ORTHOPEDIC CONSULT
From the 28th Annual Las Vegas Seminars, Pediatric Update, presented by the AAP California District IX, Chapters 1,
2, 3, and 4
David L. Skaggs, MD, Associate Director, Orthopedic Surgery, Children’s Hospital Los Angeles, and Associate
Professor of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| ORTHOPEDIC TRAUMA FOR THE PEDIATRICIAN
|
| Fracture patterns: open—fracture communicates with air; bleeding with droplets of fat sign of escaping bone marrow;
complete—100% across bone; buckle or torus—buckling of bone (risk for displacement with re-injury); greenstick—
half of bone breaks, other half bends; highest rate of refracture (often not in cast long enough); growth plate—Salter-
Harris fractures; fracture across growth plate and into joint, needs referral; if growth plate misaligned during healing,
bone grows only on one side, and bends; occult (case)—child who fell does not want to move elbow and presents with
elevated fat pad (probability of underlying fracture 76%); treat as if fracture present using splint or cast; have orthopedist
repeat x-ray in 7 to 10 days
|
| Clavicle fractures: treatment sling ≤4 wk; return to sports in 6 to 8 wk; in general, referral not needed; medial clavicle
last physis to close; posterior subluxation of clavicle growth plate fracture may affect breathing
|
| Buckle fracture of distal radius: treatable by pediatrician; put child in short arm cast or splint (4 wk adequate); need
2 x-ray views; in children <10 yr of age, much remodeling around wrist; generally, fractures around wrist in children ≤6
yr of age can heal in almost any position (however, older adolescent cannot tolerate significant angulation); fracture in
diaphyseal area of long bone—remodels less well; more frequently requires reduction or surgery
|
| Elbow fractures: in lateral view of normal anatomy, anterior line crosses capitellum (if not, suspect supracondylar or
lateral condylar fracture); normally, radius points to capitellum in every view (if not, probable Monteggia’s fracture [ulna
fractured and radial head dislocated]); ≈20% of supracondylar fractures involve neurologic or vascular injury; if supracondylar
fracture present and pulse absent, send patient to emergency department (ED) due to risk for compartment syndrome;
neurologic examination of nonemergent elbow fracture—radial nerve intact with thumbs up; ulnar nerve intact
with crossed fingers; median or anterior interosseus nerve intact with “okay” sign (thumb flexed); to avoid compartment
syndrome, elbow never should be placed at >90° flexion in child with fractured upper extremity
|
| Finger fractures: most cases treatable by pediatrician; exceptions—1) rotation; ask patient to bend and straighten fingers;
make sure nails aligned (if axial rotation present, refer); 2) fracture in joint that heals with slight step-off can cause
permanent pain and stiffness (refer); ligamentous injuries—boutonnière deformity or mallet finger; if child cannot actively
straighten finger, refer; snuff box tenderness—scaphoid fracture until proven otherwise; consider magnetic resonance
imaging (MRI) to prove diagnosis; cast indicated even if x-rays negative (high risk for nonunion)
|
| Femoral shaft fracture: frequently associated with motor vehicle accidents and football injuries; in children ≥5 yr of
age, treatment insertion of titanium rods (traction no longer used); most patients go home next day (most walking in 1 or
2 wk); cast complications—compartment syndrome (swelling within nondistensible compartments); if in doubt, put patient
in splint, allowing room for swelling (crooked cast makes straight bone); if much pain when cast put on, or within
first 24 hr, suspect compartment syndrome; if pain increasing at 2 to 4 wk, remove cast and look for foreign object; if
child irritable, remove cast to detect, eg, streptococcal infection
|
| Guidelines for referral (summary): fracture involving growth plate or joint; angulation that may require reduction
(eg, ≥15°); elbow fractures (high risk for poor remodeling); open fracture or high-energy injury
|
| ADOLESCENT IDIOPATHIC SCOLIOSIS
|
| Introduction: etiology multifactorial; most patients referred to orthopedist after school screening do not have significant
scoliosis; often, spinal curvature caused by underlying neurologic condition; typically, no history of complaints or abnormal
