Tag Archives: orthopaedics

Wrist injuries

For Emergency Departments, , ,

Episode 4 and 5 of Jess Spedding’s minor injuries series are on the wrist.

Like in adults, the wrist is a very common location for injury. As an impulse to falling we stretch out our hands and arms to protect our head and torso, and hence the acronym FOOSH – fall on the outstretched hand, that you may come across in orthopaedic and Emergency Department documentation. The wrist is the most common upper limb fracture in adults, and is most common in children along with the supracondylar (see episode 2 of this series in December 2012 / January 2013). Whilst the supracondylar occurs in the 4-8y age group, wrist fractures which are typically distal radius fractures, can occur
at any age.  Read more….

Episode 5 is on another wrist injury and one that must not be missed – scaphoid fractures.  Read more….

minor injuries series 3: ankle injury

Uncategorized, ,

Jess has written a lot of information about the assessment and management of ankle injuries which I have uploaded as a PDF here.  I have put the Ottawa ankle rules below as a taster….

The wonderful thing about ankle injuries is that there is a reliable, commonly used, validated assessment of the injury that helps you to decide if an xray is indicated. This tool was developed by a group in Ottawa, Canada and for that reason bears the name “the Ottawa Ankle Rules” which are as follows:

Carry out an ankle xray (AP and lateral) if:

  • The patient could not walk 4 paces immediately after the injury OR
  • The patient cannot walk 4 paces now OR
  • There is bony tenderness along the posterior aspect of the lateral OR
  • medial malleolus from distal tip extending up 6cm
  • (or xray the foot instead if base of 5th metatarsal tenderness)

You are very welcome to carry out an xray in those who do not fit these criteria if you are worried but there is a very low likelihood of there being a bony injury.

November 2012 published!

For Emergency Departments, For General Practitioners, , , ,

The common assessment framework triangle for assessing children in need this month with some tips on how to press the right buttons with children’s social care referrals.  Also a bit on stabilisation and transfer for the ED teams, a reminder not to use 0.18% saline and the start of a minor injuries series.  Talipes for the GPs and paediatricians among you.

Minor injuries introduction

Child Protection, For Emergency Departments, , , ,

Minor injuries Series: Episode 1 with thanks to Dr Jessica Spedding, PEM trainee, Royal London Hospital, UK

Introduction to minor injuries:

Minor injuries in children are common and mostly self limiting soft tissue injuries that heal with time. Some injuries are particular to paediatrics (pulled elbow) and others are simply much more common in children than adults (supracondylar fracture). Another consideration specific to children is consideration of growth plate involvement, which if does not heal in a good position could lead to asymmetry and growth problems. Injuries involving the growth plate are graded as Salter-Harris 1,2,3,4, or 5 and they will be discussed in more detail in a future episode of this minor injuries series.

 

Your assessment:

You need a systematic approach that assesses for important injuries that need specific management.  Your
assessment must always include consideration of non accidental injury (NAI). A sensible approach would include:

– Is the mechanism of injury described consistent with the injury sustained?

– Has the child reached the appropriate stage of development to have sustained the injury in the way described?

– Is there any delay in presentation?

– Has the child (or siblings) presented numerous times before with injuries?

– There is an excellent set of pamphlets that give evidence based guidance on when injuries point to abuse – go to www.core-info.co.uk or look out for the summaries on Paediatric Pearls

 

Upper limb injuries:

You may have come across the acronym FOOSH. This is a Fall On the Out-Stretched Hand. This mechanism is the natural response to a fall – in order to protect our head and trunk, the reflex is to put our arms out to break our fall. This mechanism causes a number of different injuries, each more prevalent in different age groups (but common in other age groups too).  Roughly speaking these could be sequenced as follows:

Age 1-3: distal radius fracture (usually greenstick or torus) or middle third clavicle fracture

Age 4-8: supracondylar fracture (varying degrees of severity, some of which require operative fixation)

Age 9-adulthood: distal radius fracture or scaphoid fracture

However one must still examine unclothed the whole limb to be sure that all sites of injury have been located. In the upper limb this would be from
fingers to shoulder, clavicle and possibly neck, in the lower limb this would be from toes to hips but also checking the pelvis and lower spine.

