EMORY-Children’s Center

Pediatric Orthopedic Emergencies

Tracy Merrill MD

Division of Pediatric Emergency Medicine Children’s Healthcare of Atlanta at Egleston and

Emory University School of Medicine

Use * † ‡ if there are authors other than our group, using * to demark us, if its only us take out *

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The Limping Child

4 year old child presents to the emergency department with a chief complaint of limping for two days

No report of trauma Afebrile No additional systemic symptoms PMH negative for joint problems or chronic disease Nontender to palpation and no pain with passive

ROM but limps when bears weight Differential? Workup?

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Transient Synovitis - Definition

Also known as “irritable hip” or “toxic synovitis” The #1 cause of acute hip pain in children Benign self limited disease of uncertain etiology

most commonly affecting the hip joint Usually occurs in children age 3 to 10 years 4 cases in adults have been reported Almost always unilateral Causes pain and limitation of the movement of the

hip, with or without an effusion Pain is the worst when walking, usually presents

with a limp or refusal to bear weight

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Transient Synovitis – Etiology, Treatment

Due to transient sterile inflammation of the synovium of the hip

No clear precipitants, ?post viral Sudden onset, gradual resolution Self limited, usually lasts 4-7 days Treated with OTC analgesics: ibuprofen and tylenol Study done showed ibuprofen decreased median

duration of symptoms from 4.5 days to 2 days No residual long term deficits Most important thing to do is distinguish it from

septic arthritis

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Septic Arthritis - Definition

Results from bacterial invasion of the joint space Can occur at any age but 50% of cases reported

occur in children under the age of 3 years Acute onset Usually monoarticular Usually the large peripheral joints Organisms can invade the joint by three possible

mechanisms:• Usually through hematogenous seeding• Adjacent osteomyelitis• Direct inoculation from a penetrating wound

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Septic Arthritis - Bugs

• Staphylococcus aureus• Streptococcus

GBS S pneumoniae S pyogenes

• Neisseria gonorrhoeae• Haemophilus influenzae

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Septic Arthritis - Presentation

Most commonly involves the hip joint “septic coxitis”

Symptoms include:• Fever• Joint pain• Limp and an inability to

bear weight• Pain with active or

passive range of motion• Joint swelling, effusion,

warmth, tenderness The patient holds their leg in

a flexed, abducted, externally rotated position

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Septic Arthritis - Presentation

May be extremely difficult to diagnose in infants and nonverbal children

Fever, irritability, and decreased po intake may be your only clues

May fuss more when handled due to movement of the affected extremity

May have decreased movement of an extremity Predisposing factors include recent URI or otitis,

skin or soft tissue infections, traumatic puncture wounds, femoral venipunctures, underlying chronic disease, or immunosuppression

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Septic Arthritis - Differential

Differential can include:• Transient synovitis• Viral arthritis• Traumatic arthritis• Periarticular cellulitis• Osteomyelitis• JRA• Acute rheumatic fever (JONES criteria)• Lyme disease• Post-infectious reactive arthritis• Oncologic process (eg. leukemia, osteosarcoma)

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Septic Arthritis - Diagnosis

Laboratory: CBC with diff shows elevated white count with a left

shift Blood cultures are positive 40-50% of the time CRP elevated ESR elevated Joint aspiration shows elevated WBC’s 10,000-

250,000 (normal is less than 200), >75% segs, and decreased glucose

Imaging:• Plain films may show a displacement or blurring of

periarticular fat pads as well as an increased hip joint space

• MRI

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Septic Arthritis - Diagnosis

Study done by Jung, et al. (2003*) found five predictors that correlated with a high probability of septic arthritis to help distinguish from transient synovitis whose presentation can be similar• Temperature >37 degrees Celsius (37.7 vs. 36.6)• WBC >11,000/mL (18.2 vs. 8.2)• CRP >1mg/dL (10.1 vs. 0.66)• ESR >20mm/h (79.2 vs. 20.3)• Joint space difference >2mm between the

affected and unaffected sides (difference of 4.0mm vs. 1.2mm)

• No significant difference found in platelet count

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Septic Arthritis - Treatment

Treatment:• Prompt orthopedic consultation• Surgical debridement of the hip through

arthrotomy• Hospitalization until fever defervescence and

signs of clinical improvement post operatively• Intravenous antibiotics for 4 weeks• Usually requires central line placement for home

administration of antibiotics

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Septic Arthritis - Treatment

