San Antonio School of Medicine June 10-12, 2011
Transcript of San Antonio School of Medicine June 10-12, 2011
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Orthopaedic SectionTravis Murray MD
Assistant Professor Pediatric Orthopaedic Surgery
UTHSCSA
Disclosure I have no financial conflicts of interest
Disclaimer:
Information taken from 2008 AAOS Academy ICL
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
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Case #111 yo male
EMS brought in for inability to ambulate for 3 days
No history of trauma
Acute Slipped Capital Femoral Epiphysis
Case #1: SCFE Issue:
AVN Medial femoral circumflex
artery
Classification
Clinical Stable: can walk
with/without crutches
Unstable: cannot walk
50% risk of AVN
Clinical Presentation
Groin pain
Hip/leg in ER
Knee pain in 1/3
#1 SCFERadiographs:Klein’s lineMetaphyseal blanch sign
MRI may be sensitive if radiographs equivocal
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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#1 SCFE Workup Hypothyroidism
Panhypopituitarism
Growth Hormone abnormality
Hyopgonadism
Radiation Therapy
Renal osteodystrophy (hyperparathroidism)
Down’s Syndrome
Consider workup <10th percentile height
<10 yrs old or >15/16 yrs
<50% percentile weight
BUN/crt, TSH,
Absolute
-image other hip
-
#1 SCFE OR table
Fracture table
Radioleucent vascular table/diving board
6.5 or 7.2 cannulated screws
Urgent vs Delayed?
#1 SCFE Screw Starting point
Screw threads
Placement in head
Capsular decompression
? Reduction
Post op Unstable: crutches up to
3 mo
Stable: 6 weeks
Complications: Intraarticular screw
Impingement
Fracture
AVN
Chondrolysis
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Case #2Oct 08
12 yo maleHip pain afterbeing tackeled infootball
c/o L hip pain
Hip fractures and dislocations
Case #2 (Hip dislocation/fractures) Blood supply (see
unstable SCFE)
Dec 08
Classification (Delbet) Transepiphyseal
Transcervical
Basicervical
Intertrochanteric
Fracture vs. SCFE Variable age
Vertical fracture through normal physis
60% complication rate
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Case #2 Delbet type I
Rarest
Birth injury/?child abuse
50% occur with dislocation
90% AVN with dislocation
Delbet type II/III
Transcervical
Most common
AVN 50%
Basicervical
AVN 30%
Nonunion/malunion 30%
Case #2 Type IV
Rare (15%)
AVN 5%
Treatment principles
Reduction
Joint decompression
Stable fixation
Surgical emergency
Gentle traction
Anteriolateral approach
Stability more important than physis
2 yo male
Playing with sister
Fell 3 stories to ground with sister
AR
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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AR
AR
#2 (Dislocations) Dislocations more common than
fractures
Posterior most common High energy (75%) > low engergy
Emergent reduction Adequate relaxation Consider imaging with floro with
traction Post reduction CT
Open reduction Non-concentric Fracture In direction of dislocation
Management Protected weight bearing Hip precautions AVN survelence
Complications AVN (3-10%) Myositis ossificians Redilocation Neurovascular injury (5%) Premature DJD
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Case #3
Displaced supracondylar humerus fracture
#3 supracondylar fracture Gartland classificatino
Type I: undisplaced
Type II: displaced with bony contact
Type III: severe displacement; no bony contact
Case #3 supracondylar humerus Delay to AM:
No increased rate of open reductinon
No increased risk of neurovascular complications
However: important for frequent neurovascular checks to assess for compartment syndrome and loss of pulse
Operative reduction
OR
Sterile technique
Longitudnal traction with elbow slightly flexed
Correct medial/lateral displacement
Flex the elbow
Pronate if medially displaced; supinate if laterally displadced
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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#3 supracondylar Consider C-arm
positioning
Optimize screen location
Careful external rotation
Check oblique views
Pin Configuration Medial and lateral
Lateral divergent alone
Medial pin
Open Reduction Irreducable
Where to open?
