unit. Therefore a final angulation of 10 degrees in the diaphysis can block 20-30 degrees of rotation. Rotational deformities do not remodel and are not accepted. Bayonetting less than 1 cm, as long as it is not angulated, does not block rotation and is acceptable in patients less than 10. For children less than 4 years old, 20 degrees or less of angulation is acceptable in the shaft and distal radius. Children over 10 years should be treated as adults and no angulation should be accepted. Immobilization consists of a long arm cast for 6 to 8 weeks, with the possibility of conversion to a short arm cast after 4 weeks depending on the type of fracture and heeling response. One exception is the torus fracture which may be immobilized in a short arm cast for 2 to 3 weeks. For all forearm fractures serial radiographs should be taken every 1 to 2 weeks to ensure the reduction is maintained. Operative treatment is indicated in fractures in which acceptable angulation can not be obtained through closed reduction, comminuted fractures with segmental bone loss, and articular epiphyseal fractures. The most common fractures that require open reduction and internal fixation are both-bone fracture in a child greater than 10 years of age and articular Salter-Harris fractures (Type III-V) of the distal radial physis. Monteggia fracture is a fracture of the proximal ulna with an associated dislocation of the radial head. Although rare, it is notable because reports have shown that up to 50% of these fractures are missed in the emergency room. This emphasizes the need for ?joint above and joint below? radiographs in all orthopedic injuries. The majority of Monteggias fractures can be treated nonoperatively, especially in younger children. Galeazzi fractures, defined as a fracture of the middle to distal third of the radius with disruption of the distal radioulnar joint are rare in children.
Femoral shaft fractures represent 1.6% of fractures in the pediatric population. They are distributed in a bimodal distribution of incidence, with the first peak being 2-4 years of age, and the second being mid-adolesence. During adolescence a geometric increase in the diameter of the cortex leads to a corresponding increase in bone strength. Therefore fractures in adolescents are caused by high energy trauma, 90% being motor vehicle accidents. In younger children femur fractures are caused by low energy injuries. Abuse is responsible for 80% of femur fractures in children not yet walking and 30% in toddlers. The remainder are caused by low energy trauma such as falls. Radiographs must include hip and knee films to rule out associated injuries. There is a high association of femoral neck fractures with femur shaft fractures and their diagnosis is often missed. Historically management has been conservative with 2 to 3 weeks of inpatient skeletal traction followed by casting. Recent improvements in operative technology had led to a trend towards operative treatment in older children. Figure 3 gives guidelines for treatment based on the age of the child.
Figure 3: Femur fracture management
Tibia fractures represent the third most common pediatric fracture (15%) after femoral and forearm fractures. Figure 4 lists common causes of tibia fractures. On the forefront of any physicians mind when presented with a tibia fracture should be compartment syndrome. Palpation of the anterior, lateral, and posterior compartments of the leg are essential and a careful neurovascular exam including palpation of the dorsalis pedis should be performed. Compartment syndrome is a clinical diagnosis in children who are alert and oriented. In a child with altered mental status the exam is and compartment pressures should be read. Pressures greater than 30 mm Hg or with 30 mm Hg of diastolic blood pressure should receive emergent fasciotomies of all four compartments to avoid neurologic and ischemic sequelae. If no compartment syndrome is present but the child has significant soft tissue damage or swelling, the patient should be admitted overnight for observation and elevation following reduction and casting.
Figure 4: Cause of Tibia fractures
Proximal Tibia Metaphyseal Fractures Proximal tibia metaphyseal fractures constitute 11% of pediatric tibia fractures and have a peak incidence of 3 to 6 years of age. These fractures are significant for their tendency to develop a valgus deformity. If the fracture is nondisplaced a long leg cast with 10 degrees of flexion at the knee can be placed. With a displaced fracture, reduction should be performed under general anesthesia and a long leg cast should be placed in full extension with varus molding to prevent valgus collaspse and malunion. Casts are maintained for 6-8 weeks with serial radiographs and weightbearing may be allowed after 2-3 weeks. If interposed tissue prevents closed reduction, an open reduction should be performed. If progressive valgus deformity occurs, it may be watched for 6 to 12 months with expectation of spontaneous correction. If correction does not occur than surgical correction with epiphysiodesis or osteotomy may be required. Diaphyseal Fractures of the Tibia 39% of tibia fractures occur in the diaphysis. Of these, 30% are associated with a fibula fracture. If the fibula is intact these fractures have a tendency to migrate into varus. If the fibula is involved they migrate into valgus. The majority of these fractures can be managed nonoperatively with closed reduction under conscious sedation followed by immobilization. Acceptable reduction in children is 50% apposition, < 1 cm of shortening, and < 5-10 degrees of angulation in the sagittal and coronal planes. Immobilization is done with a long leg cast with the knee flexed to provide rotational control and prevent weight bearing. Serial radiographs are performed to monitor for developing deformity. Operative management is indicated in < 5% of tibia shaft fractures. Indications for surgery include open fractures, complex fractures that cannot be reduced, compartment syndrome, neurovascular injury, and multiple long bone fractures. Methods of fixation include external fixation, plates, or intramedullary rods depending on the age of the patient and degree of soft tissue injury. Tissue flaps or skin grafts may be required for skin closure. Postoperatively a long leg cast is applied.
