Musculoskeletal Disorders in Children

1. Musculoskeletal Disorders in Children Brian Romito, DO PGY IV IM/ER March 2, 2006 Presented Dr Marty Hellman

2. 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

3. 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”

4. 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

6. 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

7. SH Fx for 100 • Type II: closed reduction of any displacement • Immobilization, Ice, elevation • Ortho follow up • Don’t forget the pain meds…

8. 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

9. 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

11. 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

13. 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

15. 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

16. 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

17. Fx Humoral Diaphysis (Uncommon) • Suspect Abuse, strong Force Required!!! • Closed reduction maybe required • Radial Nerve Injury assoc • Document Radial Nerve Function!!!

19. 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

21. 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

23. 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

24. Distal Humoral Physeal Fx • Twisting MOA, shears off distal epiphysis • Often Abuse • Often < 2yrs age

25. 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

27. Radial head Fractures • Uncommon in children • Radial neck > Radial Head • Most common MOA; Fall • Ortho consult obtained to guide Tx

29. 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

33. 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

34. 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)

36. 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

37. Monteggia

38. Galeazzi

39. 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

40. Scaphoid fx

41. 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

42. 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

43. 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

44. Post Hip dislocation

45. 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

46. Slipped Capital Femoral Epiphysis

47. 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

48. 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…

49. Patellar dislocation

50. Patellar dislocation