Others 2 PENGELOLAAN CEDERA KEPALA DAN CEDERA TULANG BELAKANG DIDAERAH YANG JAUH DARI SARANA BEDAH SARAF.

EPIDEMIOLOGI. Insidens Neurotrauma bertanggung-jawab atas 70% kematian dijalan-raya serta 50% kematian karena trauma. KLL merupakan 50-60% dari semua trauma kepala. Cedera traumatik penyebab kematian ketiga dinegara dengan kendaraan bermotor. Insidens tertinggi dari pasien berusia dibawah 45 tahun ke RS adalah akibat trauma. CEDERA SISTIM SARAF. FAKTOR YANG MEMPERBURUK OUTCOME. 1. 1. BERATNYA CEDERA PRIMER. 2. 2. KOMPLIKASI INTRAKRANIAL. 3. 3. HIPOKSEMIA. 4. 4. HIPERKARBIA. 5. 5. HIPOTENSI. 6. 6. ANEMIA. 7. 7. CEDERA GANDA. 8. 8. USIA. 9. 9. WAKTU PRA RUMAH SAKIT YANG LAMA. 10. 10. MASUK KE R.S. YANG TIDAK MEMADAI. 11. 11. RUJUKAN TERLAMBAT / TIDAK MEMADAI. 12. 12. OPERASI DEFINITIF TERLAMBAT. Penyebab kematian atau kecacadan yang dapat dicegah : 1. Keterlambatan resusitasi primer terhadap hipoksia, hipercarbia dan hipotensi. 2. Keterlambatan tindakan bedah-saraf definitif terutama pada hematoma intrakranial yang berkembeng cepat. Termasuk diagnostik, komunikasi dan tansportasi. 3. Infeksi kranioserebral. Cedera ganda memiliki masalah kompleks dan menyebabkan kematian dua kali cedera tunggal. Kelainan neurologis menunjukkan disfungsi otak berat. Pasien diatas 50 tahun bisa mengalami komplikasi intrakranial akibat cedera minor. MEKANISME CEDERA KEPALA. 1. 1. AREA ANATOMIS yang mengalami cedera manentukan outcome & komplikasi. 2. 2. JENIS CEDERA pada area tertentu menimbulkan pola cedera tertentu. AKSELERASI-DESELERASI.

IMPAK LOKAL. PENETRATING. CRUSH INJURY. 3. 3. PATOLOGI CEDERA KEPALA : A. A. PRIMER : SCALP. FRAKTURA. MENINGS. OTAK. B. B. SEKUNDER : PERDARAHAN INTRAKRANIAL. PEMBENGKAKAN OTAK. HIPOKSIA OTAK. KEBOCORAN CSS DAN PNEUMOSEFALUS. KELAINAN METABOLIK. INFEKSI. EPILEPSI. 4. 4. EVOLUSI CEDERA. Perburukan dengan bertambahnya waktu akan merubah pola tindakan. PERAWATAN PRA RUMAH-SAKIT. FAKTOR YANG MEMPENGARUHI OUTCOME harus dapat perhatian utama. POSISI PASIEN TIDAK SADAR. Posisi lateral dengan wajah agak diputar kearah bawah. INTUBASI TRAKHEAL. Bila GCS 8 atau gangguan jalan nafas. CEDERA SPINAL Cedera spinal leher dengan gangguan jalan nafas, mengatasi jalan nafas merupakan prioritas. PENGELOLAAN CEDERA KEPALA DI R.S. PENGELOLAAN DINI CEDERA BERAT. 1. A. B. C. D. E. 1. SURVEY PRIMER : Jalan nafas dan immobilisasi C-spine. Pola dan adekuasi pernafasan. C. Sirkulasi dan perdarahan. D. Disabilitas : AVPU/GCS, pupil. E. Exposure. Cegah hipotermia.

2. 2. RESUSITASI : A : PASTIKAN PATEN / INTUBASI. B : VENTILASI ADEKUAT/MESIN/OKSIGEN. C : PERFUSI / HENTIKAN PERDARAHAN.

NILAI REAKSI TERHADAP RESUSITASI : T/N/WARNA KULIT/REFILL KAPILER/ OUTPUT URIN. N.G.T/KATETER BILA TIDAK K.I. Survei primer dan resusitasi dilakukan bersamaan. Hipotensi jarang karena cedera kepala, kecuali pada anak-anak dengan perdarahan scalp atau cedera kepala. Pikirkan penyebab lain atau cedera kord spinal. Kadang-kadang bisa oleh cedera medulla. 3. 3. SURVEY SEKUNDER : GCS DAN CEDERA EKSTERNAL KEPALA. T/N/R/S. KEPALA HINGGA KAKI. NILAI ULANG GCS. PEMERIKSAAN RADIOLOGIS. PENILAIAN KHUSUS BEDAH SARAF. A. RIWAYAT : A. A. PENYEBAB CEDERA. B. B. KEHILANGAN KESADARAN. C. C. RESPONS PUPIL. D. D. KARDIORESPIRATOR DAN RESPONS ATAS RESUSITASI. E. E. RIWAYAT OBAT/ALKOHOL. F. F. PENYAKIT, CEDERA SEBELUMNYA. B. PEMERIKSAAN SARAF PUSAT : A. A. GCS. B. B. RESPONS PUPIL. C. C. POLA MOTOR. D. D. INSPEKSI WAJAH DAN SCALP. E. E. PALPASI WAJAH, SCALP, # DEPRESSED. F. F. PALPASI SPINE. Riwayat dan pemeriksaan adalah untuk membandingkan bila terjadi perburukan. INDIKASI CT SCANNING : 1. 1. SETELAH RESUSITASI GCS 8. 2. 2. PERBURUKAN GCS 2, HEMIPARESE, JULING. 3. 3. NGANTUK ATAU BINGUNG (GCS 9-12 > 2 JAM). 4. 4. NYERI KEPALA/MUNTAH MENETAP. 5. 5. TANDA NEUROLOGIS FOKAL. 6. 6. JELAS / DIDUGA FRAKTURA. 7. 7. JELAS / DIDUGA CEDERA PENETRATING. 8. 8. USIA > 50 TAHUN. 9. 9. PENILAIAN POST OPERATIF.

CT dilakukan pada semua kasus kecuali cedera kepala ringan. Perburukan yang cepat mungkin memerlukan tindakan bedah segera tanpa membuang waktu untuk CT. INDIKASI SKULL X-RAY : 1. 1. KEHILANGAN KESADARAN, AMNESIA. 2. 2. NYERI KEPALA MENETAP. 3. 3. TANDA NEUROLOGIS FOKAL. 4. 4. CEDERA SCALP. 5. 5. DUGAAN CEDERA PENETRATING. 6. 6. CSS / DARAH DARI HIDUNG / TELINGA. 7. 7. DEFORMITAS TENGKORAK TAMPAK/TERABA. 8. 8. KESULITAN PENILAIAN : ALKOHOL / OBAT / EPILEPSI / ANAK-ANAK. 9. 9. GCS 15 TAPI BENTURAN LANGSUNG & KERAS. Didaerah rural dimana CT tidak tersedia, foto polos mungkin memberi informasi. Buat posisi AP/lateral/Towne dan tangensial daerah impak. Foto polos berguna untuk penilaian triase. Fraktur mempengaruhi tindakan : 1. Karena ada kemungkinan perdarahan, perlu CT. 2. Fraktur terbuka termasuk basis meninggikan risiko infeksi. Fraktur depres meningkatkan kemungkinan kejang, tu. Bila laserasi dura. 3. Fraktur menunjukkan sisi operasi pada pasien dengan perburukan cepat karena perdarahan ekstradural. 4. 4. TINDAKAN DEFINITIF. PERSIAPAN UNTUK TRANSFER PASIEN. KRITERIA RAWAT : 1. 1. BINGUNG / SETIAP PENURUNAN GCS. 2. 2. TANDA ATAU GEJALA NEUROLOGIS. 3. 3. KESULITAN PENILAIAN KLINIS. 4. 4. KELAINAN MEDIS LAIN. 5. 5. FRAKTURA TENGKORAK. 6. 6. KELAINAN PADA CT. 7. 7. TIDAK ADA PENGAMAT DILUAR R.S. 8. 8. USIA LEBIH DARI 50 TAHUN. 9. 9. ANAK-ANAK SESUAI PROTOKOL ANAK. Pasien dengan kehilangan kesadaran kurang dari 5 menit atau yang tidak termasuk daftar, tidak dirawat bila telah melewati waktu 4 jam sejak kejadian. Namun diawasi dirumah dan kembali ke RS bila timbul kelainan sesuai daftar pada lembar instruksi pasien pulang. INDIKASI TRANSFER PASIEN : 1. 1. GCS 8 SETELAH RESUSITASI. 2. 2. PENURUNAN GCS 2. 3. 3. TANDA-TANDA NEUROLOGIS FOKAL. 4. 4. CEDERA PENETRATING.

