Paediatric Flashcards
What key radiological markers should you look for on assessing paediatric elbow xrays?
Anterior humeral line
Radocapitellar line
Baumann’s angle- generally between 70-75o or >5o between it and the other side
How do you draw the baumann angle?
Humeral axis- longitudinal line
Angle of the lateral condylar physis
What are the common injury age groups for supracondylar fractures?
5-7 year olds
Trampolines
How do you classify Supracondylar fractures?
Extension vs flexion type
For extension type you have:
1- non displaced
2- angulation in 1 plane with intact post cortex
3- completely displaced in 2 plane
What other imaging should you consider in supracondylar fracture as a precaution?
Ipsilateral wrist imaging- ? floating forearm- distal radius # also common
What the key things to differentiate in a vascular examination for a supracondylar fracture?
Pulsatile vs non pulsatile vs pale hand (CRT)
When to consider urgent surgical management for supracondylar fractures?
Absent radial pulse
Impaired hand/finger perfusion
Open injury
Threatened skin
What is the commonest Neurological injuries associated with a supracondylar fracture? And what is their prognosis?
AIN- commonest- closest to # site and has skin tethering
Radial nerve is close second
Nearly all cases resolve spontaneous post fixation
What are the indication for Non operative management of supracondylar fractures?
And what is the follow up/plan?
Type 1
Type 2 if:
Anterior humeral line intersects capitulum
Minimal swelling
No medial comminution
Above elbow backslab at less than 90o flexion- avoid volkmann’s ischaemic contracture
1week f/u for xrays-?displacement
3/4 week total cast time
What are the indications for operative management of supracondylar fractures?
Type 2 fractures + medial comminution/displacement
Type 3 fractures
Flexion type
Open injury
Vascular injury
If you have concerns about vascular compromise what do you need?
Vascular to be present
Most resolve with reduction
But if it does not- brachial artery needs exploration by surgeon competent in performing small vessel vascular repair
Describe how to perform surgical stabilisation of a supracondylar fracture?
WHO checklist
Brief
Supine, arm board, bipolar diathermy
Traction 5mins
Correct rotation, coronal and sagittal deformities
Hyperflexion then pronation
2 or 3 bi-cortical 2mm k wires
Divergent and lateral
If crossed being used do mini open approach to medial epicondyle. 5% ulnar nerve injury
Lower risk of loss of # reduction
Reportedly no significant difference in stability between 3 lateral and crossed k wires.
What is the post op plan for supracondylar fixation?
Neurovascular obs overnight
Fibroglass above elbow cast
Check xray + pin site review at 1 week
Pins out at 4 weeks if bony healing
further 2 weeks in cast
Complications of supracondylar fractures?
Pin migration
Infection
Gunstock deformity- cubitus varus
Nerve palsy- rarely axon/neurotmesis
Vascular injury
Volkmann ischaemic contracture- deep volar forearm compartment syndrome
Post op stiffness
What muscles does the AIN supply?
FPL + Radial half of FDP
Can they do Ok sign
What to do with a warm and well perfused hand but no pulse?
Reduce and relocate if possible + re-examine
Doppler + pulse oximetre
Inform consultant as this could wait till next available list
What to remember when assessing paediatric injuries?
NAI
BINDS
BirthHx
Imms
Nutrition
Development
Social
What is the differential diagnosis of a limping child?
Transient synovitis- post viral illness?
Septic arthritis
Developmental hip dysplasis- 0-5 years old, think delivery and post natal examination
Perthe’s (5-10 years old)
SUFE (10-15 years old)
NAI
Fracture
What can you use to assess the likelihood of septic arthritis?
Kocher’s criteria
Non weight bearing
CRP >2/ESR >40
WBC >12
Temp 38.5o
Probability scoring
0= <0.2%
1= 3%
2= 40%
3= 93%
4= 97%
48% of 3/4 point scorers had underlying osteomyelitis
Always exclude other sources of infection
How do you perform an open washout of paediatric septic hip?
Anterior approach to hip
Internervous approach between superior gluteal (TFL) and femoral nerve (sartorius)
Skin incision- Ant 1/2 of iliac crest to ASIS and extend down proximal femur
Superfiscial dissection between TFL and sartorius-avoid LCN + ligate perforators from LFA
Deep dissection between Gleutues medius and rectus femoris- adduct and ext rotate hip to put capsule under tension
Capsulotomy
Things to be aware of- LCN of femur runs in fascia between sartorius and TFL
Lateral femoral cricumflex a runs superfiscially proximally
What is SUFE?