Most occur in children less and 2.5 years. The classic description of the mechanism is external rotation of the foot with the knee in a fixed position. This creates a torsional force that leads to a spiral fracture of the tibia without involvement of the fibula. Management consists of a long leg cast for 2 to 3 weeks followed by 2 to 3 weeks in a short-leg cast. Manipulation is usually not necessary. This is a low energy injury, and the suspicion for compartment syndrome is less than other tibia fractures. Therefore, it is usually not necessary to admit the patient for observation.
Distal Metaphyseal Tibia Fractures Fractures of the distal third of the tibia comprise approximately 50% of pediatric tibial fractures. There is a peak incidence between 2 and 8 years. For nondisplaced or minimally displaced fractures treatment includes reduction under concious sedation followed by long leg casting. After 3 to 4 weeks the cast may be converted to a short leg cast. Surgical intervention is reserved for open fractures or complex fractures where stable reduction is not possible by closed means. Usually surgical treatment is performed with closed reduction and percutaneous pinning followed by a long leg cast and serial radiographs. For open fractures, external fixation is the treatment of choice. Skin grafts and flaps may be required for skin closure.
Ankle injuries are common, accounting for 25% to 38% of all physeal injuries. 58% of these injuries occur during athletic participation. Peak incidence is from 8 to 15 years. After age 16 adult fracture patterns are seen. On exam be sure to check for proximal fibula tenderness. If present, be sure to include tibia-fibula radiographs. Fractures may be isolated to the physis of the fibula, the tibia, or involve both depending on the mechanism and amount of energy.
Isolated Lateral Malleolus Injuries In children ligaments are relatively stronger than bones. Therefore bones and growth plates tend to fracture before ligaments tear. For this reason ankle sprains are less common in children than adults. More common is a Salter-Harris I fracture of the distal fibula. Because both have negative radiographic findings, the only way to distinguish them is by careful physical exam. With an ankle sprain there should be swelling and tenderness directly over the talofibular ligament, whereas with a distal fibula physis fracture the tenderness will be over the lateral malleolus growth plate. Treatment of a sprained ankle includes ace bandage, ice, elevation, and weight-bearing as tolerated. Treatment for a isolated Salter-Harris I of the distal fibula is a short-leg cast with weight-bearing as tolerated for 3-6 weeks. For a Salter-Harris III or IV of the distal fibula, closed reduction with percutaneous pinning and subsequent casting may be indicated.
Isolated Distal Tibia Physeal Fractures Fractures of the distal tibia physis pose a diagnostic challenge, and often have a poor prognosis secondary to physeal growth arrest. Axial compression can lead to a Salter-Harris V injury to the physis. Diagnosis is often delayed until premature physeal closure is found with a leg length discrepancy. In the distal tibia the medial physis fuses first, and for a period of approximately 18 months the lateral physis remains open while the medial physis is closed. This explains the occurrence of the juvenile Tillaux fractures (lateral Salter-Harris III fracture) and triplane fractures . If either of these fractures are suspected a CT scan is essential for diagnosis. For fractures of distal tibia closed reduction and casting is the treatment of choice for Salter-Harris I and II fractures. A long leg cast for 3 weeks, followed by a short leg cast for three weeks is standard. For articular Salter-Harris III and IV fractures, Tillaux, and triplane fractures anatomic reduction is required. If there is < 2 mm of displacement following closed reduction under conscious sedation then treatment is a long leg cast for 4 weeks followed by a short leg cast for 3 weeks. If >2 mm of displacement remains than reduction under general anesthesia is followed by percutaneous pinning or open reduction and internal fixation with Kirschner wires or screw fixation. Postoperative casting with long-leg cast for 4 weeks followed by a short-leg walking cast for 3 weeks is required.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|