Pediatric Trauma and Orthopedics

 

Trauma

Head Trauma

AAP defines minor head trauma as normal mental status at time of exam, no abnormal findings on neuro exam, and no evidence of skull fracture.

 

Secondary Impact Syndrome:  mild secondary head trauma can cause devastating results out of proportion to injury possibly secondary to decreased autoregulation after the first injury.

 

 

Minor Head Injury Recommendations

Definition · Isolated blunt head trauma with or without alteration in consciousness or confusion in infants and children ·

GCS 15 and normal neurological exam on initial examination

Indications for CT

H · Hematomas

° Infant less than 1 year with any scalp hematoma

° Infant age 1-2 years with more than “barely perceptible” scalp hematoma

· Headache

 

E · Emesis

 

A · Alteration in consciousness immediately following trauma

· Age less than 3 months, regardless of symptoms

· Age less than 2 years with symptoms of head injury

· Abuse, suspected or known

 

D · Depressed level of consciousness, GCS < 15

· Disorientation

· Drowsy, lethargic, irritable, behavior change

 

C · Coagulopathy · CNS disease, such as ventriculoperitoneal shunt or AVmalformation

 

T · Trauma – multi-trauma, any high risk mechanism of injury

 

S · Seizure · Skull fracture suspected on physical examination

· Sport-related repetitive injury, “second impact syndrome”

 

 

Minor Head Injury – No Imaging Needed, Observe for Symptoms ·

Children over the age of 2 years with no loss of consciousness or symptoms of head injury ·

Children 3 – 24 months with no loss of consciousness, no symptoms and no scalp hematoma

 

Caveats

The above recommendations are made with a goal of identifying all patients with intracranial injury.  If the physician wishes to identify only those patients requiring neurosurgical intervention, then those children over the age of 2 years with resolution of symptoms may be observed for 24 hours, instead of undergoing CT.  The child’s parents must be involved in any decision not to obtain CT in order to ascertain feasibility of close observation for 24 hours.

 

Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children 2 years of age), and headache. (Annals of EM Oct 2003, 42:4 p.492)

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Musculoskeletal/Peds Ortho

The Pediatric Limp

morning stiffness think RA, eveningpain think CA

Look for ptechia of HSP

Target lesion of line for monoarticular arthritis

Percy Sign-external rotation of hips with inward rolling of lower legs, sign of Leg/C/P or SCFE

ESR or CRP will be elevated >90% of the time

 

Discitis an infection seen almost exclusively in peds can present with a limp

 

Three nontraumatic causes must be ruled out in any child with a limp

Developmental Dysplasia of the Hip

Legg-Calve-Perthes

SCFE

 

traumatic causes can be occult

 

Septic Arthritis

most commonly in the hip

>50000 WBCs with >90% polys

crp is crap as is esr, wbc, etc. (J Ped Orthop 23(3):373 May 2003)

 

DOUBLE BLIND, RANDOMIZED, PLACEBO-CONTROLLED STUDY OF DEXAMETHASONE THERAPY FOR HEMATOGENOUS SEPTIC ARTHRITIS IN CHILDREN Double blind, placebo controlled showed good benefit to giving steroids, decreased course and less residual damage Odio, C.M., et al Ped Infect Dis J 22(10):883, October 2003

Osteomyelitis

get CBC, ESR and CRP.  Takes ~2 weeks to show on plain films. Back pain is unusual in peds and should be assumed to be infectious until proven otherwise.

Slipped Capital Femoral Epiphysis (SCFE)

AP and Lat of Hips and AP pelvis.  Usually with unilateral sx with bilat x-ray findings so can not compare one side to the other to rule out.

Legg-Calve-Perthes (LCPD)

avascular necrosis of femoral head Boys>girls.  4-9 y/o.

Osgood Schlatter

apophysitis of the tibial tubercle from repetitive stress.  Intermittent pain and swelling of the anterior knee associated with activity.

Salter Mnemonic (Imagine bone with head pointing up)

S-separation

A-Above

L-Lower

T-Through

ER-Impaction

Pyomyositis

Infection of muscle.  Surgical drainage of abscesses and iv abx.

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Back Pain

The child initially presented with non-specific neck complaints and neurological abnormalities. Back or neck pain is not frequently reported by children. Such complaints need to be taken seriously because half of them will have a serious cause [5]. Certain factors that should serve as a warning sign include age at onset < 4 years, symptoms lasting > 4 weeks either intermittent or persistent, systemic features, neurological features, pain worsening progressively, or recently developed scoliosis [5].

Differential diagnosis

Causes of back pain can be broadly classified in seven groups:

Trauma

Acute injury with axial loading may cause compression fractures, spinal epidural hematoma, which may present immediately after trauma or 24–48 h later, or symptoms of cord compression.

Chronic or recurrent injury is usually seen in adolescents with growth spurt and repeated lifting with back extension. Spondylolysis and spondylolisthesis are common causes of back pain in children older than 10 years of age [6]. Spondylolysis represents weakening of the pars interarticularis that connects the vertebrae at the facet joints, and usually results from excessive stresses in sports. The resultant forward slip of the vertebra causes spondylolisthesis. The typical presentation is that of an athletic teenager with low back pain, improving with rest; neurological symptoms are rare. One leg extension test is a good screening test with the patient standing on one leg with the other leg flexed at the knee; hyperextension of the back evokes back pain [7].

Scheuremann’s disease usually presents in the adolescent with back pain or painless thoracic kyphosis. Repeated trauma of the immature spine is thought to be the cause. The typical patient is an athletic adolescent boy. Pain is relieved with rest; examination may be normal or show an exaggerated thoracic kyphosis. Plain radiographs reveal anterior wedging of one or more vertebrae with disc herniation into the body of adjacent vertebra [5].