Slipped upper femoral epiphysis. Happens in adolescents when the developing ball of the femur slips off the back of the femoral neck
What is important to ascertain in the history for ?SUFE?
Can they weight bear?
NAI
Infection
Endocrinopathies- hyperthyroidism, GH deficiency, panhypopituitarism, renal osteodystrophy
Other PMHx
Important investigations for SUFE?
AP and frog leg lateral- so as to get Southwick angle and to assess Kline’s line
an arbitrary line drawn along the superior edge of the femoral neck, which is useful in detecting early slipped upper femoral epiphysis in adolescents. The line should normally intersect the lateral aspect of the superior femoral epiphysis.
Inflammatory markers
Endocrine investigations
TFTs, GH, renal fnx, bone profile
What is the critical question when it comes to SUFE?S
Can they walk
Loder’s classification
If they can weight bear risk AVN is low
If not AVN risk is 47%
Differential diagnosis of limping child?
Septic arthritis
Transient synovitis
SUFE
Perthe’s- idiopathic AVN of femoral head
DDH
Trauma
What are the controversies in SUFE?
Should have Pinning in situ- down the line osteotomies
1vs 2 screws (rotational control vs minimal damage to physis)
Contralateral fixation- ~20% will have contralateral SUFE
Classical age for SUFE?
13 year old obese boys on left hand side
If <10 endocrine cause until proven otherwise
Does the anterior humeral line always bisect the capitellum?
NO
In <5 years old touch part of it
>5 years old goes through the middle of the capitellum
What to look out for in NAI?
Hx- social worker, delayed Presentation, inconsistent history
O/E- bruising of different agers, burns, bite marks, subconjunctival haemorrhage
Xrays- femoral #s in pre walking- <1 years old, bucket handle #s
What is the physis, epiphysis and metaphysis?
Diaphysis (shaft or primary ossification centre)
Metaphysis (where the bone flares)
Physis (or growth plate) Epiphysis (secondary ossification centre)
Paediatric differential diagnosis?
TITAN
Trauma
Infection
Tumour
and
NAI
Key extra point in paediatric consenting for fractures?
Growth Arrest/deformity/limb length discrepancies
How to manage a paediatric PNI post Supracondylar fixation?
BOAST for PNI
Release constrictive banaging
Expanding haematoma?
Place in extension
Escalate
Painful post op paralysis most be explored emergently- compartment syndrome vs nerve compression
Pain and progressive loss of sensation is hallmark for critical ischaemia
Explore ulna nerve, identify + replace K wire under direct supervision
Key things to remember in management of paediatric infections?
Septic arthritis vs soft tissue (pyomyositis/abscess) vs osteomyelitis
Joint care with paeds
Full examination of extermities and spine
MRI within 48 hours
If septic then Abx
If stable Abx post deep sampling intraoperatively
If abscess then surgery
If septic A then surgery
Osteomyelitis/pyomyositis/discitis should have Abx
F/U for 12 months
Describe Baumann’s angle
This angle is formed by the humeral axis and a straight line through the epiphyseal plate of the capitulum.
Describe southwick’s angle
The angle between the line drawn perpendicular to the epiphysis and then the diaphysis.
Grading is based off of difference from unaffected side
Management of SUFE?
All for operative management
Pinning in Situ- primary option, no reduction as this can injure the retinacular vessels/physis, aim is to prevent further slippage/osteonecrosis
Osteotomies further down the line
FAImpingment management in later life
What makes you suspect NAI?
Hx, Exam, Investigations
History- inconsistent, delayed, Social worker
Exam- different levels of bruising, burns, scratches, dishelved, bites
Ix- bucket handle fractures- shaking, other fractures, femoral fractures in pre walking, rib #s
Complications of Perthes?
Growth arrest
Leg length discrepancies
Subluxation
Femoral acetabular impingement
Arthritis
For a hip spica cast how far does it extend?
Covers nipple
Distal tibia on injured side
Distal femur on uninjured side
Can do one sided walking hip spica
Make sure well padded and peroneal clear for hygine purposes
Do under II
Tend to go into varus so apply valgus force
When to explore a supracondylar fracture
Irreducible closed
Medial wire needed
Signs of ischaemia despite reduction- radial pulse does not need to be present
