MSK Disorders in Children

1
MSK Disorders in Children

• Tintinallis Ch 133

2

• Divide injuries into before and after fusion of
  physes
• Longitudinal growth occurs at the physes (growth
  plates) located at either end. Bony prominences
  that serve as sites of muscular or ligamentous
  attachment are known as apophyses

3
(No Transcript)
4

• Type I
• Low incidence of growth disturbances

5

• Type II
• Growth preserved

6

• Type III
• Bone growth relates to the preservation of
  circulation to the epiphyseal bone fragment
• Prognosis quite favorable

7

• Type IV
• Significant risk of growth disturbance
• Reduction must be percise

8

• Type V
• Usually involves knee or ankle
• Result of profound compression forces
• Diagnosis difficult, often misdiagnosed as Type I

9

• Torus Fracture
• Compression forces
• Buckling or bulging of the periosteum
• AKA buckle fracture

10

• Greenstick Fracture
• Cortical disruption and periosteal tearing on the
  convex side of the bone

11
Upper Extremity Injuries

• Clavicle Fx
• Can occur at birth
• In kids lt2 yo, suspect abuse
• Usually due to FOOSH
• Middle third most common

12

• Humerus Fx
• most treatment conservative but depends on age of
  child
• If displaced gt30 degrees, may need closed
  reduction and immobilization
• Assess radial nerve function
• Consider abuse in small children with fx of
  diaphysis

13
ElbowNormal Radiographs

• Anterior humeral line.
• A line drawn along the anterior cortex of the
  humeral shaft normally intersects the middle
  third of the capitellum.
• A normal radiographic teardrop is seen where the
  cortices of the olecranon and coronoid fossae
  come together (black arrow).
• A small normal anterior fat pad is visible
  (arrowhead).

14

• Type III
• Brachial artery and median nerve at risk of
  injury
• Compartment syndrome may develop

15

• Radiocapitellar line. A and B. A line drawn along
  the long axis of the radial shaft should
  intersect the middle of the capitellum on each
  view.

16

• Treatment Supracondylar Fx
• Type Iimmobilization
• Type II/IIIortho consult, usually requires
  pinning

17

• Lateral Epicondyle Fx
• Salter-harris type IV
• Varus stress on extended elbow
• Usually requires ORIF
• Medial epicondyle Fx
• Older children, 10-14yo
• Half associated with elbow dislocation
• Ortho consult

18

• Distal Humeral Physeal Fx
• Children lt2.5 yo
• Usually abuse
• Due to twisting mechanism
• Olecranon Fx
• Fall on elbow
• Ortho consult, may need ORIF

19
Radial Head Fracture

• Uncommon
• Due to fall

20
Elbow Dislocation

• Usually males
• FOOSH
• Reduction
• Consult ortho if neurovascular injury
• Radial nerve injury rare

21
Monteggia Fx

• Ulnar fx with dislocation of radial head
• Ortho consult

22
Galeazzi Fracture

• Radial shaft fracture with dislocation of distal
  radioulnar joint

23

• Carpal Fx rare in children
• Hallmark is pain out of proportion to exam
• Thumb spica and ortho follow up
• Phalangeal Fx
• Most common is distal tuft fx

24
Lower Extremity Injuries

• Pelvic Fx
• Rare and usually results from significant force
• Most common is ped vs car
• Avulsion type due to sudden contracture
• Most common during athletic activities
• Hip Fx and Dislocation
• rare
• High risk complicationsavascular necrosis and
  growth arrest

25

• Femoral Shaft Fx
• Boys more common
• Falls, ped vs car, mvc, or sport related
• Abuse if in child that is not yet walking

26
SCFE

• Chronic slipping of the femoral epiphysis of the
  hip
• Can get avascular necrosis and premature closure
  of the physis
• Boys more common, age 14-16
• Any adolescent with chronic groin, hip, thigh or
  knee pain needs bilateral radiographs

27
(No Transcript)
28
Knee Injuries

• Ottawa knee rules validated for kids gt2 yo
• Fx Distal Femoral physis
• May injury popliteal artery or peroneal nerve

29

• Patellar Dislocations
• MCC traumatic hemarthrosis in kids
• Pivoting on fixed lower leg
• Usually sits laterally and knee held in flexion

• Patellar Fx
• Direct blunt force
• Ortho consult

30

• Fractures of Tibial Spine
• Equivalent of ACL rupture
• Displaced, needs reduction and ortho consult

• Tibial Tuberosity Fracures
• Due to strong contraction of quad against fixed
  leg
• Sports related
• Risk of compartment syndrome (type III)
• Ortho consult

31
Toddlers Fracture

• Isolated spiral fracture of distal tibia
• External rotation of foot with the knee flexed
• Child may limp or refuse to bear weight
• Long leg splint and ortho follow up

32
Ankle Injuries

• Usually Salter-Harris type I and II
• Swelling and point tenderness
• SH type III more concerning, requiring ORIF

33
Foot and Toe Injuries

• Fractures are rare
• Most common are metatarsal and phalanges
  fractures from falling objects
• Immobilization, ortho f/u
• Fifth metatarsal fx with inverion injuries

34
(No Transcript)
35
Nontraumatic MSK Disorders of Childhood

• Acute Septic Arthritis
• MC in kids lt3yo
• Hip and knee 80
• MCC Staph aureus
• Fever and localizing sign
• Child maintains hip in flexion, abduction, or
  internal rotation

• Fever gt38.5, CRP gt30, WBC gt12, severe pain,
  tender to palpation, refusal to walk
• Joint fluid for analysis
• Treat Vanc, Clinda

36
Juvenile Idiopathic Arthritis

• High fever and chills over 2 weeks
• Faint erythematous macular coalescing rash
  (trunk, palms, soles)
• Polyarticular
• Assoc with hepatosplenomegaly, lymphadenopathy,
  and pleuritis or pericardial effusion
• Lab eval is nonspecific
• Tx aspirin, NSAIDs, pediatric rheumatologist

37

• Worrisome complication
• Macrophage Activating Syndrome
• Macrophage and T cell proliferation and
  Multi-organ system failure
• High fever, purpura, mucosal bleeding, AMS, and
  hepatosplenomegaly
• ICU admission, corticosteroids, cyclosporine A

38
Legg-Calve-Perthes Disease

• onset 4-9 yo, males 41
• Avascular necrosis of femoral head
• Mild hip pain and limp for weeks
• Tx NWB, ortho f/u

39
Osgood Schlatter

• Apophysitis of the tibial tubercle resulting from
  repeated normal stresses or overuse
• Kids 10-15 yo, running or jumping athletes
• Boysgtgirls, most bilateral
• Chronic, intermittent pain and tenderness over
  the anterior aspect of the knee and tibial
  tuberosity
• Improves with rest

40
(No Transcript)
41
Acute Rheumatic Fever

• School age children
• 2-6 weeks post strep pharyngitis
• Arthritis, carditis, choreiform movements,
  erythema marginatum, or subcutaneous nodules
• Jones Critieria
• Two major or one major and two minor
• Tx admission, high dose aspirin (75-100mg/kg),
  prednisone, PCN (erythro for PCN allergic)

42
Jones Criteria

• Major
• Carditis
• New Changing murmur
• Cardiomegaly, CHF
• Migratory polyarthritis
• Chorea
• Erythema marginatum
• Subcuntaneous nodules

• Minor
• Fever
• Arthraglia
• Hx previous rheumatic fever
• Elevated ESR or CRP
• Prolonged PR interval
• Rising titer of antistreptococcal Ab