5. 5. FRAKTURA DEPRESSED. 6. 6. FRAKTURA TERBUKA. 7. 7. NYERI KEPALA, MUNTAH, BINGUNG MENETAP > 2 JAM SETELAH MASUK R.S. 8. 8. FRAKTURA DENGAN DEFISIT NEUROLOGIS. 9. 9. FRAKTURA BASIS. 10. 10. DITEMUKAN KELAINAN PADA CT. Tidak dilakukan transfer pada mati batang otak. INFORMASI PASIEN UNTUK TRANSFER : 1. 1. NAMA DAN USIA. 2. 2. MEKANISME DAN WAKTU CEDERA. 3. 3. STATUS KARDIORESPIRATORI. 4. 4. GCS. 5. 5. RESPONS PUPIL. 6. 6. POLA MOTOR. 7. 7. PERUBAHAN OBSERVASI DASAR. 8. 8. CEDERA NON SEREBRAL. 9. 9. HASIL PEMERIKSAAN. 10. 10. KELAINAN, OBAT, ALERGI SEBELUMNYA. 11. 11. DOKTER PENGIRIM, ALAMAT, TELEPON. PENGELOLAAN KOMA DAN PENINGGIAN TI.K. 1. 1. INTUBASI DAN VENTILASI BILA GCS 8. PaCO2 25-30 mmHg. Periksa BGA berkala. Hiperventilasi wfwktif sekitar 8 jam. 2. 2. PERFUSI OTAK. 3. 3. ELEKTROLIT DAN CAIRAN I.V. 4. 4. MANNITOL 20%I.V. 1 gr/kgBB dalam 20 menit. Diberikan untuk perburukan yang mengancam jiwa agar didapat waktu untuk transfer. 5. 5. CEGAH KEPALA RENDAH. Usahakan kepala ditnggikan sekitar 200. Cegah fleksi leher gangguan jalan nafas. 6. 6. KORTIKOSTEROID TIDAK BERGUNA. 7. 7. TRANSFER KEUNIT BEDAH SARAF. CEDERA KEPALA PEDIATRIK : SEPERTI DEWASA, NAMUN HARUS DIINGAT : 1. 1. RESPONS GCS LEBIH SERING BERFLUKTUASI. 2. 2. SULIT MENENTUKAN APAKAH ADA PENURUNAN KESADARAN SAAT CEDERA. 3. 3. PEMBENGKAKAN OTAK LEBIH CEPAT : C.T. 4. 4. MUDAH KEJANG WALAU CEDERA MINOR : CT. 5. 5. BILA KEJANG SEGERA PULIH, TAK PERLU TH/. 6. 6. PELINDUNG OTAK TIPIS, MUDAH PENETRASI.

7. 7. KARAKTER TENGKORAK : CEDERA LOKAL. 8. 8. ELASTISITAS TENGKORAK : TANPA FRAKTUR. 9. 9. NILAI KEHILANGAN DARAH. 10. 10. MUDAH BENGKAK : CEGAH OVER INFUS. 11. 11. FONTANEL SEBAGAI PENDUGA T.I.K. 12. 12. SERING CEDERA NON TRAUMATIK : RIWAYAT PALSU. 13. 13. GELISAH SAAT SCANNING : A. U.

CEDERA SPINAL. 1. 1. PENGELOLAAN PRA RUMAH-SAKIT. A. A. SELALU PIKIRKAN CEDERA SPINAL. B. B. PENILAIAN KLINIS CEPAT : a. a. POLA RESPIRASI. b. b. GERAKAN VOLUNTER DAN SENSASI. c. c. TONUS DAN REFLEKS OTOT. C. C. EKSTRIKASI DARI KENDARAAN : a. a. PERTAHANKAN ALIGNMENT SPINAL. b. b. CEGAH GERAKAN PENAMBAH NYERI. c. c. GUNAKAN C-COLLAR ATAU PENGGANTI. D. D. TRANSPORT KE R.S. PRIMER. a. a. SADAR : TERLENTANG ; SESAK : HEAD UP. b. b. TAK SADAR : POSISI LATERAL. c. c. ALAT PENGANGKAT/TRANSPORT LAYAK. d. d. OKSIGEN. 2. 2. A. A. B. B. a. b. 1. 2. 3. PENGELOLAAN R.S. PRIMER. RESUSITASI. WASPADA SHOK SPINAL. SELALU PIKIRKAN CEDERA SPINAL. a. MEKANISME CEDERA DAN GEJALA. b. PEMERIKSAAN KLINIS : 1. TANDA VITAL : BRADIKARDI, HIPOTENSI. 2. POLA RESPIRASI. 3. PEMERIKSAAN NEUROLOGIS : RESPON MOTOR. LEVEL SENSORI, PERINEAL. TAK SADAR : LEVEL KERINGAT. RESPONS PLANTAR. PRIAPISM. BAHU HIPER ELEVASI PADA CEDERA C. TONUS SFINGTER. RETENSI URINER. C. C. X-RAY.

D. D. E. E. a. b. c. d. e. f. g.

PIKIRKAN CEDERA LAIN. KELOLA SHOK SPINAL : a. CAIRAN I.V : CEGAH OVERTRANSFUSE. b. METIL PREDNISOLON. c. N.G.T. d. KATETER. MONITOR OUTPUT URIN. e. CEGAH HIPOKSIA. f. CEGAH ULSERASI KULIT. g. PERTAHANKAN NORMOTERMIA.

3. 3. INDIKASI X-RAY. a. PASIEN TIDAK SADAR. 1. C-LATERAL HINGGA T 1/2. 2. CT BILA ADA YANG TAK TAMPAK / #. 3. FOTO DINAMIK BILA DIDUGA INSTABIL. 4. T/L AP/LAT. BILA ADA INDIKASI. b. PASIEN SADAR DENGAN NYERI LEHER. 1. 1. AP/LAT/OBL/ODONTOID HINGGA T 1/2. 2. 2. DINAMIK. 3. 3. ULANG 1 & 2 SETELAH BEBERAPA HARI. 4. 4. CT SEGMEN YANG CEDERA. c. PASIEN SADAR DENGAN NYERI PUNGGUNG. 1. 1. AP/LAT. T/L DAN PELVIS. 2. 2. CT DAERAH # BILA MENEKAN KEKANAL. 3. 3. CT KONTRAS BILA DUGA CEDERA U-GIT. 4. KRITERIA RAWAT. SEMUA PASIEN DENGAN ATAU POTENSIAL CEDERA SPINAL.

5. RUMAH SAKIT YANG SESUAI : a. a. R.S LOKAL : CEDERA JARINGAN LUNAK DAN FRAKTUR SPINAL MAJOR. b. b. UNIT BEDAH SARAF/ ORTOPEDI : CEDERA MEDULA SPINAL / RADIKS SARAF. KERAGUAN STABILITAS SPINAL. KEADAAN KHUSUS : PENCEGAHAN INFEKSI INTRAKRANIAL : 1. RINOREA ATAU OTOREA : KULTUR DAN TES SENSITIVITAS. 2. AEROSEL INTRAKRANIAL : ANTIBIOTIK. 3. CEDERA PENETRATING : TRANSFER. GELISAH DAN ANALGESIA :

1. 2.

1. 2.

PASTIKAN PENYEBABNYA. HANYA PARASETAMOL / KODEIN FOSFAT.

