Paediatric fractures Differences And Paediatric pitfalls.

Paediatric fractures

Differences

And

Paediatric pitfalls

Common things are common

• Fractures in upper limb > lower limb

On desktops in ED, “Paediatric fracture package” explaining fracture management and paediatric fracture quiz.

• Kids need generous analgesia– Physical – sling, POP– Medication – oral, IN, conscious sedation, GA

Fractures – kids differ

• Kids do daft things– Boys are more likely to sustain fractures

• “Plastic” skeleton– Greenstick, torus, bowing patterns– NB associated soft tissue injury

• 15% of # involve growth plates as point of weakness

Fracture patterns

Describe fracture

4 year old falls off flying fox. Deformity and pain in left mid-forearm

Physeal fractures

• Salter Harris

Trauma differences

• Relatively big head +/- poorly supportive muscles– C spine flexion higher

than adults– More likely to suffer

high C spine injuries

Trauma - differences

C spine

• Fracture

• Sublux/dislocate without fracture

• SCIWORA

• NB if there is a major distracting injury, children will not identify neck pain and the neck cannot be “cleared” clinically

12 yo female involved in high speed MVA

7 yo male involved in high speed MVA

Paediatric pitfalls of Musculoskeletal pain

• History / examination– Compliance decreases with pain

• Xrays – NB joint specific views– Backs– Joints

• Inflicted injuries

Assessment

History

• Mechanism of injury– Eg. Hurt ankle – exclude tibial fracture– Eversion – medial #: inversion – lateral #

• Referred pain– Xray - joint above and joint below

• Any fevers, rashes, medications?

Joint Examination• Look / Feel / MoveLook• Compare with normal side• Look for deformity / bruising• Can they weight bear? If so, assess gait.Feel• Point tenderness; joint line tenderness• Pulses + neurovascularMove• Active then passive ie/ watch what the kid does, then attempt to

move• Flexion/extension/abduction/adduction• Internal and external rotation

Neurovascular of handAny distracting injury limits compliance - Give analgesia!Movement• Stop – radial• Make an “L” – median• Make an “O” – ulnar• Make a fist (median), open it “make a star” (ulnar)

• Or hold piece of paper between fingers and do tug-of-war (ulnar)

Sensation• Thumb web space (radial)• Index finger (median)• Little finger (ulnar)

Limp

Acute v chronic• If pain present:

– Constant v intermittent– In same location– Worse at certain times of day

Examination• Abdomen• Spine• Lower limb• Feet

Back pain

Musculoskeletal causes commonest in adolescents.

Alarm bells for:• Child < 5 years• Night pain• Development of kyphosis or scoliosis• Altered gait eg limp• Early morning stiffness• Altered sensation +/- continence

Xrays

• Spinal Xrays = lots of radiation

• AP/lateral + oblique

Spondylo-whatsit

SpondylolisthesisSpondylolysis

Hip pain

• Groin pain– Is it referred?

• Recent fevers?– Septic arthritis, osteomyelitis, transient synovitis

• Any trauma?– Avulsion of iliac crest

• Congenital defect?– Delayed presentation of hip dysplasia

• Rheumatological– Any meds?

Hip Xrays

• NB Xraying gonads

• AP, lateral + frogs legs

Developmental dysplasia of hip• Hilgenreiner , horizontal line

between the two triradiate cartilages.

• Perkins , perpendicular to Hilgenreiner at the outer border of the acetabulum. Divides the hip joint into quadrants. The femoral head should lie within the lower medial quadrant.

• Shenton , a smooth arc between the medial femoral metaphysis and the inferior border of the superior pubic ramus. Loss of the continuous arc is suggestive of DDH or fracture of the pubis.

Elbows

• Supracondylar #– Neurovascular compromise

• Pulled elbow– Only attempt relocation if injury witnessed

• Xray – AP, lateral. Look for a figure of 8 for a “true’ lateral

Injuries – inflicted?

• 1-10% of ED presentations

Risk factors

• Kids under 18 months of age

• Socio-economic– poor, recent migrants, recently adopted from

other countries

• Developmentally delayed

Physical abuse

Abnormal bruisingChildren bump prominences• Forehead• Knees• Lower limbs

Bruises in these areas is cause for concern

Perform FBC, LFT, clotting studies

Call Paeds

Other signs

Inflicted burns

• Scalds when toilet training

• Glove and stocking after immersion

Bites

• Intercanine distance >3cm

Bones

• Alarming fractures– Any fracture in child < 1 year– Spiral fracture– “Chip” fractures of radius and ulna– Transverse fractures of midshaft radius, ulna,

femur– Skull fracture associated with apnoea

Summary of Paediatric Fractures

• Is the story consistent with injury?

• Force dissipation– Growth plates– Soft tissue

• Good analgesia– Physical – sling, POP– Medication – oral, IN, conscious sedation, GA