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Musculoskeletal Disorders in Children. Brian Romito, DO PGY IV IM/ER March 2, 2006 Presented Dr Marty Hellman. Fracture Patterns. Weakest layer is the physis (growth plate) Hypertrophic cell zone Susceptible to shearing/bending  yields fracture

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musculoskeletal disorders in children

Musculoskeletal Disorders in Children

Brian Romito, DO

PGY IV IM/ER

March 2, 2006

Presented Dr Marty Hellman

fracture patterns
Fracture Patterns

Weakest layer is the physis (growth plate)

Hypertrophic cell zone

Susceptible to shearing/bending  yields fracture

Peds; 2 types of Fracture (Fx); Open Physis vs closed Physis

definitions
Definitions
  • Physis; ephyiseal cartilage
  • Epiphysis; part of long bone (not shaft) a center of ossification, separated from shaft by layer of cartilage
  • Metaphysis; a conical section of bone b/t the Epiphysis & diaphysis of Long Bones
  • Diaphysis; “THE SHAFT”
salter harris classificaion
Salter Harris Classificaion
  • Type I: epiphysis seperates from Metaphysis thru the Growth Plate only
  • Type II: Thru Physis & Metaphysis
  • Type III: Thru Physis & Epiphysis
  • Type IV: Thru Epiphysis, Physis & Metaphysis
  • Type V: Crushing of Condrocytes; Physis Crushed
tx of salter harris fx s
Tx of Salter Harris Fx’s
  • Type I:
  • Pt tenderness over physis after injury; joint swelling & joint effusion possibly seen on Xray
  • Periosteal attachments intact
  • Low risk of growth disruption
  • Splint, cold compress & elevation
sh fx for 100
SH Fx for 100
  • Type II: closed reduction of any displacement
  • Immobilization, Ice, elevation
  • Ortho follow up
  • Don’t forget the pain meds…
salter harris fx tx for 200
Salter Harris fx tx for 200
  • Type III:

Open Reduction definative Ortho Tx

Type IV: ORIF

Type V: Casting, Ortho monitoring, anticipation of Bone growth arrest

torus fractures
Torus Fractures…
  • Buldging or buckling of periosteum “AKA Bluckle Fx”
  • No visible difformity 2 shape of extermity, soft tissue swelling and tenderness.
  • Reduction rarely necessary, splint, ortho follow up
greenstick fx s
Greenstick fx’s
  • Cortical disruption & periosteal tearing on the convex side of the bone and intact periosteum on the concave side of the Fx
  • More stable & less Pain than complete Fx
  • Need for reduction is determined by the angulation of Fx, age of child, anatomic location of injury
clavical fx for 500
Clavical Fx for 500

2 distinct times; newborn childbirth & childhood

Fx newborn usually birth Injury, may have upper extemity bracheal plexus injury (palsy) or paralysis 2º pain

