Bone and Joint Injury and Infection - Paediatric Orthopaedics

Bone and Joint Injury and Infection

·        Differential of joint swelling:

o   Acute rheumatic fever

o   Septic arthritis

o   Reactive arthritis

o   Henoch-Scholein Purpura

o   Juvenile chronic arthritis

o   Sero-negative arthritis

o   Rickets and vitamin deficiencies: A, folate, B12, C

o   Transient synovitis

o   Trauma

o   Haemophilia

o   Osteomyelitis

Supracondylar Humeral Fracture

·        Most common fracture above the elbow, typically extension injury by fall on outstretched hand

·        Type 1: undisplaced.  Type 2: displaced but some cortical contact.  Type 3: Completely displaced 

·        Complications: nerve palsy (usually resolves after 6 - 8 weeks), vascular injury (esp brachial artery), compartment syndrome 

·        Treatment: closed reduction and percutaneous pin fixation. Non-displaced fractures without collapse of the medial or lateral columns can be treated by immobilisation. Open reduction if unsatisfactory closed reduction, open fracture or if vascular compromise

Medial Epicondyle Fractures

·        Often accompanied by dislocation.  Bony fragment may be trapped in the joint preventing reduction

·        Usually treated non-surgically

Fractures of the Forearm

·        75% are fractures of the distal radial metaphases.  Loss of reduction in 1/3 of cases

Wrist and Hand Fractures

·        Radius and ulnar fractures account for 45% of childhood fractures

·        Scaphoid fractures account for only 0.45% of paediatric upper extremity fractures

·        75% of finger injuries are stable and can be treated with simple immobilisation (often little finger)

·        In toddlers and young children, most common pattern of injury is a crush injury of the finger, leading to distal phalangeal fracture, nail bed laceration and/or distal tip amputation 

·        In teenagers, diaphyseal level phalangeal fractures are common, with malrotation most apparent with digital flexion

·        In teenagers, fractures of the metacarpal neck are common (“Boxer‟s Fractures”) 

·        Fingertip trauma may lead to complete or incomplete amputation. Various treatment approaches. For more proximal amputations, replantation is now standard over 1 year. Best prognosis with sharp injuries (more common in adolescents, crush more common when younger)

   Transient Synovitis of the Hip

·        Transient synovitis is common and self-limiting, often following URTI.

·        Hip or knee pain, limp, decreased motion but normal xray

·        Main differential: septic joint.  If in doubt, aspirate

Slipped Upper Femoral Epiphysis

·        Most common disorder of the hip in early adolescence, especially overweight and boys

·        90% are chronic and stable (can bear weight) with limp for several months

·        Pain on abduction, flexion, internal rotation

·        Often pain refers to the knee

·        Treatment: Percutaneous fixation

Femoral Shaft Fractures

·        Common, generally solid healing

·        Various treatment options including spica casting and traction

·        Subsequent limb overgrowth is common but not predictable

Limb Length Inequality

·        Various causes: check for soft-tissue hypertrophy, vascular anomalies, etc etc

·        Often idiopathic.  If mild (< 1.5 cm) then monitor with serial exam and x-rays

·        Treatment depends on severity – involves surgical, gait, etc

Other

·    Legg-Calve-Perthes Disease: Poorly understood. Typically affects boys 4 to 8 years. Osteochondritis and osteonecrosis of the femoral epiphysis. Softens bone then gradually reforms in a deformed shape. ?Due to interference with venous drainage of the femoral head. May present as an incidental finding. Treatment controversial. Younger the patient the better the prognosis. Usually benign. Maintain motion 

·        Knee injury:

o  Osteochondral fractures of the knee: associated with patellar dislocations 

o  Osteochondritis Dissecans: Fragmentation or separation of a portion of the articular surface of the knee. Symptoms include vague pain, clicking, popping or effusion. Initial treatment is immobilisation 

o  See also Knee Injury

·        Physeal fractures of the distal tibia