Case Reports

High-Risk Musculoskeletal Injuries

While supracondylar fractures are common in the pediatric population, other high-risk conditions, including those that mimic orthopedic injury, should be considered based on patient symptoms and imaging studies.

Emergency Medicine. 2014 September;46(9):416-421

Author(s):

Kathryn Hewett, MD

M. Olivia Titus, MD

References

Bachman D, Santora S. Orthopedic trauma. In: Fleisher GR, Ludwig S, et al, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1538.
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Slack SE, Clancy MJ. Clearing the cervical spine of paediatric trauma patients. Emer Med J. 2004;21(2):189-193
Brown M. Hussain K, McHugh K, Novelli V, Jones D. Discitis in young children. J Bone Joint Surg. 2001;83(1):106-111.
Cushing AH. Diskitis in children. Clin Infect Dis. 1993;17(1):1-6.
Selbst SM, Lavelle JM, Soyupak SK, Markowitz RI. Back pain in children who present to the emergency department. Clin Pediatr (Phila). 1999;38(7):401-406.
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Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. J Bone Joint Surg Am. 2008;90(3):656-671.
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Case

A 2-year-old girl was carried into the ED after falling off her bed earlier in the evening. The parents did not see the child fall, but heard her crying in her room. On physical examination, the patient was in a lot of pain, would not move her left arm, and had a left elbow effusion. The radial pulse was strong, and she was able to move all of her fingers but would not move her elbow. A lateral X-ray taken of the left elbow is shown below (Figure 1).

Supracondylar Fractures

Supracondylar fractures are the most common pediatric elbow injury and disposition can range from outpatient follow-up to urgent surgical intervention. The average age of presentation is between 3 to 10 years, and the injury typically results from a fall on an outstretched hand (FOOSH) with hyperextension of the elbow. Supracondylar fractures may also occur after a direct blow to the elbow or hyperflexion.¹

The supracondylar area in children, the distal portion of the humerus, is thin and weak. The force transmitted to this region by a direct blow or FOOSH injury can fracture the humerus. The brachial artery runs along the anterior humerus and can easily sustain injury. Median, ulnar, or radial nerve injuries are also common and can result in permanent disability.² Immediate neurovascular examination is mandatory, and diminished or absent pulses, poor perfusion, and pallor are signs of ischemia. Examination should include assessment of the radial pulse and the sensory and motor function of the median, radial, and ulnar nerves. To test the median nerve (via the anterior interosseous branch), ask the patient make an “OK” sign with his or her fingers; to test the radial nerve, instruct the child to make a “thumb’s up” sign; and to test the ulnar nerve, have the child hold his or her fingers spread-out against resistance. In addition, sensation of the palmer and dorsal surfaces and in between the fingers should be confirmed.

Plain radiographs, including anteroposterior (AP), oblique, and true lateral views, should be obtained. Interpretation of pediatric elbow films can be difficult, and the stages of ossification must be considered. The helpful acronym for remembering the order of bone ossification is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, and external [lateral] epicondyle) (Table 1).

If the anterior humeral line—a line drawn through the anterior cortex of the humerus—fails to intersect the capitellum in its middle third, fracture of the distal humerus is present (Figure 2). The radial head should be aligned with the capitellum. Close inspection for a posterior fat pad, or “sail sign” is imperative as it indicates hemorrhage, joint effusion, or occult fracture. The presence of an anterior fat pad can be a normal variant; however, if the pad is wide and creates a “sail sign” then fracture must be assumed.¹

Fracture Types

Pediatric supracondylar fractures are classified into three types (Table 2). Type I fractures may be subtle on X-ray, evident only by a posterior fat pad or only seen on an oblique view. These nondisplaced fractures may be splinted with a long-arm splint. Type II fractures are angulated yet the posterior cortex remains intact. Typically the anterior humeral line is displaced, anteriorly intersecting the anterior third of the capitellum or missing it entirely. These cases require urgent orthopedic consultation for either closed reduction with splinting or open reduction with percutaneous pin placement.

Type III supracondylar fractures are completely displaced with a fracture through the anterior and posterior cortex. Since a high-risk of injury to the upper extremity vessels and nerves is associated with these very unstable fractures, routine neurovascular checks (while awaiting operative repair) are required. Supracondylar fractures are often associated with forearm or distal radius fractures; therefore, forearm radiographs should also be obtained.³

Diskitis

Diskitis is defined as inflammation or infection of the intervertebral disk. Though etiology is debated, Staphylococcus aureus is confirmed in up to 60% of cases.⁴ This infection has been described by some as being on the spectrum of vertebral osteomyelitis. Though rare, delayed diagnosis of diskitis can result in significant morbidity. Incidence peaks in early childhood between ages 3 to 5 years but may present at any age with back pain, limp, or refusal to walk. Most commonly, the lower lumbar disks are affected. Examination may reveal decreased muscle strength or reflexes, refusal to bend forward, hip pain, or tenderness of the spine. Although white blood cell (WBC) count is typically normal, more than 90% of patients with diskitis have an elevated erythrocyte sedimentation rate. X-rays usually appear normal until 2 to 3 weeks after symptoms begin, at which time narrowing of the joint space can be seen. Magnetic resonance imaging is required for diagnosis (Figure 3), and orthopedics should be consulted for possible aspiration for culture. Empiric antibiotic therapy includes an antistaphylococcal agent (eg, nafcillin/oxacillin, clindamycin, vancomycin) and a third-generation cephalosporin (eg, cefotaxime, ceftriaxone).⁵