Peds Orthopedics ================ þ Elbow Fractures - An anterior fat pad with an angle with the humerus of <19 degrees is very accurate at ruling out fractures. [Blumberg, S. M., S. Kunkov, et al. (2011). "The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children." Pediatr Emerg Care 27(7): 596-600.] OBJECTIVE: The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture. METHODS: A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow- up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture). RESULTS: Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P < 0.01). CONCLUSIONS: Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP. þ Wrist Fractures - A removable splint worn for comfort is appropriate treatment for a distal radius buckle fracture in a child. For pediatric distal radius fractures requiring reduction, further research is required to determine the optimal treatment to ensure a good functional (and cosmetic) outcome. In particular, a comparison between closed reduction with a below-elbow cast and percutaneous wire fixation is needed. [Sherbino J. How Do I Treat Pediatric Wrist Fractures? Annals of emergency medicine 2009;54:541-2.] þ Chip = Corner = Bucket Handle fracture - avulsion at edge of growth plate - from being flung about more than direct trauma - almost pathognomonic for abuse þ Salter Classification Salter I: through cartilage of physis Salter II: bit of shaft attached to distal portion Salter III: distal portion broken in two Salter IV: distal portion AND shaft broken in two through cartilage Salter V: cartilage crunched (flattened) þ "Little League Elbow": - overuse injury - splint and refer, as more serious than similar overuse in adults. þ Bowing (plastic) fractures - just bowing of a bone, mostly occur in clavicle and forearm þ Nursemaid's Elbow - Best way to reduce is to place your thumb over the radial head, grab the wrist, and slowly pronate. (94% success vs. 77% with supination) [Pediatrics 1998:102:e10] - The literature is pretty consistant in finding a recurrence rate of about 25%. Nearly half of the cases may be unrelated to a 'pull' mechanism of injury. [Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med 1990 Sep;19(9):1019-23.] Abstract: - Feeling a 'click' during the reduction almost always correlates with ability to use the extremity within 30 minutes. Delayed use of the arm may be associated with age less and 2 years [Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med 1990 Sep;19(9):1019-23.] Abstract: and presentation less than 2 hours after injury. [Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J Dis Child 1985 Dec;139(12):1194-7.] Abstract: --H. Louzon MD þ Knee Pain - Osgood-Schlatter disease: avulsion of small pieces of the tibial tubercule by the patellar tendon, mostly boys 11-15. Treatment is mostly just rest. - Sinding-Larsen-Johansson Disease: same thing only of the inferior pole of the patella. Mostly ages 10-12. Treatment the same. - Osteochondritis Dissecans: ischmic changes of subchondral bone. Usually boys ages 10-14. Low-grade pain, swelling, catching, an/or instability. - Bipartite patella: may cause pain after trauma or repetitive microtrauma. Found in 2-3% of normals, M:F ratio 9:1. Characteristics: tender over superolateral patella. X-ray: superolateral, smooth, sclerotic border, often bilateral. Treat with rest and immobilizer. - Medial Plica syndrome: remnant embryonic band, causes medial peripatellar pain that is worse with sitting squatting, or repetitive knee flexion. Also tightness, snapping, catching, weakness, or giving way. Plica is palpable at the anteriomedial femoral condyle and medial patellar facet. May "snap" with active knee extension. - Discoid meniscus: meniscal injury is rare in children, so if has clinical syndrome of meniscus injury, suspect the structural abnormality of a discoid meniscus. Although found in 1-5% of population, mostly asymptomatic. Less than 2% are medial. Usually age 10-20. þ Elbow fractures in kids: - ossification of elbow: ossify in this order, at ages 1,3,5,7,9,11 years CRITE: Capitellum, Radius, Internal (medial) condyle, Trochlea, Olecranon - most common fractures: + supracondylar + lateral condyle + medial epicondyle avulsion fracture þ Slipped capital femoral epiphysis - Frogleg view: better for showing slipped epiphysis in hip due to the direction it tends to slip.