Musculoskeletal disorders in children

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Musculoskeletal disorders in children

• Chapter 136

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anatomy

• Physis area of growth cartilage, can occur at
  one end or both ends of a long bone
• Epiphysis area of bone b/w physis adjacent jt
• Apophysis area of bone b/w physis pt for muscle
  or ligament attachment
• Diaphysis midshaft of a long bone
• Metaphysis area b/w diaphysis physis
• Pediatric long bones are less dense and more
  porous than adults so tend to bow or buckle
  rather than fracturing through through

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Fracture patterns

• Skeletally immature (open physes)
• Salter-Harris classification
• Skeletally mature (closed physes)

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Torus fractures

• Torus fractures Buckle fractures occur at the
  metaphysis and a compression force causes buckle
  or bulge in a small area.

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Greenstick fractures

• Greenstick Fracture force breaks one side of a
  bone and bends the other

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Upper extremity injuries

• Clavicle fxs occur in a newborn and in childhood
• Birth injury may have upper extremity palsy
  secondary to brachial plexus injury or
  pseudoparalysis secondary to pain
• Parents may bring in to evaluate the newborn that
  is not moving an arm or they notice a lump or
  callus
• If seen in age lt 2 yo, think abuse
• Fall on outstretched hand on onto lateral
  shoulder
• Middle 1/3 of diaphysis is most common site of fx
• If fx is at medial end, check for displacement
• Posterior is higher risk for airway compromise
  and vascular injury emergency reduction pt may
  c/o dysphagia

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Upper extremity injuries

• Humerus fxs
• Physeal fxs occur more in adolescents because
  this is a weaker area due to rapid growth
• Diaphyseal fxs must raise suspicsion of abuse
• Potential for radial nerve injury

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Upper extremity injuries

• Pediatric elbow
• Check lateral view for anterior humeral line to
  bisect capitellum in the middle third
• Radius should point to the capitellum in all
  views
• Posterior fat pad is never normal anterior fat
  pad sign is pathologic when is forms the sail
  sign
• Oblique views can be obtained if no obvious fx
  line
• If no obvious fracture line appreciated, then is
  an occult supracondylar fx until proven otherwise
  
• CRITOE (table 136-1)

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Table 136-1


Sequence of Appearance of Ossification Centers of the Elbow
Ossification Center Age of Appearance
Capitellum  3 mo2 y
Radial Head  45 y
Medial epicondyle (I)  46 y
Trochlea  810 y
Olecranon  810 y
Lateral epicondyle (E)  1012 y
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Upper extremity injuries

• Supracondylar fxs
• Most common fx in age lt 8 yo
• FOOSH w/ elbow hyperextended
• 3 types
• Brachial median nerves at risk for injury with
  posterolaterally displaced fxs (type IIIb)
• Higher incidence of compartment syndrome with
  type IIIb fxs

Type 1 are undisplaced or minimally displaced
fractures (fracture is hairline) Type 2 are
partially displaced (fragments are nearly
aligned, some bony contact is present) Type 3 (a
b) are completely displaced (fracture fragments
are far apart from each other)
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x ray of a type 2 supracondylar fracture
x ray of a type 3 fracture
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Upper extremity injuries

• Lateral condylar fxs
• Usually Salter-Harris type IV
• Varus stress on extended elbow w/ forearm in
  supination

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Upper extremity injuries

• Medial epicondylar fxs
• Not true Salter-Harris type fxs because the
  apophysis and not the physis is involved
• Extraarticular injuries
• Commonly assoc with elbow dislocations

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Upper extremity injuries

• Distal humeral physeal fxs
• Injury thought to be a twisting mechanism that
  shears off distal epiphysis
• Indicator of abuse so important to recognize
• Olecranon fxs
• Assoc w/ fxs of radial head and
• neck
• May also be a part of a
• Monteggia lesion

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Upper extremity injuries

• Radial head neck fxs
• Uncommon in kids more neck than head fxs
  (metaphyseal) mechanism is fall
• Elbow dislocation
• More common in males
• FOOSH
• Most common is posterior dislocation w/ lateral
  displacement
• Also look for medial epicondyle and radial neck
  fxs
• Ulnar nerve most commonly injured
• Watch for vascular injury esp in open fxs

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Posterolateral elbow dislocation w/ avulsion of
the medial epicondyle
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Upper extremity injuries