Antibiotic Therapy• <2 months of age: oxacillin or nafcillin plus

gentamicin for Gram negatives• 2 months to 3 years: ampicillin-sulbactam or

ceftriaxone• >3years: oxacillin, nafcillin, or ceftriaxone• Adjust based on gram stain and culture results• Consider Clinda or Vanc if suspect MRSA

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Septic Arthritis - Outcomes

Complications• Osteomyelitis, osteonecrosis• Avascular necrosis due to the pressure on blood

vessels and cartilage in the femoral head area• Epiphyseal separation• Pathologic dislocation• Growth arrest and subsequent leg length

discrepancies up to several inches• Sepsis

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Septic Arthritis - Outcomes

Prognosis• Joint destruction can occur within days leading to

longterm disability, residual deformity, arthritis, and decreased range of motion

• Prior to the discovery of antibiotics, pediatric mortality rates averaged 50%

• If diagnosed early before changes seen on plain films, have an improved prognosis

• Note that joint destruction as a result of gonococcal infection is uncommon

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SCFE: Slipped Capital Femoral Epiphysis

An acquired growth plate injury The separation of the proximal femoral epiphyses from

the metaphysis at the level of the growth plate Most commonly occurs in adolescents and

preadolescents who are vulnerable to slippage due to widened and weakened growth plates during periods of rapid growth

Occurs in 2-10 per 100,000 adolescents in the US Peak age is 10-13 in females and 12-16 in males Rarely occurs after menarche More common in males, male to female ratio is 2.5 :

1.6 More common in Pacific Islanders and African

Americans

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SCFE - Etiology

The epiphysis is located at the top of the femur and is connected to the metaphysis via the physis or growth plate

The head of the femur stays within the acetabulum while the femur slips

Occurs when the shearing stress exerted onto the femoral head is greater than the resistance provided by the physis

Occurs in the hypertrophic zone, the weakest zone of the physis

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SCFE - Risk Factors

• Obesity resulting in mechanical overload of an immature growth plate, 81% of cases are in children over the 95th percentile for BMI

• Local trauma• Hypothyroidism• Panhypopituitarism• Growth hormone administration• Renal osteodystrophy• Previous radiation therapy

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SCFE - Presentation

• Limp• Hip, groin, thigh, or knee pain• Hip pain often referred to the knee due to the pathways of

the obturator and femoral nerves• 15% of patients report pain only in the distal thigh and

medial knee• If stable, can still bear weight• As the slip progresses, eventually get external rotation of

the toes when walking• Decreased range of motion of the hip• If chronic or unrecognized, may develop atrophy of the

thigh and gluteal muscles• A stable chronic slip may suddenly worsen and become

unstable with what seems like minor trauma

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SCFE - Diagnosis

Radiography: bilateral A/P and frog leg x-rays of the hips

“Ice cream falling off the cone” the femoral head is the ice cream that falls off the femur which is the cone

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SCFE – Grades of severity

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SCFE - Treatment

• Screw fixation under fluoro to prevent further slippage

• Strict non weight bearing leading up to surgery and then partial for 6-8 weeks after surgery

• Never attempt to reduce the slip during surgery or will increase the risk of avascular necrosis

• For severe slips, a corrective osteotomy may be required

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SCFE - Treatment

• Technically only need fixation until the growth plate fuses but would be too invasive to remove the screw, so they are usually left in unless complications develop

• Some will do prophylactic pinning of the contra- lateral hip if at high risk for a bilateral slip

• Casting or bracing not required postop

• Sports restrictions for 3-6 months

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SCFE - Complications

• Avascular necrosis: altered blood supply to the proximal femoral head and physis leading to bone death, most commonly occurs in severe or unstable slips, can lead to rapid hip deterioration and severe progressive arthritis

• Chondrolysis: necrosis of the articular cartilage, can progress to severe pain, decreased range of motion, and contracture of the hip

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SCFE - Prognosis

• Occurs bilaterally in 25-40% of cases• Most contralateral slips occur within 6-12 months

of the index case• Most stable or chronic SCFE’s are treated

effectively with minimal complications, makes up >90% of all slips

• The more severe the slippage, the more altered are the mechanics of hip movement, and the sooner the hip wears down, leading to premature arthritis

• The most severe cases may eventually require total hip replacements

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Legg-Calve Perthes Disease

Aseptic necrosis of the femoral head and neck Results from a disruption of the blood supply Onset usually between the ages of 4-8 years Male to female ratio of 5:1 Bilateral in 10% of cases Present with a limp Pain may refer to the knee, medial thigh, or groin

along the distribution of the obturator nerve Exam reveals limited hip abduction and medial

rotation More advanced cases may show leg length

shortening or thigh muscle atrophy

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Legg-Calve-Perthes Disease

The exact cause is unknown but can be related to anything that may damage the blood supply to the hip:

