case abnormal klein’s line - kindercare pediatrics · lower extremity injuries in children...
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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