Regarding distal humeral fractures in children, which ONE of the following statements is CORRECT?
Answer: B: Lateral condylar fractures account for 15–20% of all elbow fractures in children (most common between 6 and 10 years) and should be sought in elbow injuries in children. The ossification centre for the lateral condyle appears between 18 months and 2 years of age and the ossification centre for the lateral epicondyle appears between 11–13 years. These fractures are unstable even with cast immobilization due to the pull from the forearm extensors. The diagnosis can be difficult because the fracture line may not be visible on AP view or the fracture line appears 7–10 days later. When there is significant displacement there is marked swelling over the lateral elbow both clinically and on X-ray. The lateral view may show the fracture line more clearly, but oblique views are considered the best to determine the degree of displacement and rotation. Multiple oblique views may be needed to accurately differentiate a non-displaced fracture from a displaced one.
A truly non-displaced fracture or fracture that is truly <2 mm displaced (minimal lateral elbow swelling) can be treated with cast immobilization with the elbow at 90 degrees and the forearm in pronation. Early orthopaedic follow-up should be arranged. A fracture that is >2 mm displaced requires open reduction and internal fixation.
Medial condylar fractures are rare (<1%), in contrast medial epicondylar fractures/avulsions occur in 5–10% of children. The ossification centre for the medial epicondyle appears around 5–6 years of age; it fuses with the humerus at 18–20 years of age. Therefore, it does not occur in children <5 years of age. In children older than this, the presence of the medial epicondyle ossification centre should be confirmed when reviewing X-rays in elbow injuries. A medial epicondylar fracture that is <5 mm displaced can generally be treated with cast immobilization. Surgical management is indicated for fractures that are >5 mm displaced.
Compared with supracondylar fractures vascular compromise is uncommon with condylar fractures.
References:
During assessment of a child with a fracture in the distal one-third of the radius, which ONE of the following injuries is MOST likely to be missed in the ED?
Answer: C: Galeazzi’s fracture is one of the most likely fractures to be missed in the ED. This is a fracture of the distal one-third of the radius with dislocation or subluxation of the distal radioulnar joint. Sometimes over-diagnosis may happen due to the inability to obtain a true AP view. In a slightly oblique view of the radius and ulna, unlike in a true AP view, the distal radio ulnar joint may appear subluxed when in fact it is not. The way to circumvent this problem is to look at the ulna styloid and the direction it points to. The ulnar styloid should be pointing to the triquetrum at all times irrespective of an AP or oblique view. If it doesn’t, it is likely that there is a dislocation or subluxation of the distal radio ulnar joint.
In Monteggia’s fracture dislocation, there is fracture of the proximal one-third of the ulna with dislocation of the radial head.
Reference:
Regarding femur fractures in children, which ONE of the following statements is FALSE?
Answer: C: Femoral shaft fractures in children are relatively common and may be secondary to a variety of mechanisms:
Shock is very unlikely to be resulting from an isolated femur fracture in a child. If shock is present, other traumatic causes for the shock such as splenic, liver or pelvic injury should be considered.
Regarding Toddler’s fracture, which ONE of the following statements is FALSE?
Answer: A: Toddler’s fracture is an occult tibial fracture that occurs in children younger than 2 years of age. This usually occurs after a fall; however, often the mechanism is not witnessed by the caregiver. The rotational stress on the distal tibia during the fall causes an oblique distal tibial fracture. The child usually presents refusing to walk or with a painful limp. It is essential to rule out fractures in other sites and issues with the hips through a carefully obtained history, examination and laboratory tests, especially when the fall is not witnessed. The diagnosis of toddler’s fracture is challenging because the fracture is not usually visible on the X-ray during the first week after the injury. When suspected, the fracture should be treated with a long leg cast and the child should be referred for orthopaedic follow-up. Repeat X-ray done in 3 weeks often shows the evidence of the fracture as periosteal new bone formation.
Regarding acute septic arthritis and osteomyelitis in children, which ONE of the following statements is TRUE?
Answer: C: In children both acute septic arthritis and osteomyelitis occur most commonly secondary to haematogenous spread. In a smaller number of children this can be due to direct inoculation from an overlying wound. Osteomyelitis in the metaphysis can spread to the joint, causing septic arthritis in the joint. Direct inoculation to the hip joint may occur during less careful femoral venous access in children. Osteomyelitis in children occur characteristically in the metaphysis of long bones, especially in femur, tibia and humerus. Brodie abscess is a form of subacute pyogenic osteomyelitis usually affecting the metaphysis of long bones or metaphyseal equivalent bones (tarsal and carpal bones, pelvis and vertebrae) mainly in children.
In acute septic arthritis, plain X-ray is frequently normal. Due to a joint effusion, a widening of the joint space may been seen; however, this is a late sign. Ultrasound, CT and MRI should show evidence of septic arthritis including the presence of a joint effusion. Although the spectrum of infecting organisms is dependent on a child’s age, Staphylococcus aureus is the most commonly isolated organism in both acute septic arthritis and osteomyelitis in children across all age groups. There seems to be an increasing incidence of infections due to community-acquired MRSA.
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