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Legg-Calve-Perthes Disease

Radiographs show:• Smaller denser femoral head• Relative osteopenia of the adjacent proximal femur and pelvis• Widened joint space• Subchondral lucent area• Irregular physeal plate, fragmented in later stages• Blurred and lucent metaphysis

Confirm with MRI or bone scan

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Legg-Calve-Perthes Disease

A temporary condition Occurs in 4 phases:

• 1. From several months up to one year, blood supply is absent, portions of the bone die, the femoral head collapses and looses it’s shape

• 2. From one to three years, the dead cells are replaced with new bone cells

• 3. Also from one to three years, the femoral head begins to remodel and obtain its shape again

• 4. Completion of the healing process

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Legg-Calve-Perthes Disease

Treatment:• Rest, often with the aid of crutches, wheelchair• Activity restrictions• NSAIDS• Traction, casting, or bracing to hold the femoral head in the

hip socket to preserve the round shape of the femoral head during remodeling

• Surgery to secure the femoral head in the hip socket• Physical therapy to keep the hip muscles strong and

maintain range of motion Complications:

• Limited hip motion• Leg length differences• Arthritis long term

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Osgood-Schlatter Disease

Tibial tubercle apophysitis Due to traction of the patellar ligament on the tibial

tuberosity An overuse syndrome Occurs most frequently in boys age 11-15 years

who are active in sports Pain to palpation of the tibial tubercle, pain with

quadriceps contraction May have overlying soft tissue swelling Radiographs are either normal or may show an

irregular tibial tubercle with or without fragmentation Often mistaken for avulsion fractures

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Osgood-Schlatter Disease

Self limited Cured by fusion of the

tubercle Treatment is limitation of

physical activity to the point of pain tolerance and RICE• Rest• Ice• Compression with ace

wrap or neoprene sleeve• Elevate

NSAIDS may help with acute pain exacerbations

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Osteomyelitis - Definition

An infection of the bone 90% of cases involve a single bone Pathogens can spread to the bone from the blood

stream from distant infections, from direct penetration from trauma, or from spread from overlying soft tissue infections

Long bones of the lower extremity are the most commonly affected from hematogenous seeding

Usually beneath the epiphyseal plates in the rapid growth areas

Up to 25% may occur in short or nontubular bones

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Osteomyelitis - Bugs

• Staphylococcus aureus is the number one cause in any age group! 70-90% of cases!

• Haemophilus influenzae• GBS and enteric rods in neonates• Salmonella in sickle cell patients• Pseudomonas aeruginosa in foot

punctures

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Osteomyelitis - Presentation

Symptoms:• Limp• Difficulty bearing weight• Bone pain, gradual onset, constant• Infants are usually fussy, febrile, and may not be

moving all extremities equally• Fever over 38.5 C in up to 80% of patients

Physical Exam:• Point tenderness on exam• Local erythema and edema once purulent

material has ruptured through the bone cortex

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Osteomyelitis

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Osteomyelitis - Diagnosis

• Laboratory White blood cell count is normal in up to two thirds of

cases! An elevated ESR is more sensitive, elevated in up to

90% of cases, peaks at day 3-5 of treatment, normalizes by 3 weeks

CRP is best for monitoring response to treatment, elevated in up to 98% of cases, peaks at day 2 of treatment, normalizes in as little as one week in uncomplicated cases

Blood culture yields an organism in 30-50% of cases• Bone aspiration for gram stain and culture yields an

organism in 50-70% of cases

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Osteomyelitis - Diagnosis

Radiographs may be normal early in the course but as bony destruction occurs, may see periosteal reactions (in 3-10 days) or lytic lesions (in 10-12 days)

Technetium-99 bone scan will show areas of increased blood flow due to inflammation, sensitivity >90% (note: your bone scan won’t be affected by needle aspiration)

If have a poor treatment response, consider MRI which can aid in finding drainable subperiosteal abscesses

If have a pelvic osteomyelitis, consider MRI early in the course of evaluation due to an increased occurrence of abscesses in these cases, or can use MRI to replace bone scan in the diagnosis of these cases