Vascular embarassment
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Post Op Splint/Cast
Follow up at one week
Pins out at three weeks
Case #4Supracondylar Pulseless Extremity After Fracture Vascular supply
Management Closed reduction and
percutaneous pinning always the first step
Then decide if vascular exploration nescessary
Vascular consult
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Supracondylar without pulse
Adequate perfusion
CRPPObserve
Elbow in relaxed position
Warm room
PulselessInadequaqte perfusion
Reduce fracture and pin
Explore and repair via anterior approach
Urgent vascular consult
(expertise in small vessel reconstruction)Consider fasciotomy
#5 Compartment Syndrome Compartment syndrome: Symptom complex
caused by elevated pressure of tissue fluid within a confined osseofascial compartment
Etiologies Fracture with muscle
damage and swelling
Trauma with vascular injury
Iatrogenic after osteotomies
Exercise induced/exertional
Pressure from external source
Subjective Complaints Pain
Beware: increasing pain, analgesic requirements, fracture requiring vascular repair
Beware fracture with associated nerve injury (ie. Supracondylar with median N injury)
Pallor
Pulselessness
Consider prophylactic fasciotomy for fractures with vessel repair >8 hrs
Parathesias
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Suspected Clinical Findings
Conclusive clinical findings
Unconscious patientInconclusive Clinical
Findings
Compartment pressure measurement
>30 mm Hg
<30 mm Hg
Continuous measurement
Repeat evaluation
Fasciotomy
<30 mm Hg
Positive clinical findings
Compartment Fasciotomy Wound Management
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Fasciotomies
#6 Polytraumatized Child ABC
ATLS
Primary and Secondary Orthopaedic Assessment
Damage Control Orthopaedics Introduced in adults in 1990’s
Control hemorrhage, soft tissue management, provisional fracture fixation
Inflammatory mediators with initial trauma
Orthopaedic surgery is “second hit”
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Pediatric Damage Control Damage Control
Acidosis with pH<7.2
Hypothermia with temp <35.5
Coagulopathy
Head injury with uncontrollable ICP
Severe pulmonary injury
Expect excessive surgical time or if ill prepared to definitvely fix all injuries
Case by case discussion with trauma surgeon, neurosurgeon, anesthesia, ICU and orthopaedic surgeon
Pearls of Polytrauma Care in Children Failure to assess all major injuries prior to going to OR
Poor radiographs, inadequate spinal eval
Have primary and back up OR plans for all injuries with equipment in the room for both
Trying new techniques is foolish. Do what works for you
Ask for help
The enemy of good is perfection—minor or even major revisions can be done at a later date
Careful repeat assessment and anticipation of complications
#7 Open Tibia Fracture Typically a result from high-energy trauma and
associated with other injuries
ED management
One inspection of wound to note size and contamination
Careful neurovascuar exam
Apply sterile dressing
Splint
IV abx
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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IV abx Cefazolin (100 mg/kg/day divided Q8 hours)
Gentamycin (5-7.5 mg/kg/day Q8 hours)
Grade II, III injuries
Penicillin (150,000 units/kg/day Q6 hours)
Farm injuries; at risk for Clostridium and anaerobes
Tetanus
If immunization unknown or last booster given >5 yrs ago
Consider tetanus immunoglobulin if unknown and high risk
Timing of Surgery When IV abx initiated in ED, timing of I&D does not
influence infection if done within 24 hrs
Grade I 2%
Grade II 2%
Grade III 8%
Degree of soft tissue contamination, skin loss, exposed bone are best guides for timing.
