A Little Bundle of…Pediatric Emergencies

If you’re the spine specialist on call at 2 a.m. and hear, “Doctor, there’s an infant in room five who’s crying and can’t move his leg, ” you may feel a bit panicky. Naturally so, given that the majority of orthopedists do not work with children and thus are not familiar with the conditions that they fall prey to.

Dr. James McCarthy, Associate Professor of Orthopedics and Rehabilitation at the University of Wisconsin School of Medicine and Public Health, explains, “Many of my non-pediatric colleagues do not frequently see many of the unusual and often serious orthopedic issues that befall children, and they get nervous when a child shows up in the ER and needs orthopedic care. It is important, however, that those who take call develop the skills to assess what are often emergency situations that can result in loss of a limb or in some cases, a life.”

Tracking Down Killer Bacteria

One of the most serious conditions sounds like it belongs in a macabre film. Dr. McCarthy: “Necrotizing fasciitis, an infection that can evolve from a simple scrape to the knee, is often called ‘flesh eating bacteria.’ This is actually a misnomer because the bacteria is not the problem…it’s the toxins they produce. A child can scrape his knee and the next day or two have pain that is significantly out of proportion to the minor injury. A fever comes on fast, and the child’s blood pressure is unstable. If the doctor on call can’t quickly diagnose the condition, then the fascia will be affected, and the child may lose his or her limb or life.”

What else should the doctor be on the lookout for? “Keep an eye out for a rash that looks like cellulitis, but is more tender, ” recommends Dr. McCarthy.

Ultimately you can’t diagnose this condition unless you do an MRI or a biopsy. The main thing to remember is that the condition progresses so quickly that you can’t afford to lose any time. An MRI can take 30 to 45 minutes—if you can get one right away. A biopsy can be done at the patient’s bedside. A non-pediatric orthopedist may only see this condition once or twice in a lifetime—but you don’t want to remember that situation as being one where the child lost a leg or died.

Dr. Peter Pizzutillo, Professor at the Drexel University College of Medicine in Philadelphia, adds, “It is difficult to pinpoint the true incidence of necrotizing fasciitis because the related research often involves both children and adults. We have seen an increase over the last five years, however, with recent literature indicating that there are approximately 1500 cases per year in the U.S. and a 30% mortality rate. Some of the factors involved in mortality are a delay of treatment for more than 24 hours, using the wrong antibiotics and failure to aggressively debride all of the involved tissue.”

But the old fashioned, simple techniques of observation and palpation can save a limb or life. Dr. Pizzutillo: “The child doesn’t necessarily look like they are in bad shape. You will typically find, however, that the skin is warm, red, swollen, and tender. If it is an infection of the fat then the skin is tender if you push on it—but there is not much discomfort. With necrotizing fasciitis, however, there is increasing pain. If you suspect this condition, you should immediately order an MRI because it will give you multiple facets of information. You will see early bony changes that would not show up on an Xray. You will also be able to see if it is osteomyelitis, myositis, or cellulitis.”

Skip the body scan, though, advises Dr. Pizzutillo, and don’t use other outmoded diagnostics. “Don’t do a CT scan because it will not let you visualize the soft tissue. And, while in the past we would often wait to see if there was gas or air under the skin, we now know that this is a later sign—and it could be dangerous to wait. Let’s say you don’t do anything and think that it’s cellulitis. The area will become more tense and firmer to the touch; then it will look black and blue because there has been some insult to the veins and capillaries. Next you will see large blisters appear, accompanied by a feeling of gas moving under the skin. Then the area will die. Before it gets this far, however, you should be aggressive about removing any tissue that looks unhealthy.”

“This is not the time to be fainthearted, ” continues Dr. Pizzutillo. “You should not make a peephole incision, but one that extends, for example, from the ankle to the groin. Essentially, you have to keep operating until you find normal tissue, along the way making sure that the patient has fluids and that the blood pressure is monitored frequently. The bacteria can travel up to the abdomen in a matter of days. Once in the abdomen the mortality rate increases to 65%. It’s incredible, but it spreads up the fascia—the superhighway of the leg.”

Testing for Septic Arthritis

Another pediatric condition in which bacteria is on the prowl is septic arthritis. Dr. McCarthy states, “This condition, which involves an infected joint, is most likely to affect children and the elderly. When the joint gets infected, the cells that fight the infection secrete enzymes that can be harmful to the joint. While it is not life threatening, there is a real risk to long term morbidity due to joint destruction. In some joints septic arthritis is easy to diagnose, but in the hip it is not so clear cut. Children generally won’t express pain when they rotate their hips; infants typically start crying and may not be able to move their leg.”

The unlucky, say, foot and ankle specialist who pulls the curtain aside and finds such a case needs to know how to test for the bacteria. Dr. McCarthy: “If not treated correctly, this condition destroys the hip. Getting a combination of lab values, as well as fluid from the hip joint will let you know if the joint is infected.”

Dr. Pizzutillo adds,

If you suspect septic arthritis, I recommend getting an ultrasound of the hip early on. If you don’t act quickly, this condition can destroy not only the cartilage, but the growth plate. The child can end up with a 30% loss of the thigh bone and a difference in leg length of six or seven inches. Once the hip dislocates the blood supply to the hip dies and the child is essentially left without a hip.

Having an immediate conversation with the parent(s) can yield information that can point the attending orthopedist in the right direction. Dr. Pizzutillo advises, “If the child is a toddler the first thing the parents usually notice is a limp—the child is walking normally one day and the next day he or she starts limping. Actually, depending on the bacteria they may not want to bear weight on it at all.”