STATUS EPILEPTIKUS : 1. 1. RAWAT JALAN NAFAS / INTUBASI. 2. 2. KONTROL SIRKULASI. 3. 3. TES DARAH UNTUK GLUKOSA, ELEKTROLIT, KALSIUM DAN GAS DARAH. 4. 4. BERIKAN 50 ML. GLUKOSA 50% IV. 5. 5. DIAZEPAM I.V. 2-4 MG/MN. HINGGA KEJANG STOP ATAU TOTAL 30 MG. 6. 6. INFUS FENITOIN I.V. PELAN (<50 MG/MN.) HINGGA TOTAL 20 MG/KG. BB. 7. 7. ANESTESI UMUM. EPILEPSI PASCA TRAUMA : 1. 1. HEMATOMA INTRADURAL. 2. 2. LASERASI DURA + CEDERA KORTEKS. 3. 3. # DEPRESSED. 4. 4. AMNESIA > 24 JAM. 5. 5. TERAPI PROFLAKTIK KONTROVERSI. LUKA SCALP : 1. CUKUR SEKITAR 3 SM. SEKELILING LUKA. 2. PALPASI HATI-HATI, CARI #. 3. 3. BILA #, JANGAN ANGKAT FRAGMEN, TRANSFER. 4. 4. HEMOSTASIS DAN JAHIT SEGERA. 5. 5. BILA TEPI LUKA BURUK, EKSISI JARINGAN NON VIABEL, JAHIT 2 LAPIS. CEDERA KEPALA MINOR : GCS 13-15. RAWAT DAN OBSERVASI : a. a. PERNAH KEHILANGAN KESADARAN. b. b. TETAP KEBINGUNGAN. c. c. < 5 ATAU > 50 TAHUN. d. d. ADA ATAU TIMBUL GEJALA NEUROLOGIS FOKAL. e. e. NYERI KEPALA HEBAT MUNTAH. PULANGKAN CEDERA KEPALA MINOR : 1. 1. TERORIENTASI WAKTU / TEMPAT. 2. 2. TANPA DEFISIT NEUROLOGIS FOKAL. 3. 3. TANPA NYERI KEPALA / MUNTAH. 4. 4. TANPA # TENGKORAK. 5. 5. ADA ORANG YANG BERTANGGUNG-JAWAB UNTUK MENGAWASI.

6.

6. BERIKAN CHECKLIST. KEMBALI KE R.S BILA : a. a. MUNTAH. b. b. NYERI KEPALA ATAU PUSING. c. c. GELISAH, MENGANTUK, TAK SADAR. d. d. KEJANG.

PENGELOLAAN KEPERAWATAN PADA NEUROTRAUMA AKUTA. 1. 1. A. B. C. D. SURVEY PRIMER : A. PENGELOLAAN JALAN NAFAS, FIKSASI C. B. PERNAFASAN DIKONTROL. C. SIRKULASI DIKONTROL. D. PENILAIAN NEUROLOGIS : PENILAIAN DASAR TERMASUK GCS. UKURAN, REAKSI TERHADAP CAHAYA, SERTA EKUALITAS PUPIL. PERIKSA GERAK DAN KEKUATAN ANGGOTA. E. E. T/N/R/S. PENGELOLAAN KEPERAWATAN. A. OKSIGEN. B. ATASI HIPOTENSI. C. PENILAIAN : GCS DAN TANDA VITAL SERIAL. LAPORKAN BILA GCS BERKURANG 2. LAPORKAN DEFISIT MOTOR; PERUBAHAN UKURAN, EKUALITAS, REAKSI TERHADAP SINAR DARI PUPIL.

2. 2. A. B. C.

D. D.

CAIRAN: KATETER BILA TIDAK K.I. BALANS CAIRAN E. E. TUBE INTRA GASTRIK BILA TIDAK K.I. F. F. POSISI : C-COLLAR HINGGA DIBUKTIKAN TAK # . SETELAH HIPOTENSI TERATASI, ELEVASI KEPALA 15-30. TIDAK SADAR TANPA INTUBASI DAN CEDERA SPINAL SUDAH DISINGKIRKAN, RAWAT POSISI LATERAL. G. G. PASIEN KONFUSI : TERAPI OKSIGEN. CEGAH SEDASI. PENGAMATAN KETAT. H. H. KEBOCORAN CSS, LUKA TERBUKA :

 LAPORKAN SETIAP KEBOCORAN CAIRAN DARI TELINGA/HIDUNG. LUKA YANG TIDAK DIJAHIT, TUTUP DENGAN KASSA YANG DIBASAHI SALINE SAAT TRANSFER. Petunjuk ini digunakan pada RS rural dimana pelayanan medis 24 jam tidak tersedia. RESUME MENGELOLA CEDERA KEPALA BERAT. 1. 1. AIRWAY + PROTEKSI C-SPINE. 2. 2. BREATHING + OKSIGENASI. 3. 3. ATASI SHOK, KONTROL PERDARAHAN. 4. 4. PERTAHANKAN CAIRAN PASCA RESUSITASI. 5. 5. PERIKSA NEUROLOGIS DINI, TETAPKAN D.K/. 6. 6. CEGAH CEDERA OTAK SEKUNDER. 7. 7. NILAI DAN TINDAK CEDERA NON SEREBRAL. 8. 8. X-RAY/CT BILA K.V SUDAH STABIL. 9. 9. KONSUL DAN TRANSFER SEGERA TERUTAMA PADA CEDERA GANDA SETELAH STABILISASI. RUJUKAN : 1. The management of acute neurotrauma in rural and remote locations. A set guidelines for the care of head and spinal injuries. The neurosurgical society of Australasia.1992. 2. ATLS. 1997 ed. First Impression. USA. 3. The Practice of Neurosurgery, 10th ed. George T. Tindall ed. Part V2 : Cranial Trauma; Part V3 : Spinal Trauma. Williams & Wilkins, USA, 1999. 4. Neurological Surgery, 4th ed. Youman ed. Part VIII : Trauma. W.B. Saunders, Philadelphia, 1996. 5. Illustated Neurosurgery. Tomio Ohta, ed. Ch. 3 : Head Injury. Kinpodo, Kyoto, 1996.

ABSTRACT
TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

Using an administrative database, we determined rates of femur fracture by year of age for children younger than 6 years and by month of age. The highest rate of femur fracture was in children younger than 1 year and in 2-year-olds; the greatest number of fractures occurred during the third month of life. While femur fractures in children are often due to accidental injury, the reasons for the peak in the first year and the subsequent decline are not clear.

INTRODUCTION
TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

The incidence of femur fractures in children is believed to have 2 peaks, one at the age of 2 to 3 years and another during adolescence.1 This view is based, however, on older studies from Scandinavia24 and a more recent study from Maryland5 and may not reflect the experience of the US population. Previous studies have also categorized children by year of age, which may be insufficiently precise for the infant or young child in whom rapid changes in size, physical ability, and behavior may affect the risk of fracture.

Although most femur fractures in children are caused by falls or other unintentional injuries, abuse is considered more likely in the child aged younger than 1 year or not yet able to walk. In this brief, we focus on this youngest group, reporting data on hospital discharges for femur fractures from a national database in which children were categorized by age in months.

METHODS
TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

The 1997 Kids Inpatient Database contains 1.9 million records of hospital discharges for children aged 18 or younger, representing nearly a third of the estimated 6.7 million pediatric discharges during that year. Using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for fracture of the proximal femur, femoral shaft, and distal femur (diagnosis codes 820821.39), we identified 3308 records of children under the age of 6 discharged from a hospital with a diagnosis of femur fracture. Fractures occurring during childbirth were excluded. Using population weights provided with the database, we calculated national estimates for the number of femur fractures in each 1-year age group. We determined fracture incidence rates by dividing the number of fractures by the estimated number of children in each age group, using population estimates for 1997 from the US Bureau of the Census. To examine the relationship between age and femur fractures more closely, we identified 2753 records for which the age in months was available. Because we lacked the population denominator to determine rates of fracture, we report the counts for this subset of patients.

