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Paediatrics Orthopae dics

Anatomy of Long Bone Secondary Ossification Ce nter

Epiphysis Develop After Birth
Epiphyseal Plate Intraarticular Fracture
Metaphysis Small Hair Line is Misleading
Diaphysis

Fracture in Children
Physeal Injury Bone Remodelling
Different Pattern of Fracture Better in
Healing is Better (Bone Remodelling) • Near to Growth Plate
Complications in Relation to Growth Plate • Plane of Joint Motion
• Young Age (2 Years Growth Remaining)
Fractures
Diaphyseal Metaphyseal Physis (Growth Plate)
↑ Malleable Cancellous Bone Weakest Point in
Plastic Deformity Prone to Skeleton of Children
Periosteum Thicker Weaker than Ligament
(compared to Adult) Hypertrophic Zone is
Usually Remain Intact in the Weakest
one side of fracture Green Stick Fracture
(Help splinting fracture)

Complications
Growth Arrest
• Angular Deformity
• Shortening

Torus Fracture
Supracondylar Humerus
• Thin Cortex
• Olecranon Fossa
(Thin Bone )
Mechanism of Injury
Normal Bone Fracture
Pathologic Fracture
Child Abuse
Pathologic Fracture Child Abuse
Caused by Trivial Injury History
Causes Vague, Not Consistent with Force
• Osteopetrosis necessary to cause injury
• Osteogenesis Imperfecta (eg. Single Vertebra Fracture after
• Rickets Child Fell from Couch )
• Fibrous Dysplasia Delay in Seeking Treatment
• Malignant Bone Tumour Poor Child-Parent Interaction
Features (no Eye Contact)
Salter Harris Classification
• Head Malnourished Child
• Chest
• Limb

Physical Examination (Soft Tissues)

Soft Tissue Injuries (80% of cases)
Clustering of Injuries (Face, Trunk, Buttocks)
Thermal Injuries (Popliteal Sparing)
I II III IV V Regularly Spaced Patterns (Scratch Marks, Radiator Burns)
Avoid Avoid Anatomical Anatomical No Salvage Imprinting (Wire Hanger Marks, Cigarette Burns)
Damage Damage Reduction Reduction
Restore Prevent
Articular Metaphyseal-
Surface Epiphyseal
Bridge
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Fractures Monteggia Fracture

Metaphyseal Corner Fracture Line Cross the Capitulum in both AP, Lateral
Lower Extremity Fractures (in Non-Weight Bearers)
Rib, Spine, Skull Fractures
Bilateral Acute Fractures
Overabundant Callus
• Improper Immobilization
• Bone over Bone
Various Stages of Healing

Metaphyseal Corner Fracture (Child Abuse)

Highly supportive of diagnosis
Secure attachment of Perichondrial Fibre
Nature of Traction Injury

Pelvis Radiograph

Callus (Child Abuse )

Due to Improper Immobilization
Bone in Bone

Subtle – AP, Obvious – Lateral

Lower Extremity Fractures in Nonwalkers

Femoral Fracture in Child < 1 y/o
Rib Fracture
• Especially Posterior (Difficult to Detect on X-Ray)(but Bone Scan helps )
• Due to Shaking, Hitting from Behind

Subtle Feature (Supracondylar Humerus Fracture)

Radiological Fat Pad Sign
Location
Personality
Displace
Angulation
Localized Bone Lesion
Bone Quality
Joint, Growth Plate

Differentiate – Fracture, Physis

Growth Plate of Medial Epichondyle
Persist until 16 y/o
Contralateral
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Management
Reduce
Hold
Rehabilitate

Casting
Remodelling Potential (Good)
Recovery from Stiffness (Good)
Fast Healing
Very well Adjusted

Position of Joint
3 Point Molding

Closed Reduction
Adequate Anaesthesia + Muscle Relaxation
Reverse the Mechanism
Relax the Deforming Force

Acceptable Reduction
No Rotation
Contact
• No Shortening (Except Femur – 1.5 cm)
Angulation
• Varus – Valgus – 10
• Recurvatum, Procurvatum

After Cast Care

Loss of Correction
Must review at 1 week
POP Care (Plaster of Paris)
Pressure Sore
Compartment
Material Inside
Wet
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Paediatric Bone, Joint Infection

