Presenting Signs and Symptoms

Children refuse to use the affected arm and hold it close to the body and in slight flexion. They do not appear to be in particular distress but may be fearful that examination will elicit pain. There is no tenderness with palpation or bony or soft tissue abnormality. Radiographs are unnecessary unless another particular injury is suspected. Edema and tenderness are present with supracondylar fractures.

A number of reduction techniques are used, including the hyperpronation method and the supination-flexion method. The hyperpronation method has proved more effective and appears to be less traumatic.¹ With the arm held in extension, the wrist is hyperpronated and a click is sometimes heard. In the supination-flexion approach the examiner places the thumb of one hand over the radial head and provides countertraction. Next, while holding the wrist, the elbow is pulled into extension. The final phase is supination and flexion at the elbow. Most children return to full functioning within 15 minutes, and the child should be observed until full range of motion is regained.

When multiple reductions fail, radiography should be considered. In a child with failed reduction and negative radiographic findings, a sling or posterior splint is necessary with close orthopedic follow-up.

Salter-Harris Classification of Fractures

The most commonly used system to identify physeal injuries is the Salter-Harris classification. Fractures are categorized as types I through V, with the higher numbers having the greater risk for growth abnormalities. All such injuries require pediatric orthopedic follow-up.²

Type I fractures result from a longitudinal force through the physis that splits the epiphysis from the metaphysis. Radiographs may reveal a widened growth plate. Identification can be difficult, particularly when the displacement is minimal, and a fracture should be suspected in children with tenderness along the physis even in the absence of radiologic findings. Type I fractures rarely result in growth disturbances and can be treated effectively with immobilization.

Type II fractures, the most common type, occur when a piece of the metaphysis remains attached to the epiphysis (Fig. 25.3). They require splinting and generally carry a good prognosis. Types III and IV are intraarticular fractures that also involve the growth plate. In a type III injury, the fracture line extends through the epiphysis into the physis. In type IV, the fracture passes through the epiphysis, physis, and metaphysis. Types III and IV carry a risk for growth retardation, altered joint mechanics, and functional impairment and thus require urgent orthopedic evaluation. Type V fractures are compression injuries and are difficult to visualize on radiographs. The diagnosis is often made retrospectively following a case of growth arrest.

Fig. 25.3 Type II Salter-Harris fracture at the metacarpophalangeal joint of the thumb.

Toddler’s Fractures

Toddler’s fractures are nondisplaced oblique or spiral fractures through the distal end of the tibia. Questioning may not reveal any significant injury, just that the child might refuse to bear weight after a day playing at the park. Findings on physical examination can range from entirely benign to diffuse tenderness along the tibial shaft. The absence of edema and ecchymosis is commonplace and not surprising. Gentle twisting of the lower part of the leg may elicit pain as the fracture plane is opened. Radiographic findings are subtle, and multiple views, including anteroposterior (AP), lateral, and oblique images, may be necessary. In the event of negative findings, a bone scan may be considered.

If the symptoms persist, one may choose to repeat the films in 7 to 10 days to look for new subperiosteal bone formation. Immobilization is sufficient to promote healing. When the child limps and radiographic findings are negative, a fracture or injury in another location should be considered. Varied pathology, including appendicitis, toxic synovitis, septic arthritis, foot and ankle fractures, soft tissue injuries, and abuse (Box 25.1), may all be manifested as a limp in a toddler.

Supracondylar Fractures

Supracondylar fractures are the most frequent elbow fractures in children and often occur in children 3 to 10 years of age. The most common mechanism is a fall onto an outstretched hand with the elbow hyperextended.

Classification of the types of supracondylar fractures is based on the extent of the injury: type I is nondisplaced (Fig. 25.4), type II is displaced posteriorly with an intact cortex (Fig. 25.5), and type III is completely displaced with no cortical contact (Fig. 25.6). Type I injuries are managed by immobilization for 4 to 6 weeks. Treatment of type II injuries is based on the extent of the damage, and an orthopedist should be consulted. More severe cases require admission, reduction, and internal fixation, but milder cases may be treated as type I injuries. All type III fractures require closed reduction with pinning in the operating room.

Fig. 25.4 Type I supracondylar fracture.

The anterior humeral line does not intersect with the capitellum. A subtle fracture is visible along the anterior surface of the humerus.

Fig. 25.5 Type II supracondylar fracture.

Fig. 25.6 Type III supracondylar fracture.

Radiographic findings may be subtle, particularly in type I injuries (Box 25.2). When a fracture line cannot be visualized easily, other findings may assist in making the diagnosis. A posterior fat pad or joint effusion located dorsal to the distal end of the humerus at the level of the olecranon fossa is always pathologic and evidence of a fracture. An anterior fat pad is normal unless it is lifted up and squared off inferiorly into a “sail sign.” A line drawn along the anterior surface of the humerus should intersect the capitellum in its middle third. Posterior displacement of the distal end of the humerus will cause the line to fall further anteriorly or miss the capitellum entirely.