RESULTS
TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

The rate of femur fracture was highest during the first year of life and in 2-year olds (Table 1 ). One-year-olds were less likely to sustain a fractured femur than those aged younger than 1 year. While the ratio of boys to girls was nearly equal in those aged younger than 1 year, all older age groups had more boys.

View this table: [in this window] [in a new window]

TABLE 1 US Population Estimates for Femur Fractures in Children, by Year of Age

In children for whom the age in months was known, the greatest number of fractures occurred during the third month of life (Figure 1 ). There were slightly fewer fractures in children aged 4 to 11 months, and fewer still in children aged 12 to 20 months. After the first peak during infancy, there was a second peak in children aged 20 to 40 months. In children older than 40 months but younger than 72 months, the number of fractures was lower and relatively constant.

FIGURE 1 Estimated number of femur fractures among children in the United States, by month of age. Source. Kids Inpatient Database, 1997.6 View larger version (22K): [in this window] [in a new window]

DISCUSSION
TOP Previous studies of femur fractures in childhood have identified a ABSTRACT peak in incidence at age 2 to 3 years. By contrast, femur fractures in INTRODUCTION children younger than 1 year of age are thought to be less common METHODS and, when they occur, to be highly suggestive of abuse.7,8 We found RESULTS that femur fractures were as common in children younger than 1 year DISCUSSION References as in those aged 2 years and older, with the greatest number of fractures occurring during the third month of life. There are few plausible explanations for a femur fracture in this age group other than intentional injury. These data suggest that an infant has as great a chance of sustaining a femur fracture from physical abuse as an older child does from all causes.

The reason for the rise in incidence at age 2 to 3 years, and the subsequent fall, is less clear. Although most children are walking by age 15 months, femur fractures were infrequent at this age. The 2- to 3-year-old may be at increased risk of injury owing to changes in gait,9 increased mobility, greater climbing ability, and exposure to vehicular traffic. The decline in femur fractures after age 3 may be due to improvements in gait and judgment, as well as to increased bone strength. Although child abuse is thought to be a less common cause for femur fracture in children who are walking,10 there are widely varying estimates of its occurrence, reflecting the difficulty of establishing the diagnosis of abuse with certainty.11 Our study, based on an administrative database, lacks the clinical detail of a case series. The sample size is large, however, and the coding of femur fractures and age are likely to be accurate.12 The rate of femur fracture in children younger than 2 years of age was 38.0 per 100 000; this is greater than the rate of 25.5 per 100 000 reported by Hinton and colleagues for femoral shaft fractures in this age group in Maryland.5 We included fractures of the proximal and distal femur, which may contribute to the higher rate we report. We cannot determine how often fractures were due to abuse or neglect, but child abuse is thought to be common in children younger than 1 year old with femur fractures.7,8 Other possible causes include heritable disorders of connective tissue such as osteogenesis imperfecta13 and motor vehicle accidents. Short falls, as occur when a child rolls off a bed or table, are unlikely to cause a femur fracture in an infant.14,15 The equal number of boys and girls younger than age 1, and the predominance of boys among those older than 1 year, may signify a shift from intentional to accidental injury. Although not as specific for abuse as the metaphyseal corner fracture or rib fracture, a single long-bone fracture may be the most common type of fracture due to abuse.16 Abuse should be suspected if caretakers provide inconsistent or implausible accounts of how a femur fracture occurred, or if there are additional unexplained injuries. A skeletal survey

may provide evidence of occult injuries and may support a diagnosis of abuse. Efforts to prevent femur fractures in children should focus on preventing physical abuse in infants and accidental injury in the 2- and 3-year-old children at greatest risk. Using an administrative database, we determined rates of femur fracture by year of age for children younger than 6 years and by month of age. The highest rate of femur fracture was in children younger than 1 year and in 2-year-olds; the greatest number of fractures occurred during the third month of life. While femur fractures in children are often due to accidental injury, the reasons for the peak in the first year and the subsequent decline are not clear.

Johns Hopkins Bayview Medical Centerhttp://www.jhbmc.jhu.edu/Ortho/consultant/5mcs.html Orthopaedic Surgery The Five Minute Orthopaedic Consultant The Five Minute Orthopaedic Consultant is a work in progress. It will be published by Lippincott Williams & Wilkens and has much more information than is listed here. If you have any comments, please let us know. Scaphoid Fracture
Hwang, John

Description: Facture of the most radial (on the side of the thumb) bone in the wrist, just distal to the base of radius. The most common fracture of a carpal bone. Frequent problems which make this subject important include nondiagnosis and nonunion. Appropriate Care: If the patient has snuffbox tenderness even though a fracture is not seen initially, the wrist should be immobilized in a thumb spica cast for two weeks. Then radiographs should be repeated. at which time the fracture edges may be better seen. For a non-displaced fracture the patient should be placed in a long arm thumb spica cast for 6 weeks, followed with short arm thumb spica cast for 6 weeks. Displaced fractures require surgery. Sciatica
Doute, Damien

Description: Pain referred down the leg in a sciatic distribution. Appropriate Care: A. Conservative- highly successful 1. Patient education (limited bending, heavy lifting; back school), back and cardio

2. 3. B. 1. 2. 3. b. c. d. e.

exercise, wt. loss Limited bedrest(1-3 days), then gradual increase activity Drugs- muscle relaxants, NSAIDS; AVOID NARCOTICS! Invasive Epidural steroids not proven acutely Chemonucleolysis (dissolving disc chemically) risky Surgery

a. if conservative RX for 6wks fails neuro deficit, cauda equina ( see below) microdiskectomy may miss associated pathology percutaneous discectomy for contained, sequestered discs Gold standard = laminotomy and discectomy

Scoliosis
Sponseller, Paul

Description: Scoliosis is a three-dimensional curvature of the spine, best appreciated on and anteroposterior radiograph and physical examination. Many different causes have been identified. The most common type is idiopathic scoliosis. Septic Arthritis
Laporte, Dawn

Description: Infection of the joint space. Appropriate Care: Septic arthritis is an orthopaedic emergency. Principles of treatment include adequate administration of bactericidal antibiotics, drainage, immobilization and supportive measures. Antibiotics must be started immediately after aspiration and blood cultures obtained. Antibiotics may be divided into initial and definitive. Initial diagnosis usually applies a combination of agent administered parentally until the identity and susceptibility of the bacteria are known. Initial antibiotic choices are based on broad coverage and a knowledge of common causative organisms. Predisposing causes and epidemiological factors can help in this selection. As cartilage does not have the ability to repair itself, drainage and dbridement of the joint by aspiration/irrigation or arthrotomy is required to eliminate the infection completely. The goals of treatment include sterilization of the joint, decompression and removal of all inflamed cells, enzymes, debris or foreign bodies; elimination of the destructive pannus; and return to full function. There is debate as to the best methods for drainage, decompression and cleansing of the joint. When septic arthritis is diagnosed early in a superficial joint, such as the ankle or elbow, it is reasonable to aspirate the joint begin appropriate antibiotics, and carefully monitor the patient for 24 - 48 hours. The joint aspiration may be repeated as necessary. Surgical drainage is indicated for all joints that do not respond to antibiotics and aspiration with in 72 hours, for those in which the synovial fluid appears to be loculated, and for infections involving the hip. Arthroscopic drainage is an alternative treatment option for certain joints

including the knee, shoulder, elbow, and ankle. The joint should be splinted in the position of the fracture or until clinical signs show a decrease in swelling and tenderness and patient has a comfortable ROM. Three - six weeks of antibiotic treatment has been proposed but more important is to understand and monitor clinical response. This can be aided by radiographs and lab tests (ESR and C-reactive protein). Oral antibiotics may be used if 1. patient demonstrates clinical response to IV antibiotics. 2. Organism causing infection is known. 3. organism is susceptible to orally administered antibiotics. 4. adequate serum bactericidal concentrations with oral administration can be reached, and 5. the patient tolerates oral antibiotics. Initial tests for gonococcal arthritis should include hospitalization. As most infections are caused by PCN resistant strains, a beta-lactamase-resistant Cephalosporin, such as ceftriaxone, is usually 1st line of tests. After local signs of infection have subsided, oral antibiotic such as amoxicillin with clavulanic acid may be substituted. Duration of antibiotic test should be at least 7 days. Open drainage is rarely necessary except with hip involvement. Key in prevention of recurrence is patient education and treatment of sexual partners. Septic Arthritis of the Foot
Cameron, Michelle

