170. Ped MSK Flashcards
How is the pediatric MSK skeleton different than adult?
physis
thicker and stronger periosteum
greater remodelling potentail
What is a physis?
growth plate composed of proliferating cartilage cells between epiphysis and metaphysis
What is the benefit of the pediatric periosteum?
thicker and stronger, physiologically active so rapid healing and increased stability, making nonunion unlikely
If a child has at least two years of growth potential remaining, a fracture adj to a joint will remodel acceptably if angulation is < _ degrees
30
What fracture patterns are unique to peds?
buckle fractures
plastic defmority
greenstick fracture
complete fractures that transect both cortices of bone
physeal fractures
Pediatric patient: plastic deformity injury of bone - what occurs?
bowing of bone w/o cortical disruption
Pediatric patient: torus/buckle fracture - what occurs and how?
linear compression, resulting in buckling of bone without cortical disruption
*common metaphysis/diaphysis
Acceptable angulation for peds fracture: children <5 lateral vs AP radiograph degree angulation allowance?
up to 35
<10
Pediatric patient: how does a greenstick fracture occur?
disrupts cortex unilaterally with periosteum on compression side remaining intact
Acceptable angulation for peds fracture: children 5-10y lateral vs AP radiograph degree angulation allowance?
up to 25
<10
Acceptable angulation for peds fracture: children >10y lateral vs AP radiograph degree angulation allowance?
5-20 degrees on lateral
but no angulation AP
Tx of greenstick fracture
casting 4-6 weeks
Low risk SH classification (which levels) and why?
I-II
germinal layer of physis not involved
How to tx SH class I-II fractures (generally)
spint/cast
ortho f/u 1 week
Which two SH involve joint surface and typically require open reduction to maintain joint stability?
III
IV
Which SH classification has risk for premature growth plate closure and is high irsk with surgical intervention
SH 5
MC fracture site of clavicle
distal, middle
XR recommended radiograph angle for clavicle
AP
SH classification I - what is this?
fracture extends through physis
SH classification II - what is this?
extends from physis into metaphysis (away from joint space)
SH classification III - what is this?
fracture extends from physis into epiphysis (toward jt space)
SH classification IV - what is this?
extends from physis into metaphysis and epiphysis
SH classification V - what is this?
crush injury of physis
Which vessels are near the clavicle?
subclavian vessels
Which massive nerve bundle is by the clavicle?
brachial plexus
What are other organ systems you need to be aware of in proximal clavicle/posterior SC displacement fractures?
trachea
esophagus
ptx
MC clavicle # tx
sling and swatch 4-6 weeks
newborn no tx
Orthopedic consult indications for clavicle #
open
nv compromise
floating shoulder (with scapular #)
significant skin tenting
consider: communited, substantial displacement, high level athl
MC fracture of peds
supracondylar humerus fracture
Why are kids at risk for supracondylar fractures?
ligaments stronger than bones
Typical mechanism of peds supracondylar fracture
fall onto extended arm –> distal bone superior and posterior
Important ossification centers in the elbow
CRITOE
Supracondylar fractures can less commonly, have impact on a flexed eblow. Which way is the distal fragment displaced?
anterior
What classifcation sysem is used to describe supracondylar fractures?
Gartland
True lateral helpful tips for supracondylar fracture
- true lateral view should demonstrate a figure-of-eight appearance of the distal humerus, with intersection of the anterior humeral line with the posterior two-thirds of the capitellum. If this line intersects the anterior one-third of the anterior capitellum or is anterior to this structure, then a supracondylar fracture with posterior displacement of the distal fragment is sugges- tive.
- Baumann angle (n 70-75 degrees - gp of capitellum intersecrted with line down center of humerus)
Which fat pad in the elbow can be normal to see … when is it abnormal?
anterior to coronoid fossa, thin can be normal but if bulging = sail sign anad suggestive of pathologic
Which fat pad in the elbow, if seen, is always pathologic?
posterior
How is an extension supracondylar fracture typically held?
in ext and slight pronation
CRITOE - Capitellum age at appearance and closure
6-12mo
14y
CRITOE - Radial head age at appearance and closure
4-5y
16y
CRITOE - Medial/internal epicondyle age at appearance and closure
5-7y
15y
CRITOE - Trochlea age at appearance and closure
8-10y
14y
CRITOE - Olecranon age at appearance and closure
8-9y
14y
CRITOE - Lateral/ext epicondyle age at appearance and closure
9-13y
16y
Gartland classification of extension type supracondular fractures - I - what does this mean?
