Musculoskeletal disorders in children
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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

Brian Romito, DO


March 2, 2006

Presented Dr Marty Hellman

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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 l.jpg

  • 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”

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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

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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

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SH Fx for 100

  • Type II: closed reduction of any displacement

  • Immobilization, Ice, elevation

  • Ortho follow up

  • Don’t forget the pain meds…

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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

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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

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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

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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

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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

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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

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Fx Humoral Diaphysis (Uncommon)

  • Suspect Abuse, strong Force Required!!!

  • Closed reduction maybe required

  • Radial Nerve Injury assoc

  • Document Radial Nerve Function!!!

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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

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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


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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

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Distal Humoral Physeal Fx

  • Twisting MOA, shears off distal epiphysis

  • Often Abuse

  • Often < 2yrs age

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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

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Radial head Fractures

  • Uncommon in children

  • Radial neck > Radial Head

  • Most common MOA; Fall

  • Ortho consult obtained to guide Tx

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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

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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

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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)

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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

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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

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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

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  • 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

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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

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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

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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

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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…

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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

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Knee Injury for 1000

  • Proximal tibial Physis Fx; uncommon, most SH Type I. Vascular injury to Popliteal Artery risk


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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

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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

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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

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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

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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,

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  • 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

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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

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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)

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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

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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

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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

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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

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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

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  • 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

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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

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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


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