Description: Bacterial or fungal infections of the joints of the foot. Appropriate Care: Acute joint infections can be treated with parenteral antibiotics and repeated aspiration of the affected joint. If purulence does not improve or if effusions continue to form beyond five to six days, or if the infection is chronic the joint should be opened surgically and be irrigated and debrided. In both acute and chronic infections, the patient should be splinted to immobilize the infected joint and be non-weight bearing on the affected extremity. Septic Knee
Cameron, Michelle

Description: Infectious arthritis of the knee joint. The most common site of septic arthritis. Appropriate Care: To prevent severe and permanent damage, the diagnosis must be made early and prompt treatment instituted. As soon as appropriate specimens arc obtained for culture, antibiotic therapy should be instituted. Empiric antibiotic therapy should cover grain positive organisms. Antibiotic coverage should be appropriately modified when the gram stain and culture results are available. The joint should be irrigated and dbrided urgently. Multiple dbridements may be necessary. Immobilization of the leg in a knee immobilizer is also recommended. Short Stature (Other)
Wang, Jinsong

Description: Short stature is defined as a height under third percentile for age of general population. There

are many causes for short stature; orthopaedic causes will be discussed here. They are most commonly osteochondrodysplasia. These are a group of disorders characterized by an intrinsic abnormality in the growth and remodeling of cartilage and bone. More than 1600 types are identified, and combined incidence is 1 in 3000 to 5000. Appropriate Care: Care includes accurate genetic counseling and the recognition and treatment of musculoskeletal abnor intrinsic medical problems. Understanding of what is normal development for each dysplasia is important. Shoulder / Glenohumeral Arthritis
Waldman, Barry

Description: Glenohumeral arthritis, while not as common as that affecting the hip and knee, results in substantial diability, especially in tasks of daily living such as personal hygiene and meal preparation. Shoulder / Proximal Humerus Fracture
Waldman, Barry

Description: The proximal humerus consists of the articular surface of the shoulder joint and the attachments of the rotator cuff on the greater tuberosity and lesser tuberosities. Fractures often occur after a fall directly onto the shoulder. Patients with osteoporotic bone are at the highest risk. Appropriate Care: A sling or swath is appropriate treatment in the emergency setting. Some authors recommend a coaptation splint which is U-shaped and extends from the axilla, around the elbow, and up over the lateral shoulder. In minimally displaced fractures this may represent definitive treatment. Shoulder Exam and Anatomy
Waldman, Barry

Description: The shoulder is composed of three bones: the scalula, clavicle and humerus. The scapula is a triangular bone which has an anterior projection called the coracoid process. It's acromial process articulates with the clavicle and the glenoid process articulates with the humeral head. The clavicle acts as an anterior strut and it articulates with the scapula and the sternum. The glenohumeral joint, together with the scapulothoracic joint, allows range of motion of the upper arm. The shoulder joint has far more range of motion than any other joint in the body. This is possibile because only 30% of the humerall head articulates with the glenoid at any given time. Unlike the hip joint, the shoulder joint has very little inherent bony stability. It relies on the strong glenohumeral ligaments that form the joint capsule and the many muscles with cross the joint, to provide stability. The muscles of the shoulder form a number of layers. The most superficial is the deltoid which abducts the arm, originating on the arcromiclavicular arch and inserting on the lateral humerus. Deep to the deltoid is the rotator cuff which is composed of four muscles: the suprspinatus, infraspinatus, subscapularis and teres minor. These muscles stabilize the humeral head in the

glenoid and primarily internally and externally rotate the humerus. The coracobrachialis and biceps muscles cross the shoulder joint and help forward flex the upper arm. The tendon of the short head of the biceps passes through the joint capsule and can be involved with intraarticular pathology. The pectoralis major and minor extend from the chest wall the the medial humerus and adduct the arm. The brachial plexus passes through the axilla and inervates the shoulder muscles, skin and the arm and hand distally. It's many branches originate in the area of the neck and shoulder. The axilary nerve wraps around the proximal humerus and inervates the deltoid. It can be injured by proximal humerus fractures or dislocations. The musculocutaneus nerve innervates the biceps and coracobrachialis before continuing distally as a sensory nerve. The radial, median and ulnar nerves all branch out from the axilla and inervate the forearm and hand distally. Slipped Capital Femoral Epiphysis
Solacoff, David

Description: A disorder of adolescents in which the femoral head moves (through the growth plate) relative to the rest of the femur. The femoral head remains in the acetabulum but moves relatively posteroinferior, as can be seen on a radiograph. From an external perspective, the most notable features are the outward rotation of the lower femur and leg, as well as the limp. Appropriate Care: Prevention of further slip is the cornerstone of therapy. The child is immediately placed at bed rest and admitted for surgery to close the physis. This is usually done via a single percutaneously placed screw. In severe unstable slips, some surgeons advocate attempted reduction of the slip by traction or gentle closed manipulation Osteotomies for severe slips are usually performed at a later date to correct severe deformity. Although controversial, prophylactic pinning of the contralateral hip is generally not recommended except in patients with known metabolic or endocrine disorders, or patients in whom appropriate follow up is unlikely. Soft Tissue Tumors
Hungerford, Marc

Description: Soft tissue tumors may occur in any area of the skeleton and at any age. They may be composed of tissue originating from muscle, fat, vessels, nerves or fibrous tissue. Benign types far outnumber malignant ones. reactive lesions also cause soft tissue tumors. The difficulty arises in differentiating the malignant from the benign. Appropriate Care: Lesions which are clearly benign may be observed if not causing symptoms. This includes popliteal cysts and ganglions in children, which often resolve with time. It also includes myositis ossificans, which may diminish with time. However, if the nature of the lseion is not clear, it is important not to fall into the trap of complacency -- a diagnostic workup should be

initiated under the direction of an orthopaedist knowledgeable about the diagnoses involved. Spina Bifida
Sponseller, Paul

Description: Spina Bifida refers to incomplete closure of the laminar arches of the spine. It may be a benign finding of no clinical consequence, such as when it occurs at the fifth lumbar or first sacral vertebra with no neurologic deficit. It may be a clinically significant problem if associated with congenital neurologic deficit at the same levels. It may occur at any level of the spine or at multiple levels, although it is most common at the caudal end. Appropriate Care: At birth, the child should be seen by an experienced neurologist, with consultation by a neurosurgeon and orthopaedic surgeon and urologist as follows. Latex exposure should be avoided. Genetic counseling should be offered to the family. Spinal Stenosis
Waldman, Barry

Description: Spinal stenosis occurs when bony or other structures cause chronic compression of a nerve root laterally or the cauda equina or spinal cord centrally. The most common source of the compressio is osteophytes that form as a result of osteoarthritis or other degenerative changes in the facet or intervertebral joints. Spine Fusion
Cohen, David

Description: A procedure to cause two or more vertebral levels to be joined together with solid bony healing. It is performed to correct spinal instability due to traumatic, degenerative or iatrogenic causes. Spinal fusions are also performed in cases of spinal deformities in order to prevent progression of deformity. Appropriate Care: In general, bone is the slowest healing tissue in the human body, but it has the ability to heal completely without a scar. The healing of a spinal fusion is similar in nature to the healing of a fracture. Either spinal instrumentation or appropriate immobilization limits the local motion that allows a fusion to heal. In adults, it takes up to 6 months for a fusion to become solid and up to 2 years for it to attain full strength. In children, bone heals more rapidly and full fusion strength can occur within 6 to 12 months. Splinting
Laporte, Dawn