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Osteomyelitis

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Osteomyelitis

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Osteomyelitis - Treatment

• All cases must be admitted for IV antibiotics• Immediate orthopedic consultation is required for surgical

debridement and draining of any subperiosteal abscesses• Total antibiotic course of 3-4 weeks, up to 6 weeks in

complicated or extensive cases• Sickle cell patients who may have areas of poorly perfused

bone as well as immunocompromised patients require longer treatment duration

• Use the max dosage range listed for the antibiotic chosen• IV route until clinical symptoms improved and afebrile for at

least 3-5 days• Can then complete treatment course with oral high dose

antibiotics

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Osteomyelitis - Treatment

Antibiotic Therapy:• Anti-staphylococcal penicillins:

Oxacillin (and gentamicin) in neonates Nafcillin or oxacillin monotherapy in older

children• First generation cephalosporins

Ancef (cefazolin)• Clindamycin if suspect MRSA• Vancomycin if clinda resistant or D test positive

for inducible clinda resistance• Linezolid as last resort for highly resistant

organisms

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Osteomyelitis - Outcomes

Complications:• Bony and cartilaginous destruction• Growth arrest• Permanent deformity• Sepsis• Chronic or recurring osteomyelitis

Prognosis:• Complications occur in only ~5% of cases,

usually when there was a delay in diagnosis or treatment

• Recurrences can occur up to 30 years later, usually the same organism, often reactivated by local trauma

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Compartment Syndrome

Due to an increase in intracompartmental pressure From anything that decreases compartment size:

• Tight closure of fascial defects• Tight dressings or casts

Or from anything that increases comparment components:• Bleeding from fractures or trauma• Increased capillary permeability from burns• Venous obstruction• Muscle hypertrophy

Can result in ischemic muscle necrosis and subsequent contracture and dysfunction

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Compartment Syndrome

The lower leg is most susceptible due to its small fascial compartments

Irreversible muscle injury may occur in as little as 6 hours from onset of ischemia

Diagnosis “The Five P’s”• Pain out of proportion to the injury, exacerbated

by passive stretching of the muscle• Paresthesia• Pallor• Paralysis• Pulselessness

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Compartment Syndrome

Treatment• Loosen all restrictive dressings or splints• Direct measurement of compartment pressures if

pain not immediately relieved• Incisional release or fasciotomy required if any

compartment pressures are over 30mmHg

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Fractures: Definitions

Alignment: refers to angulation or rotation of the fracture fragments in reference to each other

Apposition: refers to the amount of end to end contact between the fractured bone fragments

Avulsion: “chip fracture”, small fracture near a joint that usually has a ligament or tendon attached

Closed: “simple fracture”, no overlying open wound Open: “compound fracture”, open wound present Comminuted: multiple fragments Dislocation: “luxation”, disruption of the continuity of a joint Displaced: the two bone ends are separated Epiphyseal: involves the growth plate or epiphysis Greenstick: incomplete fracture Impacted: broken ends are driven into each other Intra-articular: involves the joint surface of a bone

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Fractures: Definitions

Delayed union: slower than normal healing Malunion: healing in an unsatisfactory position Nonunion: failure of bone healing Occult: can’t see the fracture on the plain films but other

positive signs suggest a fracture such as a posterior fat pad on a lateral elbow film

Pathologic: due to an underlying bone weakness, usually cysts, neoplasms, or metabolic bone disease

Stress: occurs when weak bone is stressed normally or when normal bone is stressed excessively, usually in weight bearing bones

Subluxation: partial disruption of a joint, an incomplete dislocation, most common in pediatrics is nursemaid elbow

Torus: “buckle fracture”, caused by compression of the cortex, most commonly occurs in the distal radius

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Pediatric Fractures

Fractures in children differ from those in adults Nonunion is rare due to the active periosteum and

abundant blood supply surrounding the growing bone

Continued bone growth after the fracture is healed allows for correction of minor deformities

The closer the fracture is to the end of the bone and the younger the patient, the greater the amount of angulation that is acceptable

The distal radius may correct up to 10-15 degrees per year

Side to side apposition is acceptable in long bone fractures in boys under 12yrs and girls under 10yrs

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Pediatric Fractures

Slight shortening (overlapping of 2 bone ends) is acceptable and may even be desirable in leg fractures due to the acceleration of growth seen after a displaced fracture, the tibia and femur may overgrow up to 1cm

Exceptions:• Rotational malalignment will not correct itself• Angulated midshaft fractures will not realign

Sprains are rare in children under age 12 yrs, if tenderness is present over a growth plate coupled with overlying soft tissue swelling, assume a fracture even if x-rays are negative