nondisplaced fracture
Gartland classification of extension type supracondular fractures - II - what does this mean?
displaced fracture with intact posterior cortex
Gartland classification of extension type supracondular fractures - III - what does this mean?
displaced fracture with no cortical contact
Gartland classification of extension type supracondular fractures - IIIA - what does this mean?
posteromedial rotation of distal fragment
Gartland classification of extension type supracondular fractures - IIIB - what does this mean?
posterolateral rotation of distal fragment
Which a are we worried about in a supracondylar fracture?
radial a
What nerves are more concerning in a extension supracondylar fracture when displaced posterior-lateral or medial?
median and radial
What nerve is commonly injured in a flexion injury involving supracondylar fracture?
ulnar
Supracondylar fracture, Gartland type I fracture management
posterior long arm sprint
elbow flexed 90 deg in either neutral/pronated
f/u ortho 24h
Gartland classification of extension type supracondular fractures - II and III - what does this mean?
emergent eval by ortho
type II closed reduction but if > 90 deg flexion to keep reduction, then Perc pinning
III - admission, operative reduction and pin
How to reduce a supracondylar fracture
- traction counter traction
- if distal fragment is displaced laterally, pushed inward vs medially,push outward - once L restored and lat/medial displacement corrected, thumb on anterior surface proximal fragment, fingers behind olecranon and elbow flexed
- immobilize with forearm pronated (vs laterally displaced = forearm supinated)
Defn of Monteggia fracture
fracture proximal third ulna and dislocation of radial head
Galeazzi fracture defn
fracture of distal radius and disruption of DRUJ
For a Monteggia fracture assessment of radiocapitellar line on XR, where should this line cross?
center of capitellar ossification center on lateral elbow radiograph –> a radial head dislocation will disrupt this line
Management of Monteggia and Galeazzi
ortho consult
Monteggia: radial head dislocation - radial head reduction
Radial nerve motor vs sensory exam
wrist extension
thumb and first finger web space
Ulnar nerve motor vs sensory exam
wrist flex and adduxn
little finger
Median nerve motor vs sensory exam
wrist flexion and abduction
thumb, index and middle fingers
PIN motor exam how?
radial aspect of the palm, thumb opposition
AIN nerve motor exam
distal phalanx flexion thumb and first finger
AIN and PIN sensory component?
no
What is a nursemaid’s elbow?
radial head subluxation
Why does a nursemaid’s elbow occur?
head of radius displaced from annular ligament
when does a nursemaid elbow tend to occur age wise?
between 2-3y
How does a nursemaid’s elbow occur?
axial traction causing extension of elbow and pronation –> subluxation of radial head via partial tearing or entrapping anular lig between radial head and capitellum
Nursemaid elbow typical holding position of children?
against body
slight flex at elbow with arm pronated
Two common techn nursemaid elbow
supin/flexion
hyperpronation **more effective
How to know if nursemaid reduction worked? what if it didn’t?
kiddos tend to start using their arm within 15min
if not - repeat manuever
if unsuccessful then radiograph, extremity in long arm splint at 90 deg, pediatrician f/u 24h
Toddler fracture - what is this?
nondisplaced oblique fracture of distal tibia due to minor fall/twist around age 1-4y
XR for Toddler fracture
subtle lucency oblique throigh distal tibia, terminates medially
Toddler fracture management - boot vs cast
Traditionally, immobilization involved a posterior long leg cast for 3 to 4 weeks, but recent studies have shown no differences in the clinical outcomes between various immobilization methods: cast- ing, splinting, or a cast boot.4 Casts should not extend above the knee on young toddlers, who are at risk for cast migration. Children are allowed to bear weight as tolerated after immobilization.
DDH: what does this include
neonatal instability, acetabular dysplasia, hip sublux- ation, and true dislocation of the hip.
RF of DDH
breech
female gender
fhx
incorrect LE swaddling
<3mo which 2 maneuvers for ddh
ortolani
barlow
Barlow manuever
hips in 90 deg felx and adduction, lateral pressure on hip and if unstable, can be felt toc clunk as fem head falls out of acetabulum (you dislocate the hip on purpose)
Orolani manuever - how to do?
try to relocate
hipp adduction into anterior pressure on trochnter while hip abducted -> clunk as relovates
Galeazzi test for DDH
limb length discrepancy
Infants older than 4 wk old suspected of DDH - what test to undergo?
u/s
Once ossifying nucleus of femoral head appears around 4-6mo, what test should be done to look for DDH?