pain
|
| Physical examination: Adams forward bend test—hump observable when child bends over (rotatory asymmetry);
space between arms and waist subtle sign, but easy way to identify asymmetry; with forward bending, rotatory asymmetry
present; in double curve, torso often looks symmetrical (have patient bend forward); even though curve double, rotatory
asymmetry; seen from behind, normal curve opposite of letter “S” (right thoracic; left lumbar); if curve atypical,
consider MRI; lumbar curves more difficult to detect by Adams forward bend test; look for asymmetry between arms and
torso; if child has large amount of scoliosis and no rib hump, condition probably not idiopathic; on x-ray, pedicles symmetric
on each side (no rotation); patient bends sideways when asked to bend forward—tumor in spinal cord likely;
with pain or scoliosis, MRI indicated (cervical, thoracic, and lumbar); in lumbar region, possible tethered cord (in thoracic
region, tumor or syrinx; in cervical region, Arnold-Chiari malformation)
|
| 60-second neurologic examination: have child jump up and down on one foot, then other (tests strength and balance);
have child walk on heels with toes in air (tests lumbar vertebra [L4] and ankle dorsiflexion); patellar tendon and
Achilles tendon; umbilicus reflex—thoracic vertebrae T9, T10 and T11 innervate area around umbilicus; lightly stroke
umbilicus on either side (should move to one side or other; also normal if does not move at all); if asymmetric with scoliosis,
high probability of syrinx; clonus—when push up on toe and dorsiflex ankle, 1 or 2 beats of clonus normal (if 3 or
4 beats observed, consider neurologic workup and/or MRI); popliteal angle—sensitive but not specific indicator; have
child lie down with femur pointing straight up; if tibia able to point straight up, angle 0°; if angle 90°, abnormality affecting
nerve roots (eg, spondylolysis, tumor, diskitis, or syrinx); if scoliosis present and popliteal angle 90°, obtain MRI;
feet—claw toes or cavus feet sign of neurologic problem (if bilateral, suspect Charcot-Marie-Tooth disease or Friedreich’s
ataxia; if unilateral, suspect localized spine problem); unilateral cavus foot with scoliosis requires MRI
|
| Pulmonary compromise: once curve 20°, amount of oxygen utilized decreased; 50° of curvature trigger for most surgeries
(many surgeons moving toward 45°; surgeries safer than in past)
|
| School screening: controversial; United States Preventive Services Task Force—does not recommend school screening;
even if scoliosis identified early, not clear whether bracing helpful; American Academy of Pediatrics (AAP), Scoliosis
Research Society (SRS) and American Academy of Orthopaedic Surgeons (AAOS)—favor school screening;
anecdotal evidence of benefit (children often try to hide bodies from parents)
|
| When to x-ray? consensus—not every patient needs x-ray after positive school screen; studies—most children who
screen positively at school do not have scoliosis severe enough to warrant treatment or follow-up; x-rays worthwhile to
reassure parents (amount of radiation exposure for full posterior-anterior [PA] view same as taking roundtrip flight across
United States)
|
| Whom to refer? immature patient—curve >20°; mature patient—curve >40°; other—patient having abnormal pain,
signs, or symptoms of scoliosis
|
| Treatment: conservative approach—chiropractic manipulation does not straighten scoliosis; most experts do not believe
exercise helpful; electrical stimulation proposed; advice to parents—beware of Internet (inaccurate information);
bracing—may help; Milwaukee brace little used (causes back pain); consider thoracolumbar sacral orthosis [TLSO]);
uncertain whether bracing works (little data either way); if brace source of hostility between child and parents, do not use;
surgery—effective in straightening curve; long-term implications not well known; expensive; children usually out of
hospital in 1 wk (back to school in 1 mo; speaker allows return to all sports at 3 mo); not without risk (significant rate of
death and paralysis); mobility after surgery (case)—child fused down to L3; she can touch her toes (most motion comes
from pelvis); patients rarely complain of stiffness
|
| Managing pulmonary effects of early scoliosis: treatment insertion of vertical titanium expandable rib prosthesis