Causative Organisms (Osteomyelitis, Septic Arthritis) Types of Osteomyelitis

Neonates Child Acute
> 4 y/o Adults
( < 1 y/o) (1-4 y/o) (Acute Haematogenous Osteomyelitis)
Staphylococcus Staphylococcus Staphylococcus Staphylococcus Pathology
aureus aureus aureus aureus • Inflammation
Group B Haemophilus Streptococcus Streptococci • Suppuration
Streptococcus Pyogenes (A, B, C, G, • Necrosis
pneumoniae) • New Bone Formation
HiB Vaccine Introduction • Resolution
(Inciden ce of Haemophilus Infe ctions has dropped dramatically) Subacute (Brodie’s Abscess)
Painful Limp, Systemically, No Signs of Local Infection, Insidiou s
Route of Spread X-Rays – Well-Established Lesion in Metaphysis
Osteomyelitis (OM) Septic Arthritis (SA) Common Sites – Femur, Tibia
Haematogenous Haematogenous Blood Tests – Normal
Spread from Contiguous Soft Tissue Spread from Contiguous Soft Tissue Chronic
Infection Infection Etiology
Direct Inoculation (Penetrating Injury) Direct Inoculation (Penetrating Injury) • Inadequate Treated Acute Osteomyelitis
Spread from • Delay in Treatment
Metaphyseal Osteomyelitis • Haematogenous Spread
(where Metaphysis is Intra-Articular) • Penetrating Trauma
• Open Fractures
Pathophysiol ogy • Contiguous Focus In fection
Acute Haematogenous Osteomyelitis Causative Organisms
• Staphylococcus aureus (if 2° to Acute Osteomyelitis)
• Staphylococcus aureus (Following Trauma)(but may be Polymicrobial)
• Sinus Tracts become Colonized by many Organisms
(Superficial Swabs are Unhelpful)
Classification (Cierny)
Local Spread to I II III IV
Lifts Periosteum Joint, Soft
Spread to Involucrum
Tissues
Metaphysis Formed Against
Sequestrum
Medullary Superficial Localized Diffuse
Risk Factors
↓ Moderate ↑
Normal Immune Local, Mild Systemic Major Nutritional or
System Deficiency Systemic Disorders
Non-Smoker Smoker

Septic Arthritis
Pus, Cartilage are Incompatible
Cartilage Destruction
Casual Relationship OM, SA

Epidemiology
Children (can occur at any age)
< 2 y/o < 5 y/o
50% cases 30% cases
Common Sites
Infants Older Children
Hip Knee
> 1 Joint affected (10% cases)
Clinical Features (OM, SA)
Neonates Younger Child, Toddler Adult
Irritibility Limp with Weight Symptoms of Infe ction
Lethargy Bearing
Refuse Feeding Refuse to Walk
Fever Irritable
Pseudoparalysis Fever

Clinical Examination
Osteomyelitis (OM) Septic Arthritis (SA)
All findings of Inflammation, Infe ction All findings of Inflammation, Infe ction
Pus Discharge Severe ↓ Range of Motion (ROM)
Painful Septic Joint
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Investigations X-Rays
Blood
ESR, CRP
FBC
Blood Culture
Radiological Study
Plain Radiograph
Aspiration (SA)
Other Special Radiological Imaging
US
MRI
Bone Scans Pathologic Fracture
• T-99
• Indium, Galium

Management
Principle
Supportive
• Analgesics
• Hydration
• Splint, Traction
Antibiotics Hip Dislocation Hip Dislocation
Anti-Staphylococcal Antibiotics
Anti-Streptococcal Antibi otics
1st Line 2nd Line
Cloxacillin Vancomycin Benzylpenicillin
Fucidic Acid
Drainage

Surgical Indication
Osteomyelitis Septic Arthritis
Not Responding to Medical Drainage (Treatment)
Treatment 24 – 48h • Eradicate, Dilute Bacteria Inoculum
Evidence of Subperiosteal Abscess • Destructive Enzymes from
Immune Res ponse
• Decompress
• Excision Nonviable Tissues
• Minimizing Destructive Changes

Chronic Osteomyelitis (Treatment Principles)

Antibiotics (Prolonged)
Surgical Debridement, Bony Stabilisation
(Remove All Dead, Infected Tissue, Bone)
Control of Dead Space
Soft Tissue Cover

Complications
Pathologic Fracture
Osteonecrosis of Proximal Femur
Growth Deformity
• Physeal Arrest
• Physeal Stimulation
Systemic Sepsis
Distant Seeding
Chronic Osteomyelitis
Hip Dislocation

Differential (Diverse, Limping Child)

Cellulitis
Inflammatory Arthritis
Toddler Fracture
Neoplasms (Ewing’s Sarcoma, Leukaemia)
Bone Infarction (Sickle)
Diskitis
Acute Rheumatic Fever
Transient Synovitis