PAEDIATRIC RADIOLOGYderriforded.weebly.com/uploads/1/5/2/.../paediatric... · Reduction of...
Transcript of PAEDIATRIC RADIOLOGYderriforded.weebly.com/uploads/1/5/2/.../paediatric... · Reduction of...
PAEDIATRIC RADIOLOGY
Session plan
• Brief revision about fractures
• Kiddy specific stuff
• General management of fractures
• A few pictures!
Bits of the bone
Bits of the bone
Describing fractures
Describing fractures
• Location
• Open or closed
• Type of fracture
• Displacement
• Rotation
• Angulation
• Eponymous names and classifications
Growth plate injuries
• Salter Harris classification
Growth plate injuries
• Salter Harris classification:
S – straight - I
A – above - II
L – lower - III
T – through - IV
ER – everything ruined – V
Type I and II
• Type I
– Radiograph initially normal
– There is calcification at 7-10 days
– Look for fat pads
– Act on your clinical suspicion
– Immobilise
• Type II
– Most common type
– Generally do well
Type III + IV
• Type III
– Accurate reduction essential
– Distal tibial epiphysis most common site
• Type IV
– Distal Tibia again a common site
– Accurate reduction essential
– Prognosis guarded
Triplane Fracture
• Occurs during an 18 month window, prior to physeal closure
• CT is useful to determine extent of injury &
displacement – Articular surface more
deranged than you think
• With articular derangement they need manip +/- fixation
Tillaux Fracture
• SHIII Fracture of Distal Tibia
• An ATFL Avulsion Fracture
in adolescents again
Type V
• Type V
– Can be difficult to spot on radiographs
– Consider in patients with axial load
– Prognosis guarded
Kiddy specific stuff
• Ligaments may be stronger than the bone
and growth plate
– Injuries to growth plates and buckle fractures
are common
– Physeal separations are more common than
dislocations
– Fractures often accompany dislocations
Kiddy specific stuff
• Bones are soft and elastic
– Bowing fractures
– Buckle fractures
Kiddy specific stuff
• Children rarely complain persistently
unless there is something wrong
• Can be hard to pinpoint the problem
• Have a low index for imaging
• May need to image more broadly than you
would like
• Usually don’t need comparison views
Kiddy specific stuff
• Films can be hard to interpret
Fracture healing
• Growth plate injuries heal most rapidly
• Active growth plates heal the fastest
• Growth plate injuries can impair growth
• Rate of remodelling is inversely related to
age
• Remodelling is maximal near, and in the
plane of action of, the nearest joint
• Bones grow more rapidly after injury
Management in general
• Don’t forget the ABCs
• Early analgesia
• Recognise true orthopaedic emergencies
– Open fractures and dislocations
– Neurovascular compromise
• Test and document neurovascular function
• Request appropriate radiographs
• Always consider NAI
Analgesia for kids with fractures
• Non pharmacological
– Child-centred approach
– Involve the parents
– Splintage / traction
– Distraction
– Play therapy
Analgesia for kids with fractures
• Pharmacological
– Base on severity of pain and NPO status
– Options • Entonox
• Paracetamol
• Codeine
• NSAIDs
• IN diamorphine
• IV morphine
– Don’t forget nerve blocks
Reduction of fractures or
dislocations in the ED
• May be indicated if
– It’s straightforward
– Neurovascular compromise
– Skin integrity threatened (eg) fracture-
dislocation ankle
– Delay in reduction not desirable (eg) elbow
dislocations
Open fractures
• Size doesn’t matter
• Tetanus prophylaxis
• IV antibiotics
• Clean wound or cover with saline
soaked/clear dressing
• Urgent ortho/plastics consult
Compartment syndrome
• Beware in kids: ‘rest and elevation’ is easier said than done
• Take early signs seriously
• Remember to look for: – Pain – esp with passive extension of fingers or toes
– Paraesthesia
– Purple colour or pallor
– Pulselessness
– Paralysis
– Perishingly cold
What do you think about this elbow X-
ray?
Haemarthrosis (positive fat pad
sign) without fracture
Many will have occult
fracture (usually
supracondylar or radial
head)
•C&C
•Review 10-14 days
•Can investigate further but
unlikely to affect
management
Kohler’s Disease
• Osteochondritis of the navicular
• Presents with mid-foot pain in children under 10yrs
Antalgic Gait (‘limping child’)
Tenderness in region of navicular
Localised inflammation
Osgood-Schlatter’s Disease Traction apophysitis of tibial tuberosity
Sever Disease • Calcaneal Apophysitis
(Osgood Schlatter’s Disease
of the heal)
• Occurs in 7-15 yrs (usually 10-12)
One of the so-called ‘growing pains’
• Presents with • Severe pain in the heal on exercise
• Aching on awaking
• Tenderness posterior aspect of heal
Iselin’s Disease
Pelvic Avulsion Fractures
• Usually in athletic individuals during
exercise
• Occur during acceleration bursts
• Most commonly occur during puberty
• M:F 2:1
• Ischial Tuberosity>AIIS>ASIS
• This is why you must palpate all your bony
landmarks and have a low threshold to x-
ray the young
Pelvic Avulsion Fractures
Avulsion Fractures
ASIS Avulsion Fracture
Lesser Trochanter Avulsion
Fracture
This 8yr old presented to the dept with left
hip pain and a limp
Perthe’s Disease
• Avascular necrosis of
the femoral head
• Radiographic diagnosis.
• There is a flattening and
fragmentation of the
femoral head.
Questions ?
Summary
• Describing fractures
• Paediatric considerations
• Imaging
• Management in general
• Specific injuries