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 / Move Look Compare with normal side Look for deformity / bruising Can they weight bear? If so, assess gait. Feel Point tenderness; joint line tenderness Pulses + neurovascular Move Active then passive ie/ watch what the kid does, then attempt to move Flexion/extension/abduction/adduction Internal and external rotation

Neurovascular of hand Any 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 Spondylolisthesis Spondylolysis

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 bruising Children 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