Case. Abnormal Klein s Line. Lower Extremity Injuries in Children. 10 y.o. male with thigh pain, limp. Slipped Femoral Capital Epiphysis

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1 10 y.o. male with thigh pain, limp Lower Extremity Injuries in Children Jonathan Pirie, MD, MEd, FRCPC, FAAP (PEM) KEC Case Abnormal Klein s Line 10 year old male 3 week history of right thigh and knee pain Normal Seen by family M.D. - X-rays - N No history of trauma Missing school Physical exam Wt kg limp decrease internal rotation, flexion of hip Slipped Femoral Capital Epiphysis Typically male adolescent, overweight Clinical acute or chronic, hip, groin, anterior thigh or knee pain P/E - limitation of internal rotation, flexion and abduction of hip may not be apparent on AP frog-leg view Rx: Immediate Ortho referral

2 5 yo with a limp x 3 weeks Legg Calve Perthe s Disease The etiology: vascular insufficiency Ages 4 and 8 with a distinct male predominance. Bilateral in about 10% of cases, with the hips involved sequentially, not simultaneously. Management: outpatient referral to Ortho Adolescent printer stops suddenly Pain in R Hip Avulsion # ASIS Avulsion # AIIS Avulsion # Ischial Tuberosity in a Jumper Hip-Pelvis Avulsion Fractures Most common in adolescents Mechanism: sudden, forceful, concentric or eccentric contraction of a large muscle in an attempt to accelerate or decelerate May feel a pop at time of injury Activities: runners, soccer players, jumpers Rx: rest, pain relief, non-urgent Ortho referral

3 Femur Fractures Knee Injuries commonest site: femoral shaft - middle third torsional force produced by indirect violence: long spiral or oblique # transverse # is caused by direct trauma DDx: abuse, bone tumour In both cases story doesn t correlate with findings Management: Immediate ortho referral Thomas splint for transport Ligamentous injuries uncommon, but do occur unless very trivial injury Common injuries distal femoral physis, tibial spine, tibial tubercle, patella, proximal tibial physis Hemarthrosis consider patellar dislocation with an osteochondral fracture or a tibial spine fracture Management: in most cases knee injuries can be immobilized and referred to Ortho in 7-10 days. Case 11 year old boy Skiing - fell, twisted knee Physical Exam hemarthrosis painful knee, unable to weight bear Tibial Spine # Tibial Spine #

4 Fracture Tibial Spine Pediatric equivalent of cruciate ligament injury Mechanism of injury hyperflexion of knee during fall Clinical marked pain, refusal to weight bear hemarthosis tunnel view Case: 17 year old male with cerebral palsy attempted to stand up from his chair, he turned his body and his knee buckled. He heard a crack Fell onto the tile floor landing on the lateral aspect of his left knee. His left knee is visibly deformed His patella is displaced laterally. Patella Osteochondral fracture associated with patellar dislocation Patellar Dislocations Risk Factors: Adolescent females Hypermobile joints associated osteochondral fractures of lateral femoral condyle or inferior surface of patella skyline or tunnel views Rx: reduction: extension of the knee with medial pressure on the patella immobilization in an above-the-knee posterior splint or a commercially available immobilizer Follow-up: non-urgent referral to Ortho

5 Case 14 mo. old boy fell down stair refusing to walk Physical exam difficult to examine favouring left leg good range of motion hips, ankles, knees Toddler s Fracture Mag view day 1 & 7 Typically seen in children 9-36 mo. Clinical refusal to walk or limp often minor accident or no injury recalled spiral fracture of the distal tibia may be normal Rx: immobilization in below-knee slab/cast f/u with Ortho 7-10 days Ankle Injuries Sprains uncommon with open epiphyseal growth plates three views if unsure but clinically suspicious Most common injury is SH - I unless minimally tender below knee back-slab or ankle brace duration of back slab usually 3 weeks Ankle brace for 5 days non-weight bearing then as tolerated All heal without complication yet the duration of symptoms vary considerably. Case 11 year old girl playing dodgeball, fell backwards, inversion injury ankle Physical exam soft tissue swelling and tenderness over lateral malleolus unable to weight bear

6 Tillaux Fracture (S-H type III) Occurs in adolescents as the medial tibial physis begins to close Orthopedic referral If displaced: will required open reduction & fixation Reformatted CT images in 14-year-old girl can show appearance of characteristic Salter- Harris fracture patterns emulated in triplane fractures Brown, S. D. et al. Am. J. Roentgenol. 2004;183: Copyright 2007 by the American Roentgen Ray Society

7 Triplane Fractures Salter Harris IV fracture Tillaux plus a type II Name derives from the fact that the fracture exists in the frontal, lateral, and transverse planes Unstable and requires immediate Ortho referral