The first chapter in this series looks at a common elbow problem:

Pulled elbow: (see also http://www.paediatricpearls.co.uk/2012/02/pulled-elbow/)

Proper name – radial head subluxation, mechanism is usually a sudden pulling of the child by their hand (such as to stop them running into the road or swinging a child in play), child presents having cried initially, but soon settles but refuses to use the arm, holding it slightly flexed at the elbow with the arm by their side. When you go to assess them they have no swelling or bruising or distal neurovascular compromise, but are very apprehensive about you trying to bend or pronate/supinate the elbow. In up to half of cases there may not be a “pull” mechanism in which case be more cautious in assuming the diagnosis. Don’t forget a clavicle fracture may present this way. If you feel sure the diagnosis is pulled elbow, attempt a reduction as follows:

 

 

Hold their hand as though you were going to shake hands, with your other hand gently cupping underneath the elbow, with elbow partially flexed, then firmly pronate (rotate to palm up position). You should feel the clunk of a reduction, but if not, try a firm supination (back to palm down position).  Ideally do this half an hour after some analgesia. If you do not feel a clunk it is probably not reduced but either way stop after two attempts, and then allow the child to be somewhere relaxing and ask their parent to let you know if they start playing – if reduced most will soon realise the pain with movement has gone and start playing normally within a few minutes. If not reassess and consider a differential diagnosis which may include referral for xray.

Talipes equinovarus

For General Practitioners, , ,

Talipes (Neonatal Clubfoot) with thanks to Dr Mujahid Hasan and the paediatric physiotherapy department at Barts Health

Newborn babies can present with one of two types of Talipes:

  1. Congenital Talipes Equinovarus (CTEV or fixed/structural Talipes)
  2. Positional foot problems

Click here for the Whipps Cross physiotherapists and Muj’s complete, illustrated article.

Fractures in child abuse

For Emergency Departments, For General Practitioners, , , , ,

Metaphyseal fractures, also known as a bucket handle, chip or corner fracture, occur at the growing end of the bone and only in children. Recent fractures are very difficult to see on x-ray and they are often not associated with any clinical sign of soft tissue swelling or bruising.  They may become more obvious radiographically after 11 to 14 days. They are thought to happen when the baby has been pulled or swung violently and the relatively weaker growing point of the bone breaks.  They have been noted to occur accidentally following birth injuries, following serial casting of talipes or as a consequence of appropriate physiotherapy to newborn babies. (Source: Core-info leaflet)

The picture of a metaphyseal fracture of an infant’s wrist below comes from a 2000 paper on the orthopaedic aspects of child abuse by Kocher et al and published in the Journal of the American Academy of Orthopaedic Surgeons (http://www.jaaos.org/content/8/1/10.abstract):

 

A spiral fracture refers to the direction in which the bone is fractured.  It implies that there has been a twisting force to cause the fracture. Spiral fractures can also occur accidentally in the femur once the child is walking. (Source: Core-info leaflet)

The picture below of a spiral fracture of the femur in a 2 month old comes from http://www.hawaii.edu/medicine/pediatrics/pemxray/v6c02.html (same website has a wealth of other paediatric radiological images on it if you are interested):

 

 

A supracondylar fracture is one in the upper arm immediately above the elbow and is highly suggestive of accidental injury.  The picture below comes from http://www.kidsfractures.com/, a site put together by 2 American orthopaedic surgeons who say their aim was to make parents’ experience of having a child with a broken bone a little less traumatic but I think much of the language and many of the pictures are more suited to a medical audience.

 

A simple linear skull fracture is a break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone.  They are equally prevalent in NAI and in accidental injury.  The picture below is of a linear right parietal skull fracture and comes from a Rumanian educational website, http://www.medandlife.ro/medandlife602.html.

 

This compares with a complex skull fracture which is variously defined as:

• a depressed fracture (where the skull is pushed in)

• two or more fractures of the skull

• fractures that cross the sutures (natural joining edges of skull bones) or those that are widening. (Source: Core-info leaflet)

The picture below of a complex skull fracture is from http://www.childabuseconsulting.com/child-abuse-fractures.html which houses other not-very-subtle images of non-accidental burns and bite marks as well.

 

Rib fractures in infants, particularly posterior ribs, with no history of major trauma are suspicious.  The picture below is taken from http://www.learningradiology.com/notes/bonenotes/childabusepage.htm and shows multiple rib fractures with callous formation, the ones of the left 2nd and 6th posterior ribs being the easiest to identify:

 

Paediatric Pearls for February 2012

For Emergency Departments, For General Practitioners, , , , ,

Click here for this month’s PDF digest!  It ‘s quite hard providing a balance of information for GPs and ED juniors now that I am only doing the one newsletter.  I think we’ve succeeded this month with neurodevelopmental milestones in Down’s syndrome and essential tremor aimed mainly at GPs and pulled elbow, anaphylaxis and the FEAST study aimed more towards the emergency medicine practitioners.  Many thanks to my colleagues who have contributed this month.  The FEAST video makes fascinating and inspiring watching for any health professional, regardless of specialty.  Do leave comments, questions, suggestions!

