paediatrics orthopaedics
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Paediatrics Orthopaedics
Anatomy of Long Bone
Epiphysis
Epiphyseal Plat
Metaphysi
Diaphysis
Fracture in Children
Physeal Injury
Different Patt ern of Fractur
Healing is Better (Bone Remodelling)
Complications in Relation to Growth Plate
Fractures
Diaphyseal Metaphyseal Physis (Growth Plate)
Malleabl
Plastic Deformity
Cancellous Bone Weakest Point in
Skeleton of ChildrenProne to
Periosteum Thicker
(compared to A dult)Usually Remain Intact in
one side of fracture
(Help splinting fracture)
Green Stick Fracture
Weaker than Ligament
Hypertrophic Zone is
the Weakest
Torus Fracture
Supracondylar Humerus
Thin Cortex Olecranon Fossa
(Thin Bone)
Salter Harris Classification
I II III IV V
Avoid
Damage
Avoid
Damage
Anatomical
Reduction
Anatomical
Reduction
No Salvage
Restore
Articular
Surface
Prevent
Metaphyseal-
EpiphysealBridge
Secondary Ossification Ce nter
Develop After Birth
Intraarticular Fractur
Small Hair Line is Misleadin
Bone Remodelling
Better in
Near to Growth Plate Plane of Joint Motion Young Age (2 Years Growth Remaining)
Complications
Growth Arrest
Angular Deformity Shortening
Mechanism of Injury
Normal Bone Fracture
Pathologic Fracture
Child Abuse
Pathologic Fracture Child Abuse
Caused by Triv ial Injury History
Causes
Osteopetrosis Osteogenesis Imperfecta Rickets Fibrous Dysplasia Malignant Bone Tumour
Vague, Not Consistent with Forcenecessary to cause injury
(eg. Single V ertebra Fracture afterChild Fell from Couch)
Delay in Seeking Treatment
Poor Child-Parent Interaction
(no Eye Contact)Feature
Head Chest Limb
Malnourished Child
Physical Examination (Soft Tissues)
Soft Tissue Injuries (80% of cases)
Clustering of Injuries (Face, Trunk, Buttocks)
Thermal Injuries (Popliteal Sparing)
Regularly Spaced Patterns (Scratch Mark s, Radiator Burns)
Imprinting (Wire Hanger Marks, Cigarette Burns)
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Fractures
Metaphyseal Corner Fractur
Lower Extremity Fractures (in Non-Weight Bearers)
Rib, Spine, Skull Fracture
Bilateral Acute Fracture
Overabundant Callus
Improper Immobilizat ion Bone over BoneVarious Stages of Healing
Metaphyseal Corner Fracture (Child Abuse)
Highly supportive of diagnosi
Secure attachment of Perichondrial F ibreNature ofTraction Injury
Callus (Child Abuse )
Due to Improper Immobilization
Bone in Bone
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
RadiologicalLocation
Personality
Displace
Angulation
Localized Bone Lesion
Bone Quality
Joint, Growth Plat
Differentiate Fracture, Physis
Growth Plate ofMedial Epichondyle
Persist until 16 y/o
Contralateral
Monteggia Fracture
Line Cross the Capitulum in both AP, Lateral
Pelvis Radiograph
Subtle AP, Obvious Lateral
Subtle Feature (Supracondylar Humerus Fracture)
Fat Pad Sign
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Management
Reduce
Hold
Rehabilitat
Casting
Remodelling Potential (Good)
Recovery from Stiffness (Good)
Fast Healing
Very well Adjusted
3 Point Molding
Position of Joint
Closed R eduction
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, Procurvat um
After Cast Care
Loss of Correction
Must review at 1 week
POP Care (Plaster of Paris)
Pressure Sore
CompartmentMaterial Inside
Wet
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Paediatric Bone, Joint Infectio n
