Recognize common presentations of pediatric orthopedic emergencies - PDF document

Andrea Marmor, MD Associate Clinical Professor, Pediatrics UCSF – San Francisco General Hospital  Recognize common presentations of pediatric orthopedic emergencies  Practice evidence ‐ based diagnosis and treatment strategies for pediatric orthopedic emergencies

 Panda is a 16 mo old girl brought to the ED for “crying nonstop”  She has been “not herself” for about a week, refusing to walk, always wants to be held, screams with diaper changes, and sleeping poorly  This evening, unable to fall asleep, so brought to ED  T= 38, P 160 (crying), R 32, BP 100/60  Well ‐ appearing, consolable when held, non ‐ toxic, supple neck  Full rotation at knee, ankle, hip  No tenderness or swelling of joints or bones  Screams when put on back on table, and when manipulating legs  ? tenderness over middle of spine, normal neuro exam

A. CBC, CRP, ESR B. AP and frog ‐ leg view of hips C. Aspiration of hip D. Plain films and MRI of spine E. Lumbar puncture MRI lumbar spine: diffuse bony edema of L4 and L5, with enhancement of the disc. T1 +contrast (left) and T2 (right). (from Arthurs et al, 2009)

 Inflammatory/infectious etiology  Diagnosis commonly delayed  Refusal to walk/sit/limp/crying > back pain  Recent 18 year series (Fernandez, 2000)  Mean age: 2.8 years  Only 28% febrile  Mean days of symptoms = 22 Fernandez, Pediatrics, 2000  Diagnostic pearls:  Inflammatory markers poor predictors (may be normal)  MRI best sensitivity/specificity ▪ 76% seen on plain film (narrowing of disc @ 2 ‐ 4 wks)  Consider scintigraphy – sensitive but non ‐ specific  Management  Blood cultures rarely positive  Parenteral antibiotics (vanco, clinda) recommended ▪ In some series, patients did well without antibiotics  Follow ESR/CRP

 Kodiak is a 4 week old boy brought in for “crying nonstop”  Seen by PCP yesterday, told it was colic  Not feeding well, and seems to cry more with the 5 S’s….  PMH: ex ‐ 32 weeker, got “a few days” of antibiotics after birth, no other illnesses  T= 36.0, P 190, R 50, BP 90/50  Very fussy, inconsolable  Flat fontanelle, well ‐ perfused, no rash  Slight erythema/warmth/swelling of left calf

NEXT STEPS?  This is an ill ‐ appearing, hypothermic neonate  You obtain blood cultures, a CRP/ESR and an LP  Plain film of left leg:  Osteomyelitis of the tibia  Hematogenous most likely cause in pediatrics  Multifocal disease > in neonates/S. aureus  Diagnosis:  CBC: most helpful to R/O other conditions  ESR/CRP: variable sensitivity (normal reassuring if low suspicion); PCT may be better  Blood cultures: poor sensitivity, but helpful if +  Plain films: may show findings earlier in neonates  MRI: 97% sensitive/92% specific

 Neonatal:  S. aureus (MRSA), E, Coli, GBS (late ‐ onset)  Vancomycin and cefotaxime  Infants/kids:  S. aureus (MRSA), GAS: vancomycin  Kingella? Add cefazolin  Sickle cell? Add ceftriaxone  Gobi is a 6 mo old girl, brought in for “crying nonstop”  Usually consolable when held, but now it seems to make her cry more  Dad notes that she seems to be breathing fast, but otherwise has been afebrile, eating well, and no other symptoms  No PCP identified, but has been “healthy”

 T 37.3, P 130, R 45, O2 sat 99%  Well ‐ nourished, comfortably tachypneic, no rashes/bruises, smiles and coos when sitting in dad’s lap  Screams when you pick her up, and will not lie on her back  You are able to range all of the limbs without difficulty, the rest of the exam is normal

 Virtually pathognomonic for abuse  Can be missed on plain films  Let radiologist know what you are looking for…  Thoracic cage, sternum, scapula, spine  Metaphyseal corner lesions (MCL)/bucket handle fractures