Description: Upon the discovery that a patient has a fracture, once vital systems have been assessed and stabilized and the neurovascular status of the limb with the fracture has been evaluated and

documented, attention should be turned to whether the fracture is open or closed and then to splinting the fracture. Often this is done in the field or at the site of the accident by emergency medical technicians. "Splint then where they lit" is the teaching for emergency crews. Adequate splinting 1. provides immobilization, which relieves pain, 2. prevents further soft tissue injury and avoids closed fractures from becoming open fractures, and 3. may lower the incidence of clinical fat embolism and shock. Almost anything rigid can be used as a splint in the field - sticks, slats of wood, a pillow, or rigid cardboard. Most emergency equipment includes Thomas splints, inflatable splints, and/or structural aluminum malleable splints. Thomas splints are used for femoral shaft fractures and, occasionally, knee injuries. Application uses a 1/2 ring or a full ring splint that measures 2 inches greater than the circumference of the proximal thigh. If a 1/2 ring splint is used, a strap is placed anteriorly. The ring engages the ischial tuberosity for countertraction, and traction is applied to the end of the splint with an ankle hitch. Do not leave this temporary splint on for greater than 2 hours as the ankle hitch places significant pressure on the skin, causing sloughing. Inflatable splints consist of a double-walled polyvinyl jacket with a zip fastener placed around the injured limb. The splint is inflated by blowing air into the mouth tube. A mechanical pump can produce circulatory embarrassment and should be avoided. It is felt that the pressure from inflation is transmitted directly into the soft tissue compartments and therefore one must be careful to monitor for compartment syndrome. Also, inflatable splints should not be applied over clothing because folds can cause high-pressure points and blistering. Skin mac ation may occur if air splints are used for any extended period. Structural aluminum malleable splints are made of a strip of soft aluminum, coated with polyethylene foam. These are cut into strips, weighs very little, and takes up very little room. When folded longitudinally, these floppy, malleable strips change to rigid members. They are self-padded, can be trimmed to size by scissors, conform to any contour, and are radiolucent. Open fractures should be splinted the same as closed fractures, however the wound should be covered as early as possible. If sterile dressing is not available, a clean cloth should be placed over the wound. The treatment of an open fracture is different than for a closed fracture - an open fracture is always an emergency requiring surgical treatment - thus it is extremely important to assess for and recognize when a fracture is open and to notify an orthopaedic surgeon as soon as an open fracture is diagnosed. Once a satisfactory reduction has been achieved, it must then be maintained until primary union has taken place. The object of applying a splint or cast is to keep the bone ends in apposition and the fracture aligned until the fracture heals. Immobilization in the acute period is usually best provided by some form of plaster splint. Plaster splints also provide acute immobilization for non-displaced or minimally displaced fractures and provide relief from pain caused by the fractures and inflammatory processes. The advantage of a splint over a cast is that it is not circumferential and, therefore, is more permissive of the normal possible swelling

with significantly lower risk of iatrogenic compartment syndrome. A plaster bandage consists of a roll of muslin stiffened by dextrose or starch and impregnated with the hemihydrate of calcium sulfate. When water is added, the calcium sulfate takes up its water of crystallization. This in an exothermic reaction and, after a few minutes, the plaster becomes a warm, homogeneous, solid mass. Key principles in splinting a fracture include 1. confirm fracture is not open (if open, consult orthopaedist), 2. pad the extremity well with sofroll, webril and/or felt increasing padding over bony prominences, 3. remove rings from hand in injured upper extremity, 4. splint in position of function, 5. immobilize the joint above and the joint below (when feasible), 6. do not use hot water for the plaster or more sheets of plaster than necessary as this may lead to thermal burns, 7. avoid indentations from eg. fingers, and 8. apply 3 point fixation to stabilize the fracture. Perhaps the most common splints applied are a sugartong and an ankle splint. We will discuss how to apply these in detail and then also present how to construct a splint for a boxer's fracture, and elbow fracture. A sugartong splint may be used for wrist or forearm fractures. The arm is well padded from the MCP joints to above the elbow with webril or sofroll, with higher padding or 1/4 inch felt applied over bony prominences. The padding may also be placed directly onto the plaster slabs and applied as a single unit. Plaster is measured to span from the MCP joints volarly to and around the elbow and back to the MCP joints dorsally. 8 - 12 layers (3" or 4") of plaster are measured out and these are laid on top of each other and dipped in water. The bandages are sufficiently soaked when the bubbling stops. (They can be left in the water up to 4 minutes without lowering the strength of the splint). Place the splint on the patient's arm (with adequate padding between the arm and the plaster) so that it spans from the MCP joints volarly, around the elbow which is flexed at 90 degrees, and to the MCP joints dorsally. The wrist should be held at neutral and the elbow flexed at 90 degrees. Secure the plaster with ace wraps. 3 points of force are produced by the operator who molds the splint firmly against the proximal and distal portions of the extremity (2 of the points) and locates the third point directly opposite the apex of the fracture. The position is held until the splint becomes hard. The limb is supported in a sling. An ankle splint consists of two components - a posterior slab and a U that runs from medial to lateral. This splint may be used for distal tibia, fibula, or tibia/fibula fractures, ankle sprains, or achilles tendon tears and the posterior slab alone may be used for metatarsal fractures. If the patient's condition allows, the position most conducive for applying this splint is prone with the affected limb flexed off the bed at the knee. It is simpler for a single person to apply this splint and hold the foot and ankle in neutral if that position is used. The leg should be well-padded with webril or sofroll from the toes to just below the knee. Attention (and extra padding) should be given to the medial and lateral malleolus . 4", 5", or 6" plaster is measured from 2" below the popliteal space to 2" beyond the toes. 10 - 12 sheets are then measured out. Then a U is measured from the medial aspect of the knee under the foot and up to the lat side of the knee, using 3 or 4" plaster and again 10 - 12 sheets are measured out. The post slab is applied and the

distal aspect folded back to make a reinforcing toe plate and then the U slab is applied and the splint is secured with ace wraps. The ankle is held in neutral with the ankle at 90 degrees until the splint hardens. A boxer's fracture is a fracture of the distal 5th metacarpal (MC) and is a common injury. The "Boxer splint" can also be used for 4th MC fractures. Adequate padding is applied and 4" plaster is measured from the tip of the 5th finger to 2 inches from the antecubital fossa place a gauze pad between the 4th and 5th fingers. Apply the splint to the ulnar side of the hand, creating a "gutter". Position the wrist at 25 to 30 degrees of extension and the MCP joint at 90 degrees of flexion. Secure the splint with an ace wrap and hold MCP joints at 90 degrees until splint is hard. A posterior elbow splint may be used for supracondylar humerus fractures, elbow sprains, radial head fractures, or elbow strains. The arm is well padded from distal to the wrist all the way up the arm. 4" or 5" plaster is measured from 2 - 3" from the axilla to the base of the 5th MC 10 - 12 sheets are measured and placed together. Apply the splint to the patient from 2 - 3" distal to the axilla over the elbow and along the ulnar aspect of the forearm to the base of the 5th MC. Before wrapping the elbow, overlap the corners of the splint to make a dart, being careful not to cause a pressure point. The arm is positioned with the wrist at neutral and the elbow flexed at 90 degrees. The position may be further secured with a separate slab of plaster extending from the ulnar aspect of the forearm to above the elbow. The splint is secured with ace bandages and the position held until the splint is hard. The arm is then supported in a sling. After application of any splints, the patient should be instructed as to the signs and symptoms of compression from swelling within the splint (numbness, tingling, pain), elevation of the injured limb above the level of the heart for 2 to 3 days, not getting splint wet, weight bearing restrictions, how to exercise joints not incorporated in splint, a person to call in case of splint problems or symptoms of compression, and the date for follow up. Spondylolisthesis
Cohen, David

Description: An abnormal anterior-posterior translation of two vertebral bodies relative each other due to a defect in either the pars interarticularis (spondylolysis) or the posterior ligamentous/bony restraints. Appropriate Care: In children and adolescents asymptomatic Grade 0 and I spondylolisthesis require no restrictions. If symptomatic, activity restriction and lumbar bracing in lordosis should be used for up to 6 months. Hamstring stretches and abdominal exercises should be initiated when asymptomatic in a brace. Once asymptomatic, serial radiographs should be taken until skeletal maturity. Patients who fail 12 months of nonsurgical or who have symptomatic higher grade slips require posterolateral fusions. In adults, patients with Grade 0 and I slips can be treated as if they had simple mechanical back pain. Patients with severe Grade II or higher slips will require posterior spine fusions and possible nerve route decompression. The reduction of high grade slips, the need for anterior

spinal fusion and the levels to be fused are all controversial topics. Stress Fractures
Mears, Simon