(VEPTOR); without treatment, young children with significant scoliosis die early (lungs never fully form); as spine
curves, it restricts space available for lungs and prevents normal rib movement; back surgery contraindicated (if
straighten and fuse spine of 2-yr-old, chest remains small and child will likely die early due to lack of pulmonary function);
open chest using VEPTOR and repeat every 6 mo to let lungs grow (secondarily, spine straightens); lengthen 1 to 2
cm each visit (patient goes home same day); titanium rib procedure effective for managing June syndrome
|
| LOWER EXTREMITY INJURIES IN CHILDREN: EVALUATION AND MANAGEMENT
|
Knee
| Traction apophysitis: abdomen muscles can tear apophysis from iliac crest; most common avulsion injury sartorius
tearing apophysis of superior iliac crest; worse when hamstrings pull off ischial tuberosity (must operatively screw it into
place); avulsion injuries often not discovered in time (first x-ray considered normal); treatment—rest; when pain gone,
patient can return to sports
|
| Osgood-Schlatter disease (OSD): most common traction injury; diagnosis—usually, large bump present (sometimes
looks red and warm like infection); localized tenderness; patellar tendon pulls off small pieces of bone; microfracture
heals, and more bone pulled off; soon, large bump; x-rays not helpful (in fracture, bone torn away from rest of bone;
in OSD, just extra calcification present); treatment—stretching quadriceps may help; stretching makes muscle weaker
and less powerful (less force on tibial tubercle); return to sports—disease frequently lasts 2 yr; with OSD, speaker may
let patient play through pain (limping, however, requires rest)
|
| Anterior knee pain syndrome: cause unclear and treatment not well understood; occurs frequently in adolescent girls;
usually, no malalignment; diagnosis made by history; patient points to pain at front of knee, all around patella; ask whether
it hurts—if knee bent for long time? going downstairs or upstairs? during squats? occurs in jumpers, volleyball players,
basketball players, and any athlete who does fair amount of running; patella grind test—hold patella in place so it cannot
move proximally; have patient contract quadriceps or keep leg straight and raise (straight leg raise contracts quadriceps;
patella grinds against femur); if pain reproduced, diagnosis made; treatment—generally, physical therapy, but no definitive
treatment; rest seems to help; nonsteroidal antiinflammatory drugs helpful short-term; some patients unable to participate
in jumping activities daily; if physical therapy fails, referral worthwhile
|
| Patellofemoral dislocation: almost always lateral; in acute setting, significant swelling due to tearing of blood vessels;
tenderness medial (structures torn); treatment—if patella does not pop back into place, physician can push it in; keep
child in immobilizer with knee straight for 6 wk; expectation that injury will scar down and prevent recurrence; if problem
recurs, refer (probable surgery)
|
| Osteochondritis dissecans: presentation—serious injury; usually, teenager 10 to 16 yr of age has had chronic knee
pain 1 or 2 yr; sometimes, slight crack seen in lateral x-ray; notch view (not true anterior-posterior [AP] view);
treatment—in younger children, wearing cast 6 wk sometimes effective (in older children, surgery frequently required); if
child presents with knee pain, get x-ray (especially if pain present more than few weeks)
|
| Meniscal tears: if touching child’s joint line causes tenderness, or if pain expressed when patient squats (in catcher’s
pose), suspect meniscal tear and get MRI; children <10 yr of age —MRI often falsely positive; with aches and pains in
knee, reasonable to wait few weeks to see if pain resolves
|
| Lachman test for anterior cruciate ligament (ACL) tears: when physician pulls forward on tibia, he or she
should feel tendon snap; test difficult to perform in full-grown/older teenagers (easy in infants; include in examination of
infant)
|
Tibia
| Tibial eminence fracture: small piece of bone pulled off by ACL; occurs in younger children (older patients get ligament
tears rather than bone tears)
|
| Medial collateral ligament (MCL) injury: MCL prevents leg from bending sideways; if physician able to bend leg