Disc herniation, although a common cause of back pain in adults, is relatively infrequent in children. Usually seen in the adolescent population, it accounts for 1–4% of all disc herniations [8]. Most present with back pain with or without sciatica [9]. Physical signs are more common in children, with changes in posture or gait, weak plantar flexion, and restricted straight leg testing [5]. MRI is usually diagnostic.

Infection

Spinal epidural abscess presents with systemic features and back pain with and without neurological symptoms. Staphylococcus aureus is implicated in most cases [10 and 11].

Discitis chiefly affects young children; 50% are under 4 years of age. Presentation can range from a well child sitting in a hyperextented position protecting the back to a sick febrile child who refuses to walk due to back pain [12 and 13]. The children are usually comfortable in the supine rather than in a sitting position. Usually one disc space is involved. Staphylococcus aureus is the causative organism. Plain radiographs do not show changes until after 2 weeks, when there is disc space narrowing and vertebral end-plate irregularity. Bone scintigraphy is usually positive at the time of presentation. Outcome is good and is due to good vascular supply of the juvenile disc.

Vertebral osteomyelitis is usually seen in older children; the causative organism is staphylococcus aureus. Patients present with severe back pain and systemic features.

Chronic recurrent multicentric osteomyelitis is a rare self-limiting condition that affects adolescents, and usually is associated with significant morbidity. Culture of the biopsy material is negative for any organism. Plain films are usually diagnostic.

Spinal tuberculosis, or Pott’s disease, is a rare cause but can be seen in immunocompromised children.

Extraaxial infections that cause back pain include pneumonia, urinary tract infections, and meningitis. Postinfectious conditions include transverse myelitis, in which back pain may precede weakness by 1–2 days.

Collagen vascular diseases

Back pain is occasionally seen in patients with ankylosing spondylitis. Most patients present with pain in the morning with stiffness. Most have radiographic changes of sacroilitis within 5 years of disease onset [5].

Neoplasm

Spinal neoplasms presenting as back pain in children are rare [5]. Most of the neoplasms are benign. Warning features include unremitting or recurrent pain, development of scoliosis, neurological symptoms, and unexplained anemia.

Benign tumors include:

Osteoid osteoma and Osteoblastoma; both conditions are considered to be in the same continuum [14]. Osteoid osteoma is usually a 1 cm sclerotic lesion with a radiolucent center. Osteoblastoma is identical histologically, but larger. The usual presentation is with nocturnal pain relieved by salicylates. Radicular involvement may be present and osteoblastoma may cause cord compression.

Eosinophilic granuloma is a localized form of histiocytosis X. It is usually seen in an adolescent with thoracic back pain. Radiographs usually show a well-circumscribed area of osteolysis. Neurological deficits are rare; localized lesions have good prognosis.

Anneurysmal bone cyst: One-fifth of these lesions affect the spine. It is typically seen in an adolescent with back pain or painless scoliosis. MRI usually identifies soft tissue extension and neural compression.

Malignant vertebral tumors include:

Ewing’s sarcoma is the most common malignant tumor. Back pain may be accompanied by fever and other systemic features.

Primary lymphomas: Hodgkins and non-Hodgkins may involve the spine. Spinal metastases in neuroblastoma may present with back pain.

Intraspinal tumors are very rare. One-fourth are intramedullary, usually astrocytomas, one-fourth are extramedullary such as neurofibromas, lipomas, dermoid cysts. Most are extradural, spreading from adjacent vertebra [15]. Patients present with back pain, limp, bladder or bowel changes, and neurological symptoms.

 

 

Hemoglobinopathies

Patients with sickle cell disease may present in vaso-occlusive crisis with back pain.

Psychogenic

Psychological cause of back pain is extremely rare in pediatrics; even if suspected, a thorough history and physical and appropriate diagnostic tests should be undertaken to exclude organic causes [6]. Conversion hysteria is seen in pubescent girls with bizarre exaggerated symptoms inappropriate to organic pathology.

Other disorders

Dysmenorrhoea, cystic fibrosis, Cushing’s disease, and retroperitoneal disorders are some of the other causes of back pain [5].

Evaluation

In evaluating back pain in children, neurological involvement should be ruled out first. Questions regarding incontinence or bedwetting should be asked because patients or parents may not readily volunteer such information. Queries should be made regarding changes in gait, balance, and co-ordination. History of trauma, systemic symptoms such as fever, weight loss, fatigue, and poor appetite should be asked. Any patient awakened by pain must be considered to have tumor, infection, or inflammatory condition. Physical examination should include percussion of the spine, ribs, flanks, rectum, and genital examinations. A thorough neurological examination is the key. Gait pattern should be examined.

In cases where the cause remains unknown after a thorough history and physical examination, it is appropriate to proceed to imaging studies, especially in children under 4 years of age. Plain films are more likely to be revealing in children with back pain than in adults. Oblique views should be included, along with the standard two views to assess the integrity of pars interarticularis.

Bone scintigraphy is most useful for definition of osteomyelitis and discitis. Radiolabeled WBC scans may detect paraspinal infection or abscess.

A CT scan remains a useful method for emergent evaluation of trauma or when lesions outside the spine are suspected.

An MRI is preferred for evaluation of possible intraspinal pathology and provides detailed longitudinal images of the spine, the canal, the cord and other tissues.

Laboratory investigations are directed by presentation.

(JEM April 2003)

 

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