Lower ExtremityInjuries in Children

Jonathan Pirie, MD, MEd, FRCPC, FAAP (PEM)

KEC 2015-05

10 y.o. male with thigh pain, limp

Case • 10 year old male

• 3 week history of right thigh and knee pain

• Seen by family M.D. - X-rays - N

• No history of trauma

• Missing school

• Physical exam Wt. 82.5 kg

• limp

• decrease internal rotation, flexion of hip

Abnormal Klein’s LineNormal

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

• X-ray – may not be apparent on AP – frog-leg view

• Rx: Immediate Ortho referral

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 JumperHip-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

Femur Fractures• 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

Knee Injuries

• Ligamentous injuries uncommon, but do occur • X-ray 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 #

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

• X-ray – 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

• X-ray – 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

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

Mag view day 1 & 7

Toddler’s Fracture• Typically seen in children 9 - 36 mo. • Clinical

– refusal to walk or limp – often minor accident or no injury recalled

• X-ray – 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

• X-ray

• 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

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

Copyright © 2007 by the American Roentgen Ray Society

Brown, S. D. et al. Am. J. Roentgenol. 2004;183:1489-1495

Reformatted CT images in 14-year-old girl can show appearance of characteristic Salter-Harris fracture patterns emulated in triplane fractures

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