If severe, best managed emergently
OR pearls I&D
Clean bone ends and non-viable tissue
Leave questionable tissue for second look
Consider release of compartments in severe injuries/head injured regardless of pre-op assessment
VAC for large open wounds
Stabilize fractures
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Tibial stabilization Consider cast only for Grade 1, minimal swelling, or
intact fibula
Flexible nails
Two antigrade nails
Consider cast for rotation
External fixator
Segmental loss
Severe soft tissue injuries
Not as tolorated as flexible nails
Post op care IV abx for 48 hours
Repeat debridement of severe wounds every 24-48 hours
Careful monitoring for complications
Compartment syndrome
Osteomyelitis
Pin tract infections
Loss of reduction
#8 Cervical spine injury High index of suspicion
Challenging because of osseous development and size of head
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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C-spine radiographs
Lines
Head vs. Body size
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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#9 Septic Hip 0.25% of pediatric
hospitalizations
Possibly more common than osteomyelitis
Hematogenous seeding
Contiguous osteomyelitis
Consider in any ill-appearing child with atrumatic mobility limitation
Workup
CBC, ESR, CRP, blood cx, radiographs, ultrasound
DDx Septic Joint
Transient synovitis
Reactive arthritis
JRA
Kawasakis syndrome
Henoch-Schonlein purpura
Rheumatic fever
AVN
SCFE
Trauma
Neoplasa
Lyme disease
Perthes
Other infections Osteomyelitis
Pyomyositis
Septic bursitis
Cellulitis
Septic joint vs transient synovitis Transient synovitis
One of the most common causes of hip pain
0.9% pediatric ED visits in one year
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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K.S.7 year old female with increasing hip pain, fever, chills, inability to bear weight
K.S.Aspiration and I&D septic hip
Kocher Guidelines n=282 1979-1996
History of fever (>38.5)
History of NWB
ESR >40mm/hr
WBC >12,000
PPD vs variables
0=0.2%
1=3.0%
2=40%
3=93.1%
4=99.6%
Varified later at same institusion
0=2%, 1=9.5%, 2=35%, 3=72% 4=93%
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Flynn contribution CHOP
Added CRP to algorithm
Prospective following of 53 aspirations
Temp >38.5
ESR
CRP
Refusal to bear weight
WBC >12,000
5=98% 4=93% 3=83% 2=62% 1=36% 0=16%
Workup Thorough physical exam Back/Spine
Pelvis
Leg
Plain film
U/S hip
CBC with diff, ESR, CRP
Blood culture
? MRI
? Bone scan
Factors of Poor Prognosis Less than 6 months of age
Delay in initiation of treatment >72 hrs
Concomitant osteomyelitis of femur
Inadequate I&D of hip joint
Dislocation of hip
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Antibiotic Guidelines Neonate
Strep Gram negative Neisseria gonorrheae
Abx Nafcillin Cefotaxime Gentamycin in high risk Avoid clindamycin Preservative causes apnea
Older infant Staph Kingella kingae Associated with URI, Culture in BACTEC culture
bottle
Hemophilus influenzae If not immunized
Abx Unasyn/Clindamycin Penicillin or Unasyn for
kingella kingae Vancomycin in ill pt
Antibiotic guidelines (ctd.) >5 yrs old
Staph aureus
Salmonella
Pseudomonas
Abx Nafcillin and Clindamycin
Vancomycin and Clindamycin
Ceftazidime and Gentamycin for Pseudomonas
Adolescents Staph aureus
Neisseria gonorrheae
Borrelia bergdorferi
Abx Nafcillin and Clindamycin
Vancomycin and Clinda (if ill)
Doxycycline or Amoxicillin for Borrelia
Treatment Guidelines IV abx inititated with Clindamycin (25-40 mg/kg/day)
or Vancomycin to cover MRSA
Adjust to culture and sensitivity
In absence of osteomyelitis Continue IV until clinically improved, afebrile, CRP <2
Switch to oral for 3-6 weeks
Osteomyelitis requires longer (oral or IV tx)
Follow outpatient labs (CBC, ESR, CRP)
Follow other labs for medical complications (BMP/BUN/CRT, urinalysis, LFT)
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Oral Antibiotics Requires identification of organism and sensitivity to
antibiotic
Requires appropriate oral antibiotic availability
Requires patient to tolorate oral antibiotic
Requires compliance of family in administering antibiotic
If Not met: continue IV antibiotic program via PICC or central line
#10 Necrotizing Fascitis
Pearls of Management Early diagnosis
Have high index of suspicion
Supportive measures
Appropriate antibiotics
Prompt surgical debridement
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Factors in mortality Delay in treatment >24 hours from symptom onset
Inappropriate antibiotics
Delay in surgical intervention
Failure to agressively debride all involved tissues
Immunocomprimised patient
Streptococcal toxic shock syndrom
Chickenpox
Increased mortality with involvement of abdomen, hip and back
Mortality 5% in pediatrics, 20% in adults
BREAK
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Goals Recognition of common injuries and conditions of
pediatric and adolescent athletes
Fractures (some discussed, some left out)
Improved clinical exam
Improved functional anatomy knowledge
Discussion of diagnostic choices in workup
(Some) discussion of treatment(s)
References OKU 9. Injuries and Conditions of the Pediatric and Adolescent Athelete. Chapter 62. Mininder Kocher MD
OKU: Pediatrics 3. Overuse Injuries in Pediatric and Adolescent Athletes. Chapter 3. Kevin Shea MD et al.
Cases from 2008-2009 Fellowship. The Childrens Hospital. Aurora, Colorado.
Lovell and Winter’s Pediatric Orthopaedics. Chapter 32. Sports Medicine in the Growing Child.