Description: A stress fracture occurs when repetitive stresses are applied to a bone faster than it is able to remodel to withstand this challenge. As the stressing force continues the bone gradually fatigues and eventually breaks. Remodeling occurs in response to the stress but does not happen quickly enough to prevent the break. There are two general types of stress fracture. One in which excessive forces are applied to a normal bone such as a metatarsal stress fracture in a military recruit who has just marched 20 miles in boot camp. The second is a fracture occuring with minimal force in a patient with weak bone. An example is a femoral neck stress fracture in an elderly person with severe osteopenia. Appropriate Care: Femoral neck stress fractures: Type I fractures should be treated with bedrest. Very young or noncompliant patients should be immobilized in a hip spica. Type II fractures require internal fixation with pins or cannulated screws. Type III fractures require a hip compression screw and bone grafting. Tibia or fibula stress fractures: The patient should be placed on crutches for 6-10 weeks. Foot stress fractures: If the fracture is found within 2 weeks of injury the patient should rest and not engage in the offending activity for 2 weeks. Repeat radiographs should then be taken and the patient may resume activity slowly. If a stress fracture If found after 2 weeks of onset the patient should be immobilized with a weight bearing cast for 4-6 weeks. If repeat radiogrpahs show the fracture to have healed they may slowly resume activity. Fractures of the 5th metatarsal and fractures that do not heal within 10 weeks will require bone grafting. Subungual Hematoma
Berkenblit, Scott

Description: Localized collection of blood between the fingernail and nailbed resulting from an injury or laceration of the soft tissue of the nailbed underneath an intact nail. Pressure of the hematoma against the periosteum of the distal phalanx produces significant pain. Appropriate Care: Drainage of the hematoma provides prompt relief of pain. If a fracture is present, the distal phalanx should be splinted as well. If the hematoma involves more than 50% of the nail, or if there is an underlying fracture, the nail should be removed in order to inspect and repair the underlying nailbed injury. If the fracture is nonsdisplaced, the nail should be replaced as a splint. If the fracture is displaced, it should be reduced and fixed. Supracondylar Elbow Fracture
Kinchen, Melanie

Description: Fracture between the thin bone of the medial and lateral columns of the distal humerus, just proximal to the humeral condyles.The fracture goes through the olecranon fossa of the distal

humerus, which is a weak area. Appropriate Care: Type I injuries-immobilization Type II injuries-closed reduction and immobilization or operative intervention Type III injuries-operative intervention Syndactyly
Hwang, John

Description: webbed fingers (or toes) Appropriate Care: Postoperative dressing is an important part of treatment. Dressing is extended above elbow and a long arm plaster cast can be beneficial. The same dressing is continued until post-operative day 14 to 28.

http://orthoinfo.aaos.org/fact/thr_report.cfm? Thread_ID=251&topcategory=HipPediatric Thighbone (Femur) Fracture

Description The largest and strongest bone in the body, the thighbone (femur) can break when a child suffers a sudden forceful impact. Call 911 or take your child to the doctor right away if you think he or she might have a broken thighbone. Explain exactly how the injury occurred. Tell the doctor if your child had any disease or other trauma before it happened. The doctor will give your child an anesthetic or pain relief medication and carefully examine the leg including the hip and knee. The pattern of the fracture may be one of several. The pieces of bone may be aligned or out of alignment (displaced), closed (skin intact) or open (piercing the skin). Your doctor will need X-rays to see the pattern of the break. Your child's healthy leg may also be X-rayed for comparison. An orthopaedic surgeon may check for any damage to the growth area (growth plate) near the end of the femur, which enables the child's bone to grow. If needed, surgery may restore the growth plate's function and regular Xrays may be taken for many months to track the bone's growth. Risk Factors / Prevention Common causes of pediatric femur fractures include:

Falling on the playground Taking a hit in contact sports

Being in a car crash Child abuse

Symptoms A broken thighbone is a serious injury. It might be obvious by severe pain and disability. Your child may be unable to walk or have limited range of motion, pain made worse by movement and swelling. A child with a thighbone fracture may also have other serious injuries. Treatment Options Reduction and immobilization. To treat a child's thighbone fracture, the pieces of bone are realigned and held in place for healing. Your doctor will choose an appropriate treatment. It depends upon factors such as your child's age/weight, the type of fracture, how the injury happened, whether the bone broke the skin, if there was also an injury to the child's head, etc. General guidelines for reduction while under a general anesthetic:

Your doctor may be able to manipulate certain thighbone fractures back into place from the outside (closed reduction). In some cases, it may helpful to put the child's leg in a weight and counterweight system (traction) before the bones are realigned. To treat more complicated injuries, the doctor may need to surgically realign the bone with or without implants.

General guidelines for immobilization:

A young child may need a cast to treat a femur fracture. An external or internal device may be used if the break was displaced. Adolescents usually need external or internal devices for a femur fracture.

Traction and spica casting: Your child stays in the hospital for several weeks with his or her leg in a traction device. When the thighbone fracture begins to heal, your child gets a plaster or fiberglass hip cast (spica cast) to immobilize the leg in the correct position. Early spica cast: In certain cases, infants and small children can be fitted with a spica cast immediately or within 24 hours of hospitalization. External device: An external frame immobilizes your child's fracture. It is anchored by surgical pins placed above and below the fracture site. Pin care is done at home. Internal devices: Your child's broken thighbone is immobilized internally with a rod, nailing system or plate secured directly in the bone. When the immobilization device is removed, your child may need to do rehabilitation exercises to restore range of motion and flexibility. The doctor may want to see your child again after the thighbone fracture heals to make sure healing is satisfactory.

Pediatric Femur Fractureshttp://www.wheelessonline.com/ortho/pediat ric_femur_fractures

- See: - Distal Femoral Physeal Fractures: - Hip Fractures in Children: - IM Nailing of Pediatric Femoral Fractures - Discussion: - commonest site of fracture of the femoral shaft is in its middle third, where normal anterolateral bowing of the diaphysis is at its maximum; - torsional force produced by indirect violence results in a long spiral or oblique frx, whereas a transverse frx is caused by direct trauma; - green stick frx are more common in the distal third; - birth frx from OB trauma, usually occur in mid 1/3 & are transverse; - deforming forces: - displacement of the fragments in frx of the femur depends upon the breaking force, the pull of the muscles, and gravity; - distal fragment is laterally rotated due to outward rotation of the leg by the force of gravity; - in frx of upper 1/3 of the femoral shaft, the prox frag is pulled into flexion by the psoas, into abduction by gluteus medius & minimus, & into E.R by external rotators.; - diff dx: - child abuse; - it is published that upto one half of infants and young children who sustain femur fractures are victims of child abuse; - also be aware that many of the "abuse" cases often occur from poor judgement, such as letting children ride on the hood of a slow moving car; - also note that many pediatric femur frx cases do not stem from abuse, and it is important for the orthopaedist not to alienate the parents by making ill worded comments about abuse; - bone tumor - be suspcious of femoral shaft fractures occuring from low energy trauma such as a football pile up; - poor quality films may mask a NOF, UBC, or even osteosarcoma; - associated injuries: - vascular injury: - excessive bleeding ( > 500 ml) or more is not uncommon; - source of bleeding is usually the profundus femoris artery which course around femoral shaft, the vessels of richly vascular muscles enveloping the femur, or the vessels in bone itself; - ligamentous injuries: - references: - Ligamentous instability of the knee in children sustaining fractures of the femur: A prospective study with knee examination under anesthesia. SL Buckley MD et al. J. Pediatric Orthopaedics. Vol 16. No 2. 1996. p 206. - Femoral fractures: are children at risk for significant blood loss? L Ciarallo and G Fleisher. Pediatric Emergency care. Vol 12(5) 1996. p 343-346. - Treatment Based on Age: - infants: 0 to 2 yrs: - children: 2 to 10 yrs: - children aged > 10 yrs ; - references: - Remodelling of angular deformity after femoral shaft fractures in children. - Non