sideways, MCL completely torn (discomfort restricted to medial side indicates partial tear); place child in knee immobilizer
for few weeks and discontinue sports until pain gone; vertical tenderness indicates MCL tear (joint-line tenderness
indicates meniscal tear)
|
| Acute knee injury: pain without effusion—move joint back and forth and look for tenderness; consider x-ray; if nothing
found, put in knee immobilizer and re-examine in 2 wk; most knee aches and pains resolve with time and do not require
MRI; if patient cannot actively straighten knee, suspect tear of, eg, quadriceps or patella tendon, and refer; large
effusion—aspiration helps decrease pain; if fat droplets in aspirate, diagnosis fracture
|
| Stress fractures: occur during first 3 wk of training (bone gets weaker [osteoclasts working]; at week 3, osteocytes active);
pain localized; x-rays often negative; if specific spot on tibia immediately painful with weight bearing, suspect
stress fracture; if x-ray negative, obtain MRI; shin splints—vertical pain distribution; pain develops after few minutes of
running; treatment rest
|
Ankle and Foot
| Ankle sprain: most common sports injury, especially in basketball; early ice helps speed healing; treatment—functional
ankle brace
|
| Calcaneal apophysitis (Severs disease): even normal calcaneal apophysis looks aberrant on x-ray; treatment—if
bottom of heel hurts because child wearing cleats, switch to big soft shoes (no bare feet for few weeks); consider shoe insert
|
Educational Objectives
| The goal of this program is to educate the listener about common orthopedic problems in children and adolescents. After
hearing and assimilating this program, the clinician will be better able to:
|
 | 1. Assess common bone fractures in pediatric patients.
|
| 2. Identify and manage adolescent idiopathic scoliosis.
|
| 3. Describe common knee injuries in children.
|
| 4. Distinguish common tibial problems in children.
|
| 5. Recognize and manage ankle sprains.
|
Suggested Reading
Early SD et al: Delayed neurologic injury due to bone graft migration into the spinal canal following scoliosis surgery.
Orthopedics 26:515, 2003; Flynn JM et al: The surgical management of pediatric fractures of the lower extremity. Instr
Course Lect 52:647, 2003; Gupta N et al: Effect of surgical delay on perioperative complications and need for open reduction
in supracondylar humerus fractures in children. J Pediatr Orthop 24:245, 2004; Huang EY et al: Thoracoscopic
anterior spinal release and fusion: evolution of a faster, improved approach. J Pediatr Surg 37:1732, 2002; Skaggs DL et
al: Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop
22:697, 2002; Skaggs DL et al: Lateral-entry pin fixation in the management of supracondylar fractures in children. J
Bone Surg An 86:702, 2004; Skaggs DL et al: The effect of surgical delay on acute infection following 554 open fractures
in children. J Bone Joint Surg Am 87:8, 2005; Stewart DG Jr et al: Open fractures in children. Principles of evaluation
and management. J Bone Joint Surg Am 87:2784, 2005; Stewart DG Jr, Skaggs DL: Consultation with the
specialist: adolescent idiopathic scoliosis. Pediatr Rev 27:299, 2006; Storer SK, Skaggs DL: Pearls and pitfalls in the
evaluation of pediatric congenital and developmental disorders. Instr Course Lect 55:615, 2006; Tang CW et al:
Growth arrest of the distal radius following a metaphyseal fracture: case report and review of the literature. J Pediatr Orthop
B 11:89, 2002; Vitale MG et al: Pelvic fractures in children: an exploration of practice patterns and patient outcomes.
J Pediatr Orthop 25:581, 2005; Yuan N et al: Preoperative predictors of prolonged postoperative mechanical
ventilation in children following scoliosis repair. Pediatr Pulmonol 40:414, 2005; Yuan N et al: The effect of scoliosis
surgery on lung function in the immediate postoperative period. Spine 30:2182, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. Dr. Skaggs has been a consultant,
speaker, or researcher for Medtronics, Johnson & Johnson, and Stryker Spine.
Dr. Skaggs was recorded at the 28th Annual Las Vegas Seminars, Pediatric Update, presented November 16-19, 2006,
in Las Vegas, NV, by the American Academy of Pediatrics, California District IX, Chapters 1, 2, 3, and 4. The Audio-Digest
Foundation thanks Dr. Skaggs and the Academy for their cooperation in the production of this program.
|