Tachdjian’s Pediatric Orthopaedics.
Millers Review of Orthopaedics
6th Annual International Pediatric Orthopaedic Symposium. Orlando, FL 2009 (and 5th, 2008)
Introduction Sports Injuries
increasing Increased
participation Increased recognition
of injuries Improved diagnostic
abilities (MRI, arthroscopy)
Injury patterns Age-specific Sports-specific
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Considerations of Young Athlete—Growth and Development
Growth and Development Age-related injury
patterns
Treatment considerations ACL
Anatomic considerations “Miserable
malalignment”
Considerations of Young Athlete--Training
Historically, strength training discouraged
Safe training shown to have benefits Improved performance Strenght Cardiopulmonary fitness
Preadolescent Neurogenic adaptaion
Post-pubertal Neurogenic adaptation Muscular hypertrophy
Risk is no greater than in any other sport As long as proper adult
supervision Proper techniques and safety
precautions
Endurance training controversial
Considerations of Young Athlete--Thermoregulation
Thermoregulatroy disadvantage Increased surface area
to mass Reduced sweating
capacity Greater metaboic heat
per mass unit Slower heat
acclimatization Reluctance of children
to drink
American Academy of Pediatrics recommends prehydration and enforced periodic drinkingDuring prolonged exercise
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Considerations of Young Athlete—Performance Enhancement Substances
Increasing with media exposure
Risk increases with social pressure
1990 use of androgenic steroids
4-12% estimated male use
0.5-2% of females
Lyle Alzado
wilkipedia
Adverse Effects Premature epiphyseal closure
Strain/rupture of tendons
Elevated LFT,
Hepatic cysts
Elevated BP, Total Cholesterol,
Reduced HDL
Arterioscelorotic heart disease
Cardiomyopathy
Agression/instability/psychosis
Male Acne
Male pattern baldness
Priapism/impotence
Gynacomastia
Testicular atrophy
• Female• Masculinization
• Deepening voice
• Baldness
“Big Picture” Musculoskeletal
specialist
but
MD
BLS
ACLS
ATLS
Simms—ruptured spleen
Spinal cord injury
Concussions and return to play
Sports hernia
Etc.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
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Injury Patterns Significant increase in organized sports Largely adolescent females
Trend for shift from “free play” to year-long structured sports programs
3 million new sports related injuries yearly in US 1996 cost $1 Billion Football> wrestling highest rate of injuries Cheerleading highest rate of catastrophic injuries
AAP “The AAP recommends that athletes play sports for
enjoyment, to improve self-esteem, and to improve athletic skills.”
“If these are not priorities in youth sports, then participation in sports potentially is harmful because it can decrease self-esteem, diminish athletic skills, and discourage additional participation in sports”
http://www.aap.org
Pediatric Sports “Big Picture” Preventative
Acute Fractures
Acute Soft Tissue Injury
ACL
Meniscus
Overuse
Tendonitis
Physeal stress
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Treatment Principles History
Physical Exam
RICE
Rest
Ice /Immobilization
Compression
Elevation
NSAID (anti-inflammatory)
10 mg/kg Motrin
Further imaging
Xrays
CT
MRI
Bone scan
Ultrasound
Orthopaedic Physical Exam Inspection
Palpation
ROM
“Special Tests”
Red Flags Constitutional
Symptoms
Pain out of proportion to diagnosis or history
Reconsider diagnosis
Repeat physical exam
Reconsider imaging
Reconsider labs
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Upper ExtremityClavicle Most frequently fractures
bone
Non-op treatment Sling
Operative Indications Skin at risk
Open fracture
Severe communition/shortening
Acromioclavicular AC separations
Lateral clavicular physeal fractures
Sam BradfordSambradford.com
Millers Review of Orthopaedics
Glenohumeral Instability Traumatic anterior
dislocation Anterior vs. Posterior
Bankart lesion
Hill Sachs lesion
High recurrance
TUBS
MDI Ligamentous laxity
AMBRI
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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B.W.
14 yo Arthroscopic Bankart Repair; Rotator interval closure
Shoulder DislocationsBeware!