Operative Treatment: - suspension traction:

- femoral traction pins: - spica cast: - anesthesia: eventhough this is not an operative procedure, some patients may require GEA; - key to minimizing the amount of shortening is to place lower extremity in relaxed position; - involves hip flexion, abduction, external rotation & knee flexion; - position & alignment of the frx frag are checked by periodic x-rays; - do not allow distraction of the fragments to take place; - references: - Modified functional bracing in the ambulatory treatment of femoral shaft fractures in children. - Functional fracture-bracing of long-bone fractures of the lower extremity in children. - Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilization. - Improved treatment of femoral shaft fractures in children. The "pontoon" 90-90 spica cast. - Remodelling of angular deformity after femoral shaft fractures in children. - Early spica cast management of femoral shaft fractures in young children. A technique utilizing bilateral fixed skin traction. - Immediate spica cast system for femoral shaft fractures in infants and children. - Rotational deformity and remodeling after fracture of the femur in children. JR Davids. CORR. Vol 302. 1994. p 27-35. - Operative Intervention: - children who have uncontrolled muscle spasticity, such as those w/ head injuries or severe cerebral palsy, do not tolerate external immobilization well; - in the study by JO Sanders et al, the authors determined preferance patterns of various femoral fracture patterns in children by pediatric orthopedists and whether it is practice dependent; - the authors noted a statistically significant trend by pediatric orthopedists to treat older children's femur fractures operatively and younger children's nonoperatively; - avascular necrosis after rigid rodding remains a concern; - ref: Treatment of Femoral Fractures in Children by Pediatric Orthopedists: Results of a 1998 Survey. - intramedullary nailing of pediatric femoral fractures: - external fixation:

- sliding hip screw fixation: - sliding screw is inserted just proximal to the proximal femoral physis; - ender rod fixation: - in the report by Cramer KE et al ender rod fixation for pediatric femoral shaft fractures evaluated in a prospective study; - 57 frx in 52 patients were evaluated; - patients were younger than 14 years, and had fractures in the middle 3/5, and canal size greater than 7 mm; - there were no delayed unions and all fractures healed within 12 weeks;
- Complications: - overgrowth: - Femoral shaft fractures in children: a prospective study of the overgrowth phenomenon. - Prediction of overgrowth in femoral shaft fractures in children. - Overgrowth of the femur following fractures in children: influence of handedness. - Femoral shaft fractures in children: the effect of initial shortening on subsequent limb overgrowth.

Summary Reporthttp://www.medscape.com/viewarticle/408516

Pediatric Femoral Shaft Fractures

from Medscape General Medicine [TM] Posted 02/22/2000 Brian E. Hakala, MA, MD, DuPont Hospital for Children, Wilmington, Del. John S. Blanco, MD, Kluge Children's Rehabilitation Center, Charlottesville, Va.

Abstract and Introduction

Abstract
This article reviews the epidemiology, evaluation, etiology, and treatment of pediatric femoral shaft fractures. Multiple methods of treating these fractures are available. Knowledge of the child's age, fracture type, associated injuries, and other factors enable one to choose a method of treatment. An understanding of potential complications and how to avoid them will also help attain an optimal outcome.

Introduction
Femoral shaft fractures are a common and temporarily disabling injury in children. Recent advances in adult orthopaedic traumatology have led to a more aggressive approach to the child with a femur fracture. Similar to the adult, the child's femur can fracture at the level of the hip, more distally at the knee, or throughout the length of the femoral shaft. However, pediatric femur fractures differ with regard to etiology, optimal method of treatment, as well as response to treatment, and complications. A thorough understanding of these differences is essential to appropriately treat an individual patient. Multiple treatment options are available, and controversy remains over which method is superior in a given situation. It is imperative that the treating physician balance several factors, including patient and parent preference, when selecting a method of treatment.

Epidemiology Fractures of the femoral shaft account for only 1.4% to 1.7% of pediatric fractures.[1-2] Because of the high incidence of childhood fractures, however, a femoral shaft fracture is not an uncommon occurrence in a pediatric emergency department. Pediatric femoral shaft fractures are more common in males with approximately a 2.5:1 male to female ratio.[3] The age distribution is bimodal, with peaks in the younger than 5 years and mid-teenage groups. This distribution is attributed to the relative weakness of woven bone in the young child and the increased incidence of high energy trauma in teenage children. Emergency Department Evaluation After initial assessment of airway, breathing, and circulation, additional medical evaluation to rule out associated injury should be undertaken.[4] Waddell's Triad--an intra-abdominal or intrathoracic injury, a skull fracture, and a femoral shaft fracture--should be ruled out. Blood loss from a femoral shaft fracture may be significant; however, it is uncommon for blood loss from an isolated femur fracture to necessitate transfusion.[5] Ligamentous stability of the knee should be evaluated if possible.[6] Radiographs of the hip and knee should be obtained in all patients with femur fractures (Figure 1). Temporary immobilization with a splint or portable traction device should be used to minimize discomfort and soft-tissue trauma. A thorough neurovascular examination should be performed. A search for lacerations in the area of the fracture is important to rule out an open injury requiring urgent care and more aggressive stabilization. Figure 1A. (click image to zoom) AP radiograph of 6-year-old boy (struck by car) demonstrating fracture of the right femur, dislocation of the right hip, and fracture of the left femoral neck. Figure 1B. (click image to zoom) CT scan.

Etiology While most femoral shaft fractures are associated with accidental trauma, child abuse must be considered, particularly in children younger than 1 year.[7] As many as 30% of femoral shaft fractures in children younger than 4 years may be the result of child abuse, and the most common cause of femur fractures in the nonambulatory infant is nonaccidental trauma.[8] Factors suggestive of child abuse include bruises, burns, multiple fractures in various stages of healing, and late presentation. Osteogenesis imperfecta,[9] stress fractures,[10,11] and pathologic fractures may also be encountered. Aneurysmal and unicameral bone cysts, nonossifying fibroma, and eosinophilic granuloma also may lead to pathologic fracture in the child. Classification Diaphyseal fractures are classified based on their pattern, degree of comminution, and softtissue disruption, if open. Fractures may be transverse, oblique, or spiral. Transverse fractures are often produced by a direct blow to the limb, while torsion often produces a spiral

fracture. High energy injuries produce more comminuted fractures. Children may also sustain fractures of the femoral neck and intertrochanteric region, as well as proximal or distal growth plate fractures. This latter group of fractures is beyond the scope of this review, so readers are referred to other sources for a description of these injuries.[12,13] Historical Treatment Horizontal traction was advocated by Buck in the 1860s. Bryant, however, advocated vertical traction. Hamilton, practicing in the 1890s, recommended splint treatment for femoral shaft fractures. Spica casting was begun in the 1890s at Johns Hopkins University. In 1940, Kuntscher[14] described intramedullary nailing. Blount[15] recommended casting with or without traction and believed that surgery was almost never needed.More recently, better results were reported when adolescents and children with head injuries are treated operatively in comparison to those treated nonoperatively.[16] Decision Making Age, fracture pattern, fracture location, soft-tissue injury, the presence of other fractures, physician and family preference, and the social situation all affect the treatment of a child with a femoral shaft fracture. Treatment modalities include the Pavlik harness, traction, immediate spica casting, traction followed by spica casting, external fixation, plating, flexible nailing, and intramedullary nailing. Section 1 of 5 Dr. Hakala is a Clinical Fellow in the Department of Orthopaedic Surgery, duPont Hospital for Children in Wilmington, Del, and Dr. Blanco is Associate Professor of Orthopaedic Surgery, Division of Pediatric Orthopaedics, Department of Orthopaedic Surgery, Kluge Children's Rehabilitation Center, Charlottesville, Va. Hakala BE, Blanco JS. MedGenMed 2(1), 2000 [formerly published in Medscape Orthopaedics & Sports Medicine eJournal 4(1), 2000]. Available at: http://www.medscape.com/viewarticle/408516
Medscape General Medicine 2(1), 2000. 2000 Medscape