• Radial head subluxation (Nursemaids elbow)
• Peak age is 2-3 yo
• More common in girls
• Mechanism is sudden longitudinal traction on arm
  w/ elbow extended
• Annular ligament of radius displaces into the
  radiocapitellar articulation
• Arm is adducted, semiflexed prone position
• Do not need xrays unless suspect fx
• Reduction via supination or hyperpronation
  technique

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Fig 136-2,3
Supination technique. Hold the elbow at 90
degrees, then firmly supinate the wrist and flex
the forearm toward the ipsilateral shoulder.
Hyperpronation technique. Hold the elbow at 90
degrees, then firmly pronate the wrist
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Upper extremity injuries

• Forearm injuries
• Xrays should be of both the jt above below due
  to the high assoc of related fxs/dislocations
• Radial ulnar shaft fxs usually occur at the
  distal 1/3 of forearm mechanism is FOOSH
• Bowing bulging type fxs are common in the
  forearm (greenstick/torus/buckle)
• Monteggia fx ulnar fx w/ dislocation of radial
  head
• Galeazzi fx radial shaft fx w/ dislocation of
  DRUJ
• Salter-Harris type I II injuries of distal
  radius physis are very common
• All types of fxs need ortho consult

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Upper extremity injuries

• Wrist injuries
• Scaphoid fxs nonunion is not as much of a
  concern as in adults
• Mechanism is fall with hyperextended wrist
• Phalangeal fxs
• Most common is crush injury caught in door
• Tuft fxs considered open because there is an
  assoc nail bed lac, consider axbx

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Lower extremity injuries

• Pelvic fxs
• Most common mechanism is peds vs. MVC
• Will not have the life threatening bleeding from
  pelvic vessels like in adults
• Likelihood of assoc injuries high (GU GI abd
  chest CNS)
• Avulsion type fxs more common in peds
• Unusual before 8 yo
• c/o sudden pain point tenderness over fx site
  w/ STS
• Hip injuries
• Proximal femur fxs (head neck) have high
  incidence of AVN and growth arrest
• Less common in trochanteric/subtrochanteric
  regions
• Dislocations are rare most common is posterior

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Lower extremity injuries

• Fxs of femoral shaft
• More common in boys peaks at late-toddler
  mid-teenage
• Most common mechanisms are falls MVC peds vs.
  MVC
• Abuse should be considered in anyone not walking
  yet (spiral femur fxs)
• Will not have hemodynamic instability from
  isolated femur fxs so look for other source in
  trauma pt.

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Lower extremity injuries

• SCFE
• Chronic slipping of the femoral epiphysis of the
  hip
• Most common cause of hip disability in
  adolescents
• Complications include AVN premature closure of
  the physis
• Obese kid subjected to minimal trauma MgtF
• Pain may refer to thigh or knee
• Get bilateral xrays

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Lower extremity injuries

• Knee injuries
• Ligamentous injuries less common than fxs
• Fxs through the distal femoral physis are
  uncommon but carry high complication rate
• Popliteal artery peroneal nerve injuries can
  occur
• Growth arrest secondary to permanent physeal
  damage
• Patellar injuries are usually dislocations
• Most common cause of traumatic hemarthrosis in
  peds
• Patellar fxs are uncommon
• Proximal tibial injuries to the tibial spine,
  tibial tuberosity, proximal tibial physis

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Lower extremity injuries

• Tibia fibula fxs
• Most common fxs occur at the shaft
• Always check for impending compartment syndrome
• Toddlers fx isolated spiral fx of the distal
  tibia
• External rotation of the foot w/ flexed knee

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Lower extremity injuries

• Ankle injuries
• Ligamentous injuries are uncommon prior to
  physeal closure because of the strong nature of
  the ligaments compared to the strength of the
  open physes
• Fxs of distal fibula are Salter-Harris I II
• Fxs of distal tibia are also Salter-Harris I II
• Tillaux fxs - Salter-Harris III fx of
  anterolateral portion of distal tibia
• Salter-Harris IV is a triplane fx involving fxs
  in the sagittal, coronal transverse planes

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Lower extremity injuries

• Foot phalanx injuries
• Fxs here are uncommon
• As ossification increases w/ age, then fxs more
  common
• Fxs of metatarsals phalanges are relatively
  common mechanism is object dropped on foot
• Crush injuries may cause vascular compromise and
  compartment syndrome

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Dont mow the lawn barefoot!