Upper ExtremityGymnastics Overuse physeal injury
Rest
Rest
Rest
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Little Leaguer’s shoulder Chronic stress fracture of
proximal humeral physis 11-13 yo pitcher Poor mechanics Frequent throwing
Treatment: Rest Teaching pitching
mechanics Throw counts
Tachdjians
Throw countsLeague age (years) Pitches allowed
Up to 10 75
11-12 85
13-16 95
17-18 105
Pitches Days rest
61+ 3
41-60 2
21-40 1
1-20 none
Age 7-16
Pitches Days rest
76+ 3
51-75 2
26-50 1
0-25 none
Age 17-18
OKU 9
Little Leaguer’s Elbow Throwing athletes High-performance female
gymnast• Medial epicondyle
fragmentation/avulsion OCD of radial head Ulna hypertrophy Olecranon apophysitis With age: UCL and medial
flexor-pronator group problems
Tachdjians
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Gymnast elbow--arthroscopy
Hand Thumb MCP joint
most common
UCL “gamekeepers or skiers” thumb
Fractures/dislocations
Mallet finger
Jersey finger
Hand Fractures Hastings and
Simmons (1984) Review of 354
fractures
Majority treated sucessfully non-op
Small percentage=large percentage of complications
HIGH RISK FRACTURES Displaced articular
fractures
Physeal fractures of distal phalanx
Phalangeal neck fractures
Open fractures
.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Risk Factors Associated With Poor Results
Failure to obtain adequate injury radiographs
False assumptions regarding remodeling potential
Falure to evaluate clinical deformity
Mallet Finger
Mallet Finger
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Jersey Finger Avulsion of profunds
from distal phalynx
Rugger Jersey Finger
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Seymore Lesion Displaced physeal
fracture with interposed nailbed
Failure to recognize: infection, physeal arrest, nail plate deformity
Phalyngeal Neck
“Door jam” in childhoodSports in AdolescentsPoor remodeling potential
Phalangeal neck Displaced acute
CRPP
Late Consider osteocalsis if
fracture line still positive
Chronic malunions: Sucondylar fossa
reconstruction Goal >90 degrees
flexion
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Phalanx/Metacarpal fx Phalangeal shaft
Check for malrotation CRPP for
malrotated/angled fracture >10 degrees
Unicondylar fractures Displaced Open vs CRPP Preserve collaterals and
soft tissue attachments
Gamekeeper thumb: SH III fx of P1 thumb ORIF if displaced
Scaphoid
Finger Dislocations Complex MCP
dislocations Often simple dislocation
converted to complex Interposed volar plate
Reduction: Wrist flexion,
hyperextend MCP, volar pressure onto dorsum of phalanx
Open reduction: dorsal
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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SpineSpondylolisthesis
Spondylolisthesis
Spondylolysis
Hyperextension
Gymnasts
Offensive lineman
Divers
SpineMechanical Back Pain Low back pain
Non-radicular
No constitutional symptoms
Better with rest
NSAIDS
Activity
Films/MRI
Pelvis/HipApophyseal Fractures
Apophyseal Fractures
Iliac apophysis
ASIS
AIIS
Ischial Tuberosity
Greater/Lesser Trochanter
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Pelvis/HipHip dislocation/FNFx
Rare injuries
Younger
Lower energy
Older
High energy
Reduce ASAP
Consider floro during reduction
Protected weight bearing
Monitor for AVN
ACL tear Acute Hemearthrosis ACL tear (ligament)
Meniscal tear
Patellar dislocation
Osteochondral fracture
Age <12, Tanner 1-2
12-skeletal maturity
>skeletal maturity
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
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Tibial Spine ACL equivilant injury in
children
Hyperextension/axial load on extended leg/knee
Patellar Dislocation More common dx when
patient presents with “knee dislcoation”
Commonly lateral
Xrays, MRI for osteochondral fragment
Meniscus Fibrocartilage structures
Twisting injury to knee
Pain with twist, deep flexion
Discoid meniscus Painless popping in
young child
Prone to tear
Bilateral
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
MM15 yo male with symptomatic knee pain, OCD
OCD
MM
Tibial Tuberosity Transitional fractue
Eccentric contraction of quads
Risks
Compartment syndrome
Extensor lag
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Thigh Contusion Direct blow to muscular
compartment
Motion as tolorated
NSAIDS
No resistance training
No stretching
SCFE Always remember to
examine hip with knee complaints
Compartment Syndrome Compartment pressure>
perfusion pressure
High index of suspicion
Pain out of proportion
Escilating pain requirements
“P”
Acute
Extertional
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Ankle Sprain
AAFP
Transitional Ankle Fractures Distal tibial growth plate
closes eccentrically
Tillaux
Triplane
Thank You Questions?