pediatric orthopedic trauma for pas...10/8/17 5 ¡ 2 yo male ¡ dancing around and twisted his leg,...
TRANSCRIPT
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¡ Ihavenodisclosures
¡ Upperextremityfractures¡ Lowerextremityfractures¡ Nonaccidentaltrauma
¡ Whatarethey?§ Fracturesoftheradius,ulnaand/orhumerus
¡ Whogetsthem?§ Activechildrenusuallyafterafall§ Anyagerange
¡ Whydowecare?§ Painfulinjuriesthatsometimesrequiresurgery
§ Atriskforcompartmentsyndromeandneedclosemonitoring
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¡ UsuallytreatedintheEDandsenthome
¡ Caseexample:4yofellonoutstretchedhand
¡ 4dayslaterdoingok
¡ 1weeklaterxraysshowsomeshifting
¡ 3weekslatercompletelossofreductionwithouthealing
¡ Nowthisbecomesandoperativeproblem
¡ Postoppatientwillbeadmittedforneuromonitoringandpaincontrol
¡ Lesscommonfracturesbutmorecommonlyadmittedformonitoring
¡ TypicallyamidshaftfracturethatwillbereducedintheEDwithsedationandmonitoredforpainandswelling
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¡ 10yomale¡ Felloffplaygroundbridge
¡ TreatedintheEDwithreductionandcasting
¡ Oftengoontoneedsurgicalintervention,especiallyinolderkids
¡ Admittedforpaincontrolandmonitoring§ Whattolookfor?§ Castmanagement?§ Activity?
¡ 4yomalefellfrommonkeybars
¡ ThreadypulseinED¡ TakenemergentlytoOR
¡ Placedintolongarmcastpost-opandbivalved
¡ Post-opmanagement:§ Closemonitoringbynursingandresidents
§ WatchCapRefill,sensation,pinkfingers
¡ Pinsstayfor3-4weeksundercastandpulledintheoffice
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¡ Whatarethey?§ Femur,tibiaand/orfibulafractures
¡ Whogetsthem?§ Walkingageactivechildren
§ Childrenplayingsports§ Childrenincarorbikeaccidents
¡ Whydowecare?§ Commoninjuriesthatneedappropriatemanagement
¡ Typicallyhighenergyinjury¡ Treatmentvariesbylocationandageofpatient§ Upto6months:pavlikharness
§ 6monthsto5yo:spicacast
§ Over5yo:surgicaltreatment¡ Femoralneckfractures:surgicalemergency¡ Openfemurfractures:surgerywithin12hours
¡ 6montholdmale¡ Momwasholdinginonearmandbabyarchedhisbackandshelostcontrolandtwistedhislegtocatchhim
¡ Otherwisehealthy
¡ Fullexamforotherinjuries
¡ Socialworkconsult§ Evaluatefornon-accidentaltrauma
¡ Pavlikharnessfor4weeks
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¡ 2yomale¡ Dancingaroundandtwistedhisleg,refusedtobearweight
¡ Fullexamforotherinjuries
¡ Socialworkconsult§ Againtoevalfornon-accidentaltrauma
¡ SpicacastappliedintheEDorORfor4weeks
¡ Kidsinspicasgetadmittedforcastfinishingaswellasloanercarseatarrangement
¡ Castsarewaterproofedonthefloorbythenursingstaff
¡ Keepingthemdryisparamount
¡ Teachingparentstomanagethemisalsoofutmostimportance
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¡ 14yomale¡ Collidedwithanotherplayerwhileplayingbaseball
¡ Severerightlegpain,inabilitytowalk
¡ Requiressurgicalintervention
¡ PaincontroluntilORavailable
¡ Non-weightbearingfor6-8weeks
¡ 12yofemale¡ MVC¡ Leftlegandgroinpain
¡ Skinintact¡ Nootherappreciableinjuries
¡ Femoralneckfractureinskeletallyimmatureisasurgicalurgency/emergency
¡ Lossofbloodsupplytothefemoralheadisashighas50%
¡ Outcomesimprovewithexpeditedintervention
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¡ Openreductionpercscrewfixation ¡ CaseExample:¡ 26dayoldmale¡ BroughttoOSHforrefusaltouserightarm,transfertoUIHCforfurtherworkup
¡ HPI:§ Perdad:babywasonthecouch,dadturnedtogetacleandiaperandbabyfelloffthecouch
§ DadmayhavepulledhimoutofhisSwaddleMetooforcefully
¡ PMH:§ Bornnearterm,c-sectduetopreviousoneweekearlyformaternalHTN
§ Fussybutotherwisehealthy¡ Social:
§ 2ndborn§ Parentsarenotmarriedbuttogetherx4yr§ Historyofdomesticdispute4yearsagoforwhichdadgotamisdemeanor
¡ FH:§ Noknownorthopedicorcongenitalconcerns
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¡ “PediatricNAIisstatedtoinvolveactsofcommissionoromissionwhichdirectlyorindirectlycauseharmtothechild,withwide-rangingnegativeeffectsonnormaldevelopmentprogressiontoseriousinjuryanddeath”
¡ Likelygrosslyunderreported/diagnosed¡ Allsocioeconomic,cultures,gender,raceatrisk¡ LowSES,unplannedpregnancyhigherrisk¡ Pre-term,twingestation,specialneedshavehigherrisk
¡ MissingNATdiagnosisincreasesriskofdeathforthatchild
¡ Majorityofvictimsareunder2yo¡ Upto56%under1yo¡ 85%ofaccidentalpedfracturesareover5yo
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¡ Redflags:§ Vaguehistory§ Historydiscordantwithageanddevelopment
§ Unknownmechanism
§ Delayinseekingcare§ MultipleERvisits
¡ Birth/developmentalhistory§ Bewareofdevelopmentaldelayasarisk
§ Non-ambulatorykidsmuchmorecommon¡ Pastmedicalhistory
§ Anycoagulopathies,connectivetissuedisorder¡ Familyhistory
§ Coagulopathies,OI,othergeneticdiseases
¡ Bruisingismostcommonpresentation§ Increasedaccidentalinjuryfrequencywithincreasedmobility
§ Non-accidental▪ Largearea▪ Awayfrombonyprominence▪ Shapeofanobject▪ Multipleclustered
¡ Fractures§ Anyfracturecanbefromabuse
¡ 1.2%ofchildrenhavemultipleaccidentalfractures
¡ 74%ofnonaccidentalvictimshavemultiplefractures
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¡ Femurdiaphysealfracturesinnon-ambulatoryareclassicandhighlysuggestive§ NoassociationbetweenpatternandNAT,canbeanypattern
¡ Humeralfractures<15mootherthanSCHareassociatedwithNAT§ Spiralfracturesareuncommonandhighlysuggestive
¡ History§ Childifageappropriate§ Suspectedperpetrator/s§ Witnesses
¡ Labs§ Toruleoutmetaboliccausesanddrugexposure▪ Ca,phos,alkphos,VitD,PTH▪ Hairtestingfordrugexposure
¡ Skeletalsurvey¡ HeadCT
§ EvaluateforICHandnon-displacedskullfractures¡ Retinalexam
§ Commonforretinalhemorrhagewithshaking