XR
Adverse effects of not treating ddx
aseptic necrosis fem head
arthritis
back apin
First line tx ddh
pavlik harness - in flex and abd position so fem head is reduced into acetabulum
If pavlik harness doesn’t work or kids >6-8mo are found to have ddh, what needs to be done?
OR reduction
spica cast removal
Pediatric hip pain: what is transient synovitis?
self limited inflamm process
peak incidence 3-6y
mc boys >
RF transient synovitis
viral illness recent
allergic hypersen
minor trauma
Differentiating septic arthritis from transient synovitis
septic: fever, unwilling too bear weight at all, ill, imaging needs to be done to r/o dx transient syno
DDX categories of hip pain in children
trauma
infection
inflamm
neoplasm
hem
miscellanous
DDX of hip pain in children - traumatic causes?
hip/pelvic fractures
overuse injuries
Infectious causes of hip pain inchildren
septic ar
om
myositis
lyme
Inflammatory causes of hip pain in children
transient synovitis
juv RA
rheumatic fever
Neoplasm causes of hip pain in children
leukemia
osteoegnic or Ewing sarcoma
metastatic dis
Hem causes of hip pain in children
hemophilia
sickle cell anemia
Miscellanous causes of hip pain in children
legg calve perthes
slipped capital femoral epiphysis
Kocher criteria for septic arthritis
fever >/=38.5
inability to bear weight
esr >/=40
cbc ?/=12
If patients have 3 or 4 kocher criteria, likelihood of septic arthritis?
93%
100%
If pt have no Kocher criteria, risk of septic arthritis?
2%
Kocher criteria with addition of CRP - why and what level is important to know?
risk stratifiation
CRP <1 means 87% probability no septic arthritis
If unclear on kocher criteria, imaging of choice for septic arthritis?
u/s
transient synovitis tx
nsaid
AAT
f/u PCP 24h
RF septic arthritis of the hip/knee in children
trauma
hemophilia induced hemoarthroses
db
intraarticular injection
surgery
IVDU
Adverse effects of septic arthritis?
pressure necrosis
AVN
Which bacteria are mc in septic arthritis in children?
staph aureus, gas, strep pneumnoniae
neonate - bgs, gram negative
neonate and adol: rf neisseria
sickle cell -salmonella
Birth - 3mo organisms for septic arhtritis to consider and tx?
Group B streptococcus (Streptococcus agalactiae) Staphylococcus aureus Gram-negative organisms Neisseria gonorrhoeae
Nafcillin 75–150 mg/kg/day q6h or oxacillin 75–100 mg/kg/day q6-8h, and cefotaxime 100–150 mg/ kg/day q8h or cefepime 100 mg/kg/day q12h
3mo - 5yr organisms for septic arhtritis to consider and tx?
S. aureus
Streptococcus pneumoniae Streptococcus pyogenes Kingella kingae Haemophilus influenzae
Nafcillin, 150–200 mg/kg/day q6h or oxacillin 100–200 mg/kg/day q4–6h, and ceftriaxone, 50–100 mg/kg/ day q12ha
5-12y organisms for septic arhtritis to consider and tx?
S. aureus S. pyogenes
Nafcillin 150–200 mg/kg/day q6h or oxacillin 100–200 mg/kg/day q4–6h, and ceftriaxone 50–100 mg/kg/ day q12ha
> 12y organisms for septic arhtritis to consider and tx?
S. aureus
N. gonorrhoeae
Nafcillin 150–200 mg/kg/day q6h or oxacillin 100–200 mg/kg/day q4–6h, and ceftriaxone 50–100 mg/kg/ day q12ha
Atypical bug for septic arthritis?
kingella kingae
oral gram negative bacterium in children <4y
*can have noraml wbc, normal acute ph reactans
Synovial fluid interpretatiion for + concern for bacteria - WBC, PMN
WBC >50,000 cells per %PMN >90 Pyogenic arthritis microliter or Gram stain
positive
Synovial fluid interpretatiion for equioval concern for bacteria - WBC, PMN
WBC 20,000–80,000
%PMN >70
Lyme disease Tuberculosis
Synovial fluid interpretatiion for negative concern for bacteria - WBC, PMN
Negative
WBC < 5,000
%PMN <25
Transient synovitis Traumatic arthritis Reactive arthritis
Tx of septic arthritis (not abx)
decompression of joint - open arthrotomy, I+D
Legg-Calve Perthes disease - what is this?