Pulled elbow

For Emergency Departments, For General Practitioners,

Dr Furqan Ahmed is an Emergency Medicine middle grade doctor seconded to paediatrics for a few months as part of his training.  I hope he is learning from us, we are certainly picking up things from him.  He has put together the following guide to “pulled elbow” or “radial head subluxation” for Paediatric Pearls.

Pulled elbow, Nursemaid’s elbow, is a dislocation of the elbow joint caused by a sudden pull on the extended, pronated arm. The technical term for the injury is radial head subluxation.

Pathophysiology:

The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn.

As children age, the annular ligament strengthens, making the condition less common. The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm.

Causes, incidence, and risk factors

Radial head subluxation is a common pediatric presentation generally occurring between the ages of 1 and 4 years, although it can happen anytime between 6 months of age and 7 years. After age 3, children’s joints and ligaments gradually grow stronger, making radial head subluxation less likely to occur.

The injury occurs when a child is pulled up too hard by the hand or wrist. It is often seen after someone lifts a child up by one arm (eg. when trying to lift the child over a curb or high step).

Other ways this injury may happen include:

  • Breaking a fall with the arm
  • Rolling over in an unusual way
  • Swinging a young child from the arms while playing

 

Signs and symptoms

When the injury occurs, the child usually begins crying right away and refuses to use the arm because of elbow pain.

  • The child may hold the arm slightly bent (flexed at 15-20 degrees) at the elbow and pressed up against the abdominal area (pronated).
  • The child will move the shoulder, but not the elbow. Some children stop crying as the first pain goes away, but continue to refuse to move the elbow.
  • Tenderness at the head of the radius may be present.
  • Erythema, warmth, oedema, or signs of trauma are absent.
  • Distal circulation, sensation, and motor activity are normal

Treatment

Inform child and caregiver that the reduction may be uncomfortable, but the discomfort will end quickly after reduction. Parents should not attempt these manoeuvres at home unless advised by a physician.

To resolve the problem, the affected arm must be held with one hand/finger on the radial head and the other grasping the hand making sure the elbow is in 90° of flexion. While applying compression between these two hands, the forearm of the patient is gently supinated and the arm flexed. The manipulator will usually feel a “click” if the manoeuvre is done properly, the child will feel momentary pain, and usually within 5 minutes, the forearm will be functioning well and painlessly.  NB: although a ‘click’ signifies reduction, absence of a ‘click’ is noted in some successful reductions.

Differential diagnoses:

  • Fracture, Elbow
  • Fracture, Wrist
  • Hand Injury, Soft Tissue

 

Indication for xray:

Child not using arm 30 minutes after a reduction.  External signs of trauma such as swelling, abrasions, or ecchymoses.

Consultations

If radiographic findings demonstrate no fracture, repeat attempts at reduction are unsuccessful, and the child does not regain normal function after 30-40 minutes, the safest management is to support the arm in a sling (or splint and sling) and have the child reevaluated in 1-2 days time.

Prognosis

The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.

For those who have had one occurrence, the chance of recurrence is approximately 20-25%.  Those 24 months and younger may have the greatest risk of recurrence.

 

References

  1. ^ Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW (2012). “Manipulative interventions for reducing pulled elbow in young children”. Cochrane Database Syst Rev (1): CD007759. doi:10.1002/14651858.CD007759.pub3. PMID 22258973. 
  2. ^ Toupin P, Osmond MH, Correll R, Plint A (September 2007). “Radial head subluxation: how long do children wait in the emergency department before reduction?”. CJEM 9 (5): 333–7. PMID 17935648. http://www.cjem-online.ca/v9/n5/p333. 
  3. ^ Kaplan, RE; Lillis, KA (2002 Jul). “Recurrent nursemaid’s elbow (annular ligament displacement) treatment via telephone.”. Pediatrics 110 (1 Pt 1): 171–4. PMID 12093966. 
  4. ^ Macias CG, Bothner J, Wiebe R (July 1998). “A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations”. Pediatrics 102 (1): e10. PMID 9651462. http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=9651462.

January 2012 PDF ready

For Emergency Departments, For General Practitioners, , , , , ,

Do you know your valgus from your varus?  Or your myclonic epilepsy from your sleep myoclonus?  A link this month to new asthma patient information leaflets and some reminders of NICE’s “Do not do recommendations” in feverish children.  Also the BSACI egg allergy guideline.  Do leave comments on any of these topics below.