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Epiphyseal Fractures

The epiphyseal plate consists of zones or layers:• Germinal cell layer, closest to the joint• Zone of proliferation• Zone of hypertrophic cartilage• Zone of provisional calcification

Most epiphyseal fractures occur through the weakest zone, the zone of hypertrophic cartilage

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Epiphyseal Fractures

Salter I and II fractures are transverse and do not extend vertically across the germinal cell layer, prognosis for normal healing is good

Salter III, IV, and V fractures extend vertically across the growth plate and have the highest risk for growth disruption and angular deformity, accurate reduction is mandatory and often requires surgery

Salter V fractures are crush injuries and have the worst prognosis

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Pediatric Fractures

Call orthopedics for all of the following fractures:• Open fractures, often require meticulous cleaning

and debridement to prevent infection• Femur fractures, require prolonged traction,

special casting, or surgery• Displaced supracondylar humerus fractures• Salter III, IV, or V fractures (except fingers, toes)• Any closed angulated or displaced fractures for

which reduction attempts are unsuccessful• Any injury involving neurovascular compromise

or signs of compartment syndrome

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Pediatric Fractures

Immediate care when patient presents to the ER:• Elevate and ice• Stabilize obvious fractures on an armboard, in a

sling, or on a stack of towels• NPO except for pain meds• Pain control depending on severity

IV Morphine PO Lortab

• Document last po intake• Consent signed for sedation if has obvious

deformity• Assess neurovascular status distal to the injury

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Buckle Fractures

Torus or buckle fracture of the distal radius

The most common fracture in the pediatric population

Occurs from a fall onto an outstretched hand

May present a few days after the injury with mild wrist pain

Stable fracture, treated mainly for comfort

Treat with a lower arm sugartong splint in the ER

Later get a short arm cast or a removable volar wrist splint for 3-4 weeks

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Clavicle Fractures

Occurs from a fall onto the shoulder or falling onto an outstretched hand Surgical correction only if open, skin tenting present, comminuted, or

has neurovascular injury Better to accept angulation/deformity than to attempt open reduction in

most cases The scar from an open reduction is usually more displeasing to the

patient and family than the bony prominence of a malunion Simple sling and swathe for 2-3 weeks or until painfree

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Proximal Humerus Fractures

Common between the ages of 9-15yrs Occurs from a fall onto the arm or a direct hit The proximal humeral growth plate has an amazing

ability to remodel Reduction is only needed in patients near skeletal

maturity whose fracture has more than 50-70 degrees of angulation, in open fractures, or if has neurovascular injury

Most common complication is axillary nerve injury, test deltoid function and sensation lateral deltoid

Immobilize in a simple sling for 3-4 weeks Gentle pendulum exercises and shoulder range of

motion exercises can be started in the second week

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Proximal Humerus Fractures

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Supracondylar Fractures

Make up 60-80% of all pediatric elbow fractures Peak incidence ages 5-7 years Results from a fall with the elbow hyperextended, the

hyperextension forces the olecranon into the olecranon fossa transmitting the force up into the distal humeral metaphysis

The distal fragment is usually displaced posteriorly The anterior humeral line which should bisect the capitellum, is

malaligned anterior to the capitellum Has the highest complication rate of any pediatric fracture

including neurovascular injury, compartment syndrome, and malunion• Vascular injury occurs in ~2.5%, most commonly the

brachial artery• Neuronal injury occurs in ~17% of Type III fractures, can

affect the radial, median, or ulnar nerve

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Supracondylar Fractures

Type I is nondisplaced Type II is displaced partially

with the posterior periosteal hinge intact

Type III is displaced completely with no contact between fracture fragments

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Supracondylar Fractures

Type I can be treated with a posterior long arm splint with the elbow in 90-110 degrees of flexion, will later get a long arm cast for 3-4 weeks

Type II and III are usually treated with closed reduction and percutaneous pinning

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Forearm Fractures

The distal radius physis is the most commonly injured physis in the body

Salter II fractures are the most common type of radial physis injury

Most displaced fractures involve apex volar angulation with the distal fracture fragment being displaced dorsally

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Forearm Fractures

Most distal forearm fractures can be treated with closed reduction, but midshaft fractures are more unstable and often require pinning or plate fixation

Remodeling of the distal radius may correct up to 10-15 degrees of angulation per year

Therefore, angulation up to 30 degrees may be accepted in children under the age of 10 years, and up to 15 degrees in children older than 10 years as long as they have open physes

