1 / 55

Pediatric Orthopedics in the ED

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.

marcel
Download Presentation

Pediatric Orthopedics in the ED

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pediatric Orthopedics in the ED • Common presentations, common fractures, and common sense treatments. • James Thorburn

  2. Overview • Housekeeping - terms and unique physiology of children • General Approach • Upper body (limbs) injuries - FOOSH • Lower body - Approach to limping child

  3. What’s the difference? • Periosteum is thicker, stronger, and more biologically active • More plastic deformities • GROWTH PLATES !! • Ligaments stronger than bones

  4. Ortho talk

  5. Fracture description

  6. Buckle Fracture (#)

  7. Greenstick #

  8. Salter Harris

  9. Initial Approach • ABC’s - just like everything else • Quick assessment for: • Neurovascular compromise (NVI) • Open # • Bleeding - femur and pelvis (C’s)

  10. History • Mechanism of injury - important • time • exact location of pain • other associated symptoms • “SAMPLE”

  11. 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

  12. Pain meds • Ibuprofen (advil): 10 mg/kg per dose • Acetaminophen (tylenol): 15 mg/kg per dose • Narcotics: • Fentanyl - IV, or intranasal (1-2mcg/kg) • Morphine - 0.1mg/kg SQ, 0.1-0.5/kg PO

  13. SPLINT! • Don’t be me • back slab!

  14. FOOSH • Examine clavicle to wrist! • Clavicle # • Elbow # • Forearm #

  15. 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)

  16. Case • 13 year old, fall off scooter • SAMPLE hx • Quick physical • Fentanyl 1.5mcg/kg x 40kg = 60 mcg intranasal • Place backslab • X-rays.

  17. Clavicle # • Majority in the middle 1/3 • Sling for support (if old enough)

  18. Elbow # • No one likes elbows • ROM important • NV exam quite important • supracondylar # most common

  19. Possible #s • Supracondylar • Medial/lateral condylar • Radial head # (older kids) • Olecranon #

  20. X-ray approach • 5 things to look at, and won’t miss • Fat pads • Anterior humeral line • Hourglass sign • Proximal radial line • Ossification centres

  21. Fat Pads

  22. Capitellum is key

  23. Hourglass

  24. Ossification - CRITOE

  25. Supracondylar # management • Pain management • Non-displaced - back slab and “U” slab and follow up with ortho • displaced - consult ortho from department • compartment syndrome!

  26. Not Sure? No prob! • ++ pain • Posterior fat pad/ anterior sail sign • Back slab and follow up for R/A!!

  27. 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

  28. Management • X-ray? not usually necessary • Reduction • Hyperpronation • Supination and flexion

  29. Can’t reduce? • Consider x-ray • try both techniques • immobilize? sling? • Arrange follow up

  30. Monteggia

  31. Galeazzi #

  32. Management of buckle and greenstick # • Casting vs splinting • Dr. Boutis • Either for 3 weeks

  33. Approach to the limping child • Differential is huge!! • History is important • Don’t ignore caregiver • Estimate of 25% no diagnosis

  34. Differential - categories • Traumatic vs non-traumatic

  35. Traumatic • Cause may be obvious - #!!! • Beware occult # - sprains/strains not as common in kids • Buckle # • Greenstick # • Toddlers #

  36. 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.

  37. 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!!

  38. No trauma? • Think articular vs systemic • important questions: • Fever? • Rash? • Preceding illness? • Constitutional symptoms? • GI sx?

  39. Ddx Articular • Transient synovitis • Septic Arthritis • Legg-Calve-Perthes • SCFE • JRA • Reactive arthritis

  40. Ddx Extraarticular • Malignancy • Testicular torsion • Sickle cell crisis • Rheum / vasculitis

  41. 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

  42. Transient Synovitis • Self limited inflammation of synovial lining (resolve 3-10 days) • classically viral prodrome, but not necessary

  43. Septic Arthritis • Danger to life and limb!!

  44. History clues • Just how sick is the child?

  45. History • Fever - how long? how high? toxic? • Persistence of non-weight baring? • Viral prodrome?

  46. 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

More Related