Causative Organisms (Osteomyelit is, Septic Arthritis)
Neonates
( < 1 y/o)
Child
(1-4 y/o)> 4 y/o Adults
Staphylococcus
aureus
Staphylococcus
aureus
Staphylococcus
aureus
Staphylococcus
aureus
Group B
Streptococcus
Haemophilus Streptococcus
Pyogenes
Streptococci
(A, B, C, G,
pneumoniae)
HiB Vaccine Introduction
(Incidence of Haemophilus Infections has dropped dramatically )
Route of SpreadOsteomyelitis (OM) Septic Arthritis (SA)
Haematogenous Haematogenous
Spread from Contiguous Soft Tissue
Infection
Spread from Contiguous Soft Tissue
Infection
Direct Inoculation (Penetrating Injury) Direct Inoculation (Penetrating Injury)
Spread from
Metaphyseal Osteomyelitis(where Metaphysis is Intra-Articular)
Pathophysiology
Acute Haemat ogenous Osteomyelitis
Spread to
Metaphysis
Lifts PeriosteumInvolucrum
Formed Against
Sequestrum
Local Spread toJoint, Soft
Tissues
Casual Relationship OM, SA
Clinical Features (OM, SA)Neonates Younger Child, Toddler Adult
Irritibility Limp with Weight
Bearing
Symptoms ofInfe ction
Lethargy
Refuse Feeding Refuse to Walk
Fever Irritabl
Pseudoparalysis Fever
Clinical Exam ination
Osteomyelitis (OM) Septic Arthritis (SA)
All findings ofInflammation, Infe ction All findings ofInflammation, Infe ction
Pus Discharge Severe Range of Motion (ROM)
Painful Septic Joint
Types of Osteomyelitis
Acute
(Acute Haematogenous Osteomyelitis)
Pathology
Inflammation Suppuration Necrosis New Bone Formation Resolution Subacute (Brodies Abscess)
Painful Limp, Systemically, No Signs of Local Infection, Insidious
X-Rays Well-Established Lesion in MetaphysisCommon Sites Femur, Tibia
Blood Tests Normal
Chronic
Etiology
Inadequate Treated Acute Osteomyelitis Delay in Treatment Haematogenous Spread Penetrating Trauma Open Fractures Contiguous Focus InfectionCausative 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)
I II III IV
Medullary Superficial Localized Diffuse
Risk F actors
Moderate
Normal Immune
System
Local, Mild Systemic
Deficiency
Major Nutritional or
Systemic Disorders
Non-Smoker Smoker
Septic Arthritis
Pus, Cartilage are IncompatibleCartilage Destruction
EpidemiologyChildren (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)
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Investigations
Blood
ESR, CRP
FBC
Blood Culture
Radiological Study
Plain Radiograph
Aspiration (SA)
Other Special Radiological Imaging
US
MRIBone Scans
T-99 Indium, GaliumManagement
Principle
Supportive
Analgesics Hydration Splint, TractionAntibiotics
Anti-Staphylococcal AntibioticsAnti-Streptococcal Antibiotics
1st
Line 2n
Line
Cloxacillin Vancomycin Benzylpenicillin
Fucidic Acid
Drainage
Surgical Indication
Osteomyelitis Septic Arthritis
Not Responding to MedicalTreatment 24 48h
Drainage (Treatment)
Eradicate, Dilute Bacteria InoculumDestructive Enzymes from
Immune Response
DecompressExcision Nonviable TissuesMinimizing Destructive Changes
Evidence ofSubperiosteal Abscess
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 StimulationSystemic Sepsi
Distant Seeding
Chronic Osteomyelitis
Hip Dislocation
Differential (Diverse, Limping Child)Celluliti
Inflammatory Arthriti
Toddler Fractur
Neoplasms (Ewings Sarcoma, Leukaemia)
Bone Infarction (Sickle)
Diskiti
Acute Rheumatic Fever
Transient Synoviti
X-Rays
Pathologic Fracture
Hip Dislocation Hip Dislocation
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