“TODDLERS’ FRACTURE”  Consider in infant/toddler with limp  May be due to unrecognized trauma  When stable, minimal symptoms  Imaging: Multiple views may be necessary  Consider child abuse if:  Multiple fractures, < 12 mo, mid ‐ shaft fracture  13 yo Atlas has been limping for 3 mo  Complaining of L knee pain 4 months ago, but able to play soccer  Exam:  Well ‐ appearing, mildly obese male  Tanner IV, VS WNL for age

 Lies with L leg flexed and externally rotated  Obligate external rotation on flexion of L hip  Internal rotation of L hip severely limited  Knee exam normal

Normal Abnormal

 Fast facts:  Average age 11.2 in girls/12.7 in boys – decreasing ?  Usually idiopathic, 20% bilateral  Black > Hispanic > Asian > Caucasian  Diagnosis: AP and bilateral frog ‐ leg views  Management: surgical  Stable (90%) = able to weight bear  Unstable = NWB immediately (20 ‐ 50% risk of osteonecrosis)  AP view  Frog’s Leg view

 Avascular necrosis of the femoral head  Ischemia ‐ > collapse ‐ > remodeling  More common in boys, age 4 ‐ 8 at onset  Etiology: unknown (trauma, radiation, steroids may also cause ANFH)  Treatment: Immediate orthopedic referral  75% of cases resolve spontaneously with remodeling of femoral head  Ussuri is a 5 year old boy with 1 week of R knee pain and limp  Maybe fell playing soccer last week: not getting better, knee seems swollen  No previous bone/joint problems

 T39.1, non ‐ toxic, pain with weight on R leg  R leg: knee is swollen, erythematous and warm, with decreased extension/flexion  Full ROM hip and ankle  Plain films show a small joint effusion  Labs:  WBC =12,000, ESR = 15, CRP =75 mg/dL  TS = Self ‐ limited inflammation of hip/knee  Differentiation from septic arthritis?  Kocher criteria:  WBC > 12, ESR > 40, CRP > 2mg/dL, temp >38.5, unable to bear weight  Validation? Variable PPV/NPV  General principles:  No prediction rule has 100% NPV  If suspicion is low, and BOTH ESR/CRP are normal (<20; <2) ‐ > SA unlikely

 Most common cause of hip pain in kids 3 ‐ 10 years of age  Etiology unknown  Management: NSAID’s, rest  1 ‐ 2% develop LCP  Joint aspiration reveals 40,000 WBC  What is your next step?

 Steroids prior to abx:  Reduce duration of sx, treatment and hospitalization and improve long ‐ term outs  Antibiotic choice  Vancomycin for good MRSA/GAS coverage  + cefotaxime in neonate (E Coli)  + consider cefazolin for Kingella in kids < 3  + ceftriaxone in teens/sickle cell Harel 2011; Odio 2003  Nandi is a 15 yo girl complaining of R knee pain for 2 months  Pain is intermittent, improves at night  Told she has “growing pains”  No specific trauma, but has been unable to play basketball  Exam: tender mass distal R thigh, otherwise normal

A. Age 15 B. Improves at night C. Unable to play basketball D. Mass/tenderness on exam E. All of the above Codman’s triangle Calcified soft tissue mass Osteosarcoma of distal femur

 Osteosarcoma > Ewing’s  Peak age: 13 ‐ 16, boys:girls = 1.5:1  Delay in dx common: average 2 ‐ 3 mo  Clinical:  Intermittent pain, improves at night  Mass in 30 ‐ 40%  Long bones most frequently involved  Constitutional symptoms are rare Ewing’s Sarcoma: Onion ‐ skinning Osteosarcoma: sunburst reaction Pelvis> long bones

 Pedi orthopedic emergencies may present as crying, limp or refusal to walk  Consider in neonates/infants with unexplained fever  Diagnosis/Treatment:  MRI = study of choice for discitis, OM  Plain films sufficient to diagnose SCFE, LCP and bone malignancies (but get the right views!)  CRP/ESR: if normal = reassuring against septic arthritis (but get fluid if concern is high)  Steroids before antibiotics in SA enhances recovery