DO NOT need specific Tx, pain control and careful handling of infant

clavical fx for 1000
Clavical Fx for 1000
  • Childhood Fx possibly abuse
  • Middle 1/3 most common
  • Tx Arm Sling
  • Lateral or medial end may require ORIF b/c ligamentous attachments
humoral fx ha ha ha not
Humoral Fx, ha ha ha NOT
  • May occur at Proximal humorus, humoral dyaphsysis and supracondylar fx
  • Fx Proximal Humorus good healing…May occur at physis or proximal humoral metaphysis
  • Physeal Fx; more common in adolescence; relatively weak during growth spurt
  • Proximal Humoral Metaphyseal Fx are more common in Pre-adolesence
  • Tx depends on age of child & degree of displacement
  • >30º displacement often need closed reduction & immobilization
fx humoral diaphysis uncommon
Fx Humoral Diaphysis (Uncommon)
  • Suspect Abuse, strong Force Required!!!
  • Closed reduction maybe required
  • Radial Nerve Injury assoc
  • Document Radial Nerve Function!!!
supracondylar fx
Supracondylar Fx
  • Most common Fx child < 8 peak 5-7y/o’sCause; fall on out stretched Hand
  • Classification based on Fracture fragment displacement
  • Type I: minimal to no displacement stable
  • Type II: displaced w/ variable displacement but Posterior cortex intact Ortho consult
  • Type III: Need Ortho consult
  • IIIa: Post med rotated; radial nerve risk damage
  • IIIb: Post Lat rotated; bracheal art & med nerve risk
lateral condylar fx
Lateral Condylar Fx
  • Usually Salter Harris IV; 10% of elbow Fx in children
  • Varous stress with forearm in supination (arm up & flat)
  • Complications; nonunion, malunion, osteonecrosis, cubitus valgus, pardy ulnar nerve palsy
  • STAT Ortho CONSULT
medial epicondylar fx
Medial Epicondylar Fx
  • 10-14y/o’s
  • Not TRUE SH fx
  • Simple Fx of Medial Epicondyle are Extra-articular limited soft Tissue involvement
  • ½ assoc w/ elbow dislocation
  • Ortho Consult
distal humoral physeal fx
Distal Humoral Physeal Fx
  • Twisting MOA, shears off distal epiphysis
  • Often Abuse
  • Often < 2yrs age
olecranon fx
Olecranon Fx
  • Gen result from fall to elbow
  • If displaced < 5 mm may be immobilized
  • > 5 mm displacement Ortho Consult
  • Maybe part of Monteggia lesion, careful eval of Radial head
radial head fractures
Radial head Fractures
  • Uncommon in children
  • Radial neck > Radial Head
  • Most common MOA; Fall
  • Ortho consult obtained to guide Tx
elbow dislocation
Elbow Dislocation
  • Most freq males, fall outstretched Hand
  • Most common POSTERIOR dislocation
  • Neuro Injury ~10%; ulnar neuropathy most common
  • Assoc w/ Medial Epicondyle entrapment
  • Arterial Injury rare
  • Obtain Post reduction film
  • Good long term prognosis
nurse maid s elbow
Nurse Maid’s Elbow
  • Peak 2-3 yo Girls> boys L> Right
  • MOA; sudden longitudinal traction on outstreatched arm
  • Annular ligament of Radius displaces into Radio-capitellar articulation (baby will not move arm)
  • Adducted semiflexed in Prone position (think Jerry’s kids)
  • No significant pt tenderness to palpation
  • Attempts to pronation/supination PAIN
reduction nursemaid s elbow
Reduction Nursemaid’s Elbow
  • Supination technique: hold elbow 90º firmly supinate the wrist, then flex elbow (firmly)
  • Hyperpronation Technique: hold elbow 90º & firmly pronate wrist
  • Full arm function should return w/in 30 minutes…if not consider Alternative to diagnosis (ie fracture)
forearm injury s
Forearm Injury’s
  • Isolated injury to ulna is extremely rare… typically same force causes fracture/dislocation to Radius
  • Combination of Ulnar Fx + Dislocation Radial Head = Monteggia Fx; immediate eval by Ortho
  • Galeazzi Fx; radial shaft fx, w/ assoc dislocation of distal radioulnar joint; immediate ORTHO eval
wrist injuries
Wrist Injuries
  • Fx of Carpal bones quite rare in children
  • Scaphoid fx in older kids MOA; Fall outstretched Hand w/ snuffbox TTP, suspected fx even w/o radiographic finding; thumbspika splint and Ortho f/u
phalangeal fx
Phalangeal Fx
  • Most common injury to distal phalanx is child catches his or her hand in a door
  • Any distal Tuft fx be immobilized
  • If nail bed injury “Open” Antibiotics indicated
  • Significantly rotated or displaced fx need reduced & Ortho Consult
and no hitting below the belt
And No Hitting BELOW THE BELT
  • Pelvic Fx; Infrequent in Peds… due to cartilage

Require tremendous Force, except Avulsion injury due to sudden muscle contractions (ie kicking soccer ball), mngt conservatively… Ortho Referral

NON-avulsion; Most common MOA; MVC

hip injury
Hip Injury
  • Proximal Femur Fx; rare… Involving head or Neck of Femur  risk of Avascular Necrosis & Growth Arrest (unlike Trochanteric & Subtrochanteric Fx)
  • Hip Dislocations; Most (in adolescence) POSTERIOR & Trama… < 10yrs can occur w/ minimal trauma. IF Reduction in > 6 hrs, 20X risk of Avascular Necrosis of Femoral Head
lower extemity for 200
Lower Extemity for 200
  • Femoral Shaft Fx; Significant Force Boys> Girls

Falls, MVC, Ped vs Automobile, ABUSE if KID NOT WALKING YET!!! Immediate ORTHO CONSULT

Slipped Capital Femoral Epiphysis; most common cause hip disability in Adolesence… Obese, boys 3x >girls. Sx Hip pain or reffered pain to thigh or knee. Adolescent c/o groin, hip, thigh or knee pain B/L hip radio graph. Ortho consult even if no XRAY evidence per Hx

knee injuries
Knee Injuries
  • Ligamentous Injury < common than Fx
  • OTTAWA Knee rules validated for ≥ 2y/o

need xray; > 55y/o, TTP Fibular Head, Isolated TTP Patella, Inability flex knee to 90º, inability to take 4 steps immediately after injury & in ED