“Infants who are still crawling will show no signs of this condition except that they stop eating, ” continues Dr. Pizzutillo. “At our facility if we have a baby who is not eating we then look for infection everywhere. If we can’t come up with a problem in other systems, such as the bladder or kidney, then the physical exam will usually show some limitation of joint motion. Also note that the child will not necessarily have a fever. I would recommend consulting with a pediatrician on these cases as they usually have a high index of suspicion for septic arthritis.”

Fixing Fractures in Children

The hip is also prone to other grave “mischief, ” namely, fractures. “These are not very common in children, ” explains Dr. McCarthy, “but they are difficult to treat, with estimates of complication rates up to 60%. If not treated within 24 hours there is an increased chance of avascular necrosis of the femoral head, as well as long term disability. Fortunately, hip fractures are usually easy to diagnose via Xray and a careful (hip) exam.”

And what might the imaging show? Dr. McCarthy: “There are four kinds of hip fractures, transepiphyseal, transcervical (the most common), cervicotrochanteric, and intertrochanteric. Treatment for each of these will involve some degree of reduction, joint decompression, and stable fixation. The managing orthopedist should aim for gentle traction, abduction, and internal rotation.”

Going into detail, Dr. McCarthy notes, “It is preferable to avoid crossing the physis with the fixation device, but stability is ultimately more important. If the child is less than three years old you would use smooth pins, and perhaps cannulated screws for older children.”

An attending orthopedist might also meet a youngster who has taken a spill from a jungle gym or come crashing down after a pillow fight, and landed on her elbow. Dr. Pizzutillo explains, “Supracondylar fractures of the elbow are the most common elbow fracture in children. Doctors dread seeing this condition because of the potential for compartment syndrome. Approximately 2% of these patients have major blood supply issues, while 7% have neurologic problems such as injury to the anterior interosseus nerve (leaving them unable to pinch with the thumb and index finger). With compartment syndrome, it is a direct trauma that makes the muscles swell, and that swelling is occuring in a rigid environment. Because the compartment is made of a tough material and doesn’t stretch, any swelling adds a lot of pressure and prevents blood from going into the muscle and draining…so the muscle and nerve dies.”

As for treatment of compartment syndrome, Dr. McCarthy recommends, “first make the diagnosis, then get the patient to the OR urgently (within six to eight hours of the injury).”

Open fractures, says Dr. Martin Herman, a pediatric orthopedic surgeon at St. Christopher’s Hospital for Children in Philadelphia and Associate Professor of orthopaedic surgery at Drexel University College of Medicine, are particularly dicey. “When the bone is exposed to air there is a particular risk of infection. To address this possibility, the child should be given antibiotics as soon as he arrives in the ER, along with a tetanus shot update if necessary. Inspect it, noting its size, contamination, bone exposure, and level of hemorrhage. You should also perform a careful neurovascular assessment, ideally prior to the administration of pain medication or intubation. Then you apply a sterile dressing, grossly realign the limb and splint, and take radiographs of the entire bone.”

Sharing his OR experience, Dr. Herman adds, “Only debride tissue that is obviously non-viable, and leave questionable tissue for a second look later. Consider releasing compartments in severe injuries or in a child with a head injury, regardless of the pre-operative neurovascular assessment. A VAC (Vacuum Assisted Closure) dressing may be applied to large open wounds, and fasciotomy wounds. Fractures associated with small open wounds with minimal swelling and that are stable after reduction may be treated with cast immobilization and not fixation. Fracture stabilization, however, is indicated for most open fractures. And while the ideal duration is undetermined, it is generally thought that IV antibiotics should be administered for 48 hours after surgery. Several debridements may be necessary, and should occur at 24-48 hour intervals. And depending on the degree of soft tissue injury, you may want to call in a plastic surgeon for a consult.”

Treating Multiple Injuries

When do you really need to pull out all the stops (and pull in all the specialists)? When a child has multisystem trauma. Dr. Herman: “What often appears to be an isolated injury can actually be a number of injuries all at once, including head and thoracoabdominal injuries. The mantra here is: don’t expect the orthopedic surgeon to be the only person involved—you will need a neurosurgeon and a general surgeon. You might have, for example, a closed head injury, liver laceration, displaced supracondylar elbow fracture, right femoral shaft fracture and a fracture of the distal femur. In such a situation you would immediately do damage control orthopedics—manage any hemorrhaging, attend to soft tissue problems, and do external fixation or splinting to limit the amount of initial surgery. When the child is more stable, other procedures can be done to definitively manage fractures and other injuries, usually within several days.”

Dr. Herman continues, “After the initial assessment for life or limb threatening injuries, get the initial imaging to include radiographs and CT scans of the head, neck, thorax, and abdomen. Then do a more thorough orthopedic evaluation by examining not just the obvious sites of injury but all extremities and the spine. You should, among other things, look for swelling of the extremities, deformity, crepitus, and limited range of motion.”

Some of the most important things to consider in a multisystem trauma situation, says Dr. Herman, are continual reassessment and having enough resources.

We get better outcomes with these patients when they are assessed frequently and when the trauma team is able to accurately anticipate possible complications. And you’ve got to have enough of a team to get the job done. Don’t be scared to enlist the help of an attending or two if necessary.

Even after listening to the sage advice of these three doctors, there is still much more to learn. That is why, say Drs. Herman, Pizzutillo, and McCarthy, it is important to attend instructional courses in pediatric orthopedics at venues such as the annual meeting of the American Academy of Orthopaedic Surgeons, as well as the specialty societies. After all…more training, less trepidation.