With more severe injuries, the difficulty is not in making the diagnosis but rather recognition and reduction of complications. Morbidity includes range-of-motion abnormalities, neurovascular compromise, and long-term deformities. A thorough examination and documentation of neurovascular status, pain control, and stabilization are mandatory. The limb should be splinted in the deformed position. Motor and sensory function of the median, ulnar, and radial nerves is at risk. Direct vascular injury is uncommon, but because a potential for compartment syndrome does exist, examinations should be repeated frequently and recorded.³

Presenting Signs and Symptoms

Pain and limp are the most common reasons for seeking care in the emergency department, and symptoms may have been present for weeks to months. Pain, which can range from dull and intermittent to severe and persistent, can be present in the hip or referred to the knee, groin, or anterior aspect of the thigh. Sometimes a history of trivial trauma prompts medical evaluation. Physical examination reveals a hip in flexion with mild external rotation. Range of motion is limited, especially full flexion, medial rotation, and internal rotation.

Diagnostic Testing

Radiographic studies should include both AP and frog-leg views because an AP view alone may miss the diagnosis. On the AP view of a normal hip, a line drawn along the superior margin of the femoral neck cortex should transect the epiphysis by a small margin. With a slipped capital femoral epiphysis, the line passes outside the epiphysis or just at the superior edge. Contralateral images or full pelvic views are helpful; however, up to 25% of cases of slipped capital femoral epiphysis are bilateral.

Treatment

Diagnosis of slipped capital femoral epiphysis necessitates urgent orthopedic evaluation. Management is surgical and consists of placing screws through the femoral neck into the epiphysis. Delay in diagnosis or management may lead to avascular necrosis and long-term disability.

Presenting Signs and Symptoms

The disease is initially clinically silent and may come to medical attention incidentally as a result of trauma. The onset of symptoms is usually insidious. Pain may be present in the hip or be referred to the hip, knee, anterior aspect of the thigh, or groin. Tenderness is rarely present, and symptoms include an antalgic gait with decreased hip abduction and medial rotation.

Diagnostic Testing

AP and frog-leg views of the pelvis allow optimal visualization of the femoral head. Disease findings include widening of the articular cartilage, subchondral fractures, irregularity, and flattening of the epiphysis.

Treatment and Disposition

Treatment includes pain management with nonsteroidal antiinflammatory drugs (NSAIDs) and referral to a pediatric orthopedic surgeon. The majority of children with this disease do well with observation and nonsurgical intervention.⁴

Presenting Signs and Symptoms

Children suffering from septic arthritis are frequently ill appearing with a fever of 104° F (40° C) or higher, limited range of motion in the affected joint, and pain and swelling.⁵ The pain is constant and increases with movement. In the case of septic arthritis of the hip, the child lies in a position of comfort with the hip slightly flexed, abducted, and externally rotated. An infected knee will be erythematous, edematous, warm, and tender to palpation.

Diagnostic Testing

Plain radiographs, a complete blood count, erythrocyte sedimentation rate, C-reactive protein, and blood culture are necessary in the evaluation of children with suspected septic arthritis. Radiologic findings include joint space widening, soft tissue swelling, and displacement of adjacent fat pads. Comparison views may be helpful because a difference of only a few millimeters from the teardrop of the acetabulum to the medial metaphysis of the femoral neck may be significant. In young children, lack of ossification limits the usefulness of radiographs, and ultrasonography provides more detail.

A convincing clinical or laboratory picture justifies joint aspiration for fluid analysis, including protein, glucose, Gram stain, and culture. Joint fluid yields a positive culture in approximately 50% to 75% of cases. Blood culture is much less effective and is positive in approximately one third of cases.

Treatment

Definitive therapy is intravenous administration of antibiotics and surgical drainage of purulent material from the joint. Because the potential for joint destruction is great and the yield of Gram stain is low, empiric antibiotic therapy in the emergency department is indicated. Coverage should include an antistaphylococcal agent, either a β-lactamase–resistant penicillin, clindamycin, or a first-generation cephalosporin. Gram-negative coverage should also be considered for neonates.

Presenting Signs and Symptoms

Although patients will sit in a position of comfort and complain with movement of the limb, the affected joint has full range of motion.⁵ This is in stark contrast to septic arthritis, in which the child appears systemically ill, is in significant pain, and cannot move the affected join through full range of motion.⁶

Diagnostic Testing

The white blood cell count, erythrocyte sedimentation rate, and C-reactive protein findings are usually normal or slightly elevated, consistent with an inflammatory process.⁵ Radiographs are often normal or may reveal a mild effusion with joint space widening. Because sufficient overlap exists in some manifestations of septic joint and toxic synovitis, synovial fluid is necessary to make the diagnosis (Table 25.1). When obtained, synovial fluid is sterile.

Table 25.1 Septic Arthritis versus Toxic Synovitis

Data from Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999;81:1662-70.

Treatment

Treatment is directed at relief of symptoms with NSAIDs on an outpatient basis. Pain usually lasts 3 to 4 days but may persist for a few weeks. Children return to full activity with no associated morbidity.