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ChildHealth: OrthopaedicsFracturesinPaediatricsDifferenceinPhysiology Growth (epiphyseal) Plates Hyaline cartilage between epiphysis and metaphysis Areas of bone allowing it to grow in length Not found in adults: These plates fuse during puberty, the remenants of which become epiphyseal linesDifferenceinPhysiology Bone type Children’s bones contain more cancellous bones -> are more spongey and vascularised Bones are more malleable/flexible Hence, able to form greenstick fractures, where one side breaks and the other side is intact Bones are less strong More likely to get a buckle/torus fracture following compression TypesofFractures Does anyone know ANY types of fractures (adult and paediatric)?TypesofFractures TypesofFractures Salter-Harris (Growth Plate) SALTR mnemonic Straight across Above BeLow Through CRush Investigations Bloods group and save Imaging X ray: rule of 2s 2 views 2 joints 2 occasions (compare with old images if availbale) CT/MRI: soft-tissue injuryManagement Conservative Consider safeguardingNon-AccidentalInjury Delayed presentation Developmental/Milestone delay Inconsistent history Multiple injuries Injuries at sites not exposed to traumaManagement Medical Pain managementAnalgesicstoAvoid Codeine and tramadol: Unpredictable metabolism Aspirin: Reye’s syndrome risk, avoid in asthmatics Exception: Kawasaki diseaseManagement Surgical Mechanical aligment Closed/open reduction Stability External casts K wires Intramedullary wires Intramedullary nails Screws Plate and screwsManagement Salter-Harris Type 1/2: usually minimally displaced closed reduction If 5+ day post-injury, do not attempt manipulation If poorly aligned: operative management immobilisation Type 3/4: greater displacement consider ORIF Type 5: referral to specialistsPrognosis Usually good If missed/mismanaged -> Disruption Early closure of growth plateIrritableHip Transient Synovitis Definition Irritation to synovial membrane Most common cause of hip pain in Often preceded by viral URTIPresentation Limp Avoiding weight bear Groin/hip pain Low grade temperature Note: If temperature and systemic signs, consider septic arthritis Management Safety net: if feverish, go to A&E Usually improves 1-2 weeksArthritis:SepticAetiology Staphylococcus aureus (most common) Neisseria gonorrhoea (gonococcus) in sexually active teenagers Group A streptococcus (Streptococcus pyogenes) Haemophilus influenza Escherichia coli (E. coli) Riskfactors Age (younger, <3) Pre-existing joint abnormalities Immunodeficient Recent trauma/surgery Skin infectionPresentation Joint pain with systemic signs Usually knee/hip Stiffness Reduced movement Systemic symptomsManagament Investigations Joint aspiration MC+S (before abx) raised WCC Imaging: USS, MRI ABCDE Abx asap initially IV (2 weeks) 4-6w oral Irrigation and debridement (washout)Arthritis:IdiopathicJuvenileIdiopathicArthritis Idiopathic arthritis seen in <16s lasting >6w Associated with HLA A2, HLA B27 Risk factors Female FHx (first degree) Down’s syndrome Subtype Joint involvement Other features Oligoarthritis (most common) 1-4 large joints RF negative polyarthritis 5+ large/small joints Symmetrical RF+ polyarthritis 5+ large/small joints Symmetrical h Fever spikes Salmon-colour rash Systemic-onset (Still’s) 1+ joints Generalised lymphadenopathy, hepatosplenomegaly, serositis Psoriatic arthritis Enthesis related 1+ weight bearing joints Sacroilitis Undifferentiated Does not fulfil any category OR fits 2+ categories Differentials Cancer/malignancy Septic arthritis Reactive arthritis Osteomyelitis Rheumatic fever SLEInvestigations Bloods FBC exclude malignancy and infection JIA: thrombocytosis, anaemia, leukocytosis RF Anti-CCP ANA: +ve more susceptible to uveitis HLA-B27: enthesitis-related JIAInvestigations Imaging XRay undetectable in early disease rule out fracture USS: abnormal in early stages MRI contrast enhanced: most-sensitive for soft tissue and bone erosions Check for uveitisModerate intensity exercises Management aerobics, flexibility, strengthening Corticosteroids NSAIDs severe/systemic JIAgement for Initial symptomatic treatment use shortest possible duration limit to 2w at a time consider calcium/vit D supplements if Intra-articular glucocorticoid injections long-term preferred initial treatment If all else fails: Biologics 2nd line: DMARDs TNFa inhibitors: etanercept, 1st line: Methotrexate adalimumab, infliximab Leflunomide IL6 inhibitors Sulfalazine selective B cell blockade JAKiOthercausesof limps PerthesDisease Idiopathic avascular necrosis of the femoral head Disrupted blood flow to the femur Idiopathic: No trigger Consider SUFE if triggered by trauma Classic presentation: 5-8 year old (primary school) boy with a limp and pain in the hip/groin Management: ConservativeSlipped Upper Femoral Epiphysis Head of femur slips along growth plate Classic presentation: Secondary school boys, catogorised as obese, following minor trauma Pain often disproportionate to trauma. Externally rotated hip, limited internal rotation. Management: SurgeryDevelopmentalDysplasia oftheHip Structural abnormality in hip during gestation -> instability in hip Risk factors: FHx, Breech presentation, Multiple pregnancy Picked up during the NIPE: Ortolani and Barlow Confirm with USS Manage ASAP: Easier to manage when young Pavlik Harness