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
Peds; 2 types of Fracture (Fx); Open Physis vs closed
Physis
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
• 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
• 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
• 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
• Type III:
Open Reduction definative Ortho Tx
Type IV: ORIF
Type V: Casting, Ortho monitoring,
anticipation of Bone growth arrest
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
• 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
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
• 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
• 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 Preadolesence
• Tx depends on age of child & degree of displacement
• >30º displacement often need closed reduction & immobilization
Fx Humoral Diaphysis (Uncommon)
• Suspect Abuse, strong Force Required!!!
• Closed reduction maybe required
• Radial Nerve Injury assoc
• Document Radial Nerve Function!!!
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
• 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
• 10-14y/o’s
• Not TRUE SH fx
• Simple Fx of Medial Epicondyle are Extraarticular limited soft Tissue involvement
• ½ assoc w/ elbow dislocation
• Ortho Consult
Distal Humoral Physeal Fx
• Twisting MOA, shears off distal epiphysis
• Often Abuse
• Often < 2yrs age
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
• Uncommon in children
• Radial neck > Radial Head
• Most common MOA; Fall
• Ortho consult obtained to guide Tx
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
• Peak 2-3 yo Girls> boys L> Right
• MOA; sudden longitudinal traction on
•
•
•
•
outstreatched arm
Annular ligament of Radius displaces into Radiocapitellar 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
• 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
• 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
Monteggia
Galeazzi
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
Scaphoid 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
• 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
• 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
Post Hip dislocation
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
Slipped Capital Femoral Epiphysis
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
• 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…
Patellar dislocation
Patellar dislocation
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
Tibial Tuberosity FX
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
• 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
Toddlers fx
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
• 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)
• < 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
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
• 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
Henoch-Schonlein-Purpra
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
• 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)
Kawasaki Dz
Kawasaki 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
Legg-Calve-Perthes 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
Osgood-Schlatter Dz
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
• 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
• 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
Quiz
1)
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
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
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