Fx thru Distal Femoral Physis; uncommon, signif complications… popliteal artery lies close to Dist Metaphysis, peroneal Nerve may be injured… risk Growth Arrest 2º physeal damage

knee injury for 500
Knee Injury for 500
  • Patellar dislocation; most common cause of traumatic Hemarthrosis in children… MOA pivot knee of fixed LE

May reduce w/o waiting for XRAY. XRAY post REDUCTION

Proximal Tibial Injury; ACL inserts on tibial emminance… ligament & insertion much stronger than epiphyseal bone in kids…

tibial tuberosity fx 3 types
Tibial Tuberosity Fx; 3 types;

Tpye I; Fx thru small distal portion tibial tuberosity; Tx; immobilization

Type II Fx; Fx splits the growth plate of the tuberosity of the proximal tibia

Type III; Involve joint; risk compartment syndrome

Displaced Type II & III need reduction & immediate Ortho Consult

knee injury for 1000
Knee Injury for 1000
  • Proximal tibial Physis Fx; uncommon, most SH Type I. Vascular injury to Popliteal Artery risk

DOCUMENT INTACT PULSES!!!

tib fib fx
Tib Fib Fx
  • Toddler’s Fx; spiral Fx Distal 1/3 of tibia…

child limping, unable to bear wt

pain w/ palpation & rotation distal tibia… Xray maybe normal, F/U Bonescan or xray 1 week Immobilize long leg splint w/ Ortho F/U

ankle injuries
Ankle Injuries
  • May involve distal tibula, fibula or both. Most SH type I, SH type III 25% of distal tibial fx & require ORIF
  • Tillaux Fx; SH III of Anterior LAT portion of Distal tibia surgical reduction
  • Triplane fx; Sagittal, Coronal & Transverse planes… SH IV Multiple Fx Fragments… ORTHO
foot phalanx fx
Foot & Phalanx Fx
  • Hind foot = calcaneous & talus
  • Mid foot = navicular, cuboid, 2nd 3rd cuneiforms
  • Metatarsals
  • Phalanges

Fx to forefoot common… hind & mid foot uncommon

Non-displaced fx metatarsals & phalanges splint & Ortho referral

Displaced Fx & intra-articular involvement may require ORIF

septic arthritis acute
Septic Arthritis (Acute)
  • < 3y/o’s most common; knee>hip>elbow
  • Hematogenous route
  • Early;  synovial fluid & protein, PMN > 50K, glu
  • Neonates do NOT appear ill, ½ of time NO Fever
  • Older child; Fever, localizing signs
  • Plain films No Dx early on… widening joint space Joint effusion late findings on XRAY
  • D/dx; trauma, sickle cell, JRA, Osgood Slaughter, etc
septic arthritis for 200
Septic Arthritis for 200
  • Labs; CBC, Blood Cx, ESR, CRP, Throat Cx
  • ½ WBC < 15K
  • 90% ESR> 70
  • New borns; Group B-strep, GNR, Neisseria, Staph
  • Infant; staph, strep, H Flu, GNR
  • Child, Staph, Strep, GNR, Neisseria,
henoch schonlein purpra
Henoch-Schonlein-Purpra
  • Purpura, arthritis, abdm pain & Hematuria
  • Small vessel vasculitis mediated by immune complexes
  • Purple palpable Rash; initially blanches, trunk, buttocks, pereum, lower extremities
  • GI tract involved risk Hemmorrahge
  • Arthritis; knees & Ankles
  • Supportive care, Admit, IFV, Tylenol prn
  • Complications; bowel perf, ARF, Nephrotic Syndrome
juvenile rheumatoid arthritis
Juvenile Rheumatoid Arthritis
  • 3 types; Oligo Arthritis, polyarticular, systemic
  • Oligo; 1+ joints of LE; permanent joint damage uncommon
  • Polyarticular; sim to Adult presentation, C-spine common w/ risk of AtlantoAxial subluxation, 20 to 40 separate joints affected
  • Systemic; Fever >39 min 2weeks, chills, rash on trunk palms & soles (also RMSF, Syphylis, Hand-foot mouth Dz)

Often Hepatosplenomegally, pleuritis, pericardial effusion

Require Arthrocentesis to R/O suppurative arthritis… admit if in Doubt

kawasaki dz
Kawasaki Dz
  • 80% present < 4yrs… 95% present < 10y/o
  • Acute febrile vasculitis of childhood… involves coronary arteries
  • Diagnostic Criteria; Fever 5 days duration (100%), B/L conjunctivitis (85%), ’s oral mucosa (90%), Erythema extemities (plams & soles) 75%, Polymorphish rash (80%), Cervical Lyphadenoplathy 70%
  • Assoc Features; arthralgia, arthritis, thrombocytosis, aseptic meningitis, hepatitis, cardiac (Coronary A aneurysms, myocarditis, percarditis, dysrrhythmias), Mitral or Aortic insufficency