Remember, rotational deformities will not remodel

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Forearm Fractures

Place a sugartong splint in the ER and then a cast for 4-6 weeks

Most common complication is growth arrest, occurs more commonly with difficult or open reductions

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Boxer’s Fracture

Distal 4th or 5th metacarpal fractures

Results from hyperflexion of the metacarpal neck due to punching or hitting a hard object or wall

Treated with an ulnar gutter splint, then a cast for 3-4 weeks

Never reduced in the ER, all go to ortho clinic for follow up and have outpatient surgical repair if residual dysfunction is present

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Femur Fractures

62% occur in the shaft of the femur or diaphysis

One of the most common fractures in children

The most common fracture requiring hospitalization

Between the ages 1-6 yrs, usually due to falls

Between the ages 6-9 yrs, usually due to auto vs. ped

Over the age of 10 yrs, usually due to MVC’s, sports accidents

Under the age of 12 months or in any child who is not yet walking, 80% are due to non accidental trauma

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Femur Fractures

Treatment is often age dependent• Newborns to age 6 months: Pavlik harness• 6 months to 5-8 years: spica cast• 6-12 years:

Traction followed by a spica cast External fixation Flexible intramedullary nailing, no casting, just

a knee immobilizer needed post op, rods are removed 9-12 months later

• Skeletally mature with closed physes: Rigid intramedullary locking nails Compression plate fixation

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Femur Fractures

Pavlik harness Spica cast

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Femur Fractures

Remodeling of an infant treated with Pavlik harness

Flexible intramedullary nailing in an older child

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Femur Fractures

External fixation Rigid intramedullary interlocking nails

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Tibia Fractures

50% occur in the distal third of the tibia

39% occur in the midshaft region 30% have associated fibular fractures Due to falls, sports, MVC’s, and auto

vs pedestrian accidents Proximal third tibia fractures are rare

but the most complicated, tend to heal with a valgus deformity, treated with a varus molded long leg cast with knee flexed 10 degrees for 4-6 weeks, some valgus deformities resolve spontaneously so they aren’t surgically corrected unless persist into adolescence

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Tibia Fractures

Middle and distal third tibia fractures require long leg splints in the ER followed by casting

Casting duration dependent on age• Young children wear a long leg cast for 3-4 weeks• Adolescents wear a long leg cast for 4 weeks, then switch

to a short leg cast for 4 weeks, then an aircast walking boot for 4 weeks

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Toddler’s Fracture

Nondisplaced spiral fracture of the distal third of the tibia

The most commonly identified fracture in preschool-aged children presenting with a limp

Occurs from a fall that causes a twisting torque on the lower leg

Typically seen in patients aged 1-3 years as they are learning to walk, but can occur in children as old as 6 years

Long-leg or below-the-knee walking cast for 3-4 weeks

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Ankle Fractures

Ankle inversion/eversion injuries can cause avulsion fractures of the lateral/medial malleolus tips respectively, or distal fibular physis fractures

Avulsion fractures of the distal medial or lateral malleolus may persist radiographically despite casting

Sometimes confused with a normal ossification center, if tender with overlying soft tissue swelling, treat as a fracture

Salter Harris I fractures of the distal fibula account for 15% of pediatric ankle fractures, often cannot be seen radiographically, it must be presumed in a growing child with tenderness over the physis

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Ankle Fractures

Normal Pediatric Ankle Medial malleolus avulsion fracture

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Nursemaid Elbow

Subluxation of the radial head due to a pulling or sudden traction injury followed by entrapment of the annular ligament between the radial head and the capitellum

Age 1-5 years Left side more common Slightly higher incidence in girls Usually caused by someone

lifting up a toddler by the lower arm or when a child suddenly pulls away or drops down while holding hands with a parent, also occurs from swinging a child as in playing “airplane”

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Nursemaid Elbow

Presents with the arm hanging limp down by the side, nontender to palpation, but the child refuses to use the arm

Can reproduce pain with elbow flexion or supination

Reduced by applying pressure to the lateral aspect of the radial head while applying traction to the lower arm followed by supination and flexion at the elbow

This method works in 80-90% of cases

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Nursemaid Elbow

An alternative method is hyperpronation at the wrist If unable to reduce, splint with elbow flexed at 90

degrees and send for orthopedic clinic follow up Often hear or feel a click Child usually cries briefly 10 minutes later the child is using it fully and

reaches for a toy or popsicle No splinting or sling necessary Motrin or Tylenol for soreness Tends to recur in 26% of cases

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» The End… Questions???