Tx; IV IG, ASA (100mg/kg/day)

legg calve perthes dz
Legg-Calve-Perthes Dz
  • 80% b/t 4-9y/o range is 2-13y/o’s
  • Avascular necrosis of the femoral Head
  • Male: Female 4:1
  • Mild Hip pain,limp progressive over weeks to months
  • 4 stages; initial, fragmentation, reossification, healed
  • Initial Xray; widening of cartilage space
  • 2nd Xray sign; subcondral stress Fx line Femoral Head
  • 3rd;  radio opacity of Femoral Head (new bone deposited on avascular trabeculae)
  • Further distortion of femoral head & subluxation
osgood schlatter dz
Osgood-Schlatter Dz
  • Apophysitis of Tibial tubercal; over use or normal use… insertion of petallar tendon
  • Series of micro avulsions
  • 10-15 y/o’s Boys > Girls
  • More common in running or jumping athletes
  • Self limited Dz improves w/ conservative Therapy
post streptococcal reactive arthritis
Post Streptococcal Reactive Arthritis
  • Group A Strep Infxn w/ symptom free interval followed by Aspetic inflammation of 1+ joints
  • 10 days after strep Infxn; acute rheumatic F 21 days post Infxn
  • PSRA = Non-migratory mono or oligo arthritis, freq assoc Erythea Nodosum, or Erythema Multiforma

TX: NSAIDS, antibiotic prophylaxis contraversial

  • ARF= polymigratory Arthritis
acute rheumatic fever
Acute Rheumatic Fever
  • GABHS infection; mucoid types 3, 5, 18
  • Connective tissue of Heart, Joints, CNS, Sub Q tissues of skin targeted by immune RXN
  • Carditis, valvulitis; mitral & aortic valves
  • Arthritis is periarticular
  • Jones Criteria; Major; carditis, migartory arthritis, chorea, erythema marginatum (serpintine rash), Sub Q nodules
  • Minor Criteria; fever, arthralgia,  ESR/CRP, prolonged PR interval,  ASO titer
  • Tx: Admit, consult Pediatric Cardiologist, High dose ASA (75 to 100mg/kg/day), PCN, ? Steroids if CHF
transient synovitis of the hip
Transient Synovitis of the Hip
  • Benign self-limited process of the Hip…
  • 8x > freq than septic arthritis Children b/t 3 to 6 yrs
  • Most Post Viral, ? trauma, bacterial, or Post Vaccine
  • Pts at risk for Septic Arthritis w/ temp > 38.5 ESR>20

Leukocytosis, severe Pain, TTP of joint, spasm, refusal to walk

Joint Aspirate if suspect septic arthritis, if periphrial WBC, ESR  and hip effusion…

Synovial fluid; Gram Stain, Aero/anaerobic cx, AFB

Tx NSAIDS, limit activiy 1 to 2 weeks

slide74
Quiz
  • A type II SH Fracture is a fracture thru

A) Physis

B) Physis & Metaphysis

C) Physis & Epiphysis

D) Physis, Epiphysis, metaphysis

2) A Monteggia Fracture is

A) A radial head fracture w/ Posterior radial dislocation

B) Ulnar Fracture w/ Anterior dislocation of Proximal Ulna

C) Ulnar Fracture + Dislocation Radial Head

D) Radial shaft Fracture + Dislocation of Ulna

slide75
Quiz

3) A Galeazzi fracture is:

A) A radial head fracture w/ Posterior radial dislocation

B) Ulnar Fracture w/ Anterior dislocation of Poximal Ulna

C) Ulnar Fracture + Dislocation Radial Head

D) Radial shaft Fracture w/ assoc dislocation of distal radioulnar joint

4) Jones Criteria for Acute Rheumatic fever

A) carditis

B) Migartory arthritis

C) chorea

D) erythema marginatum (serpintine rash)

E) Sub Q nodules

F) All of the above

G) A, B, and C

slide76
Quiz

5) Regarding Nurse Maids Elbow;

A) The Radial Annular ligament displaces into Radio-capitellar articulation

B) A horizontal torsional force causes a perpendicular translational force on the radius thus dislocation

C) The elbow must have rapid extension for cure

Answers:

1) C 2) C 3) D 4) F 5) A