idiopathic necorsis of capital femoral epiphysis, form of osteochronodsis
Legg-Calve Perthes disease - epidemiology
boys
3-11y
bilateral 10-15%
later onset of disease, less favorable outcome
Legg-Calve Perthes disease -disease process
favors resorption of femoral head vs reformation so get bony head deformity, mechanical weakening
MC signs Legg-Calves-Perthes disease
limp
trendelenburg sign
limited IR and abd of hip
Imaging recommendations for Legg-Calves-Perthes
xray - ap and frog leg lateral
4 ph of Legg-Calves-Perthes
initial
fragmentation
reossification
healed
Legg-Calves-Perthes: initial phase - what happens to femoral haed?
loss of blood supply
Legg-Calves-Perthes: what happens as the bon dies after loss of blood supply?
medial joint space widesn
fem head less round due to subchondral collapse/cresent sign –> hip joint becomes painful, stiff an and inflamed
Legg-Calves-Perthes: fragmentation phase
epiphyses begins to fragment as new bone begins to form
reshapes femoral heaed
Legg-Calves-Perthes - reossifcation phase
continued bone density repair as femoral head cont to reshape
Legg-Calves-Perthes: healed stage?
radiographs of proximal third of femur and fmeoral head
Slipped capital femoral epiphyses: what is this?
posterior and inferior slippage of proximal femoral epiphyses onto the metaphysis
SCFE: epidemiology
boys 2x >girls
13.5y boys, 12 forgirls
bilateral 18-50% of pt
SCFE: how does this happen?
obese
rapid growth
endocrine d/o
MC endocrine d/o with SCFE?
hypothyroid
growthhorm deficiency
chronic renal failure
SCFE: what is the Drehman sign?
obligatory ER when affected hip is flexed
SCFE classification depends on which 2 things?
stability of physis
risk of AVN
When is a SCFE considered stable?
if can ambulate with or without crutches
SCFE: signs of slippage on an AP radiograph? and what is this?
Klein line (superior margin fem neck: normal line interset with eophysis symmetircally vs in SCFE no intersection)
Slip severity in SCFE determined by the ___ method
wilson
relative displacement of epiphyses on metaphysis in frog leg lateral
Wilson method for SCFE: what constitutes mild?
epiphyss displacement less than 1/3 width of metaphysis
Wilson method for SCFE: what constitutes moderate?
displacement of 1/3 to one half width
Wilson method for SCFE: what constitutes severe slip?
displacement > 1/2 of the width
SCFE emergency medicine managment
NWB
ortho for screw
Complications of SCFE
AVN
chrondolysis
Lyme can cause a ___ arthritis
mono
Lyme disease: erythema migrans - which abx?
Amoxicillin 50 mg/kg/day TID PO × 14 days Doxycycline 2–4 mg/kg/day BID PO × 10
days
Alt
Cefuroxime 30 mg/kg/day BID × 14 days
2nd line:
Azithromycin 10 mg/kg daily × 10–14 days
Lyme disease: facial palsy- which abx?
Amoxicillin 50 mg/kg/day TID PO × 14 days Doxycycline 2–4 mg/kg/day BID PO × 14
days
2nd line:
Azithromycin 10 mg/kg daily × 10–14 days
Lyme disease: meningitis- which abx?
Ceftriaxone 100 mg/kg/day daily IV × 14 days
Cefotaxime 180 mg/kg/day q8h IV × 14 days
Lyme disease: carditis- which abx?
Amoxicillin 50 mg/kg/day TID PO × 14–21 days
Doxycycline 2–4 mg/kg/day BID PO × 14–21 days
Ceftriaxone 100 mg/kg/day daily IV × 14-21 days
Cefotaxime 180 mg/kg/day q8h IV × 14–21 days
Lyme disease: arthritis- which abx?
Amoxicillin 50 mg/kg/day TID PO × 28 days Doxycycline 2–4 mg/kg/day BID PO × 28
days
Lyme disease: persistent arthritis post therapy- which abx?
Retreat with one of oral regimens: “Amoxicillin 50 mg/kg/day TID PO × 28 days Doxycycline 2–4 mg/kg/day BID PO × 28
days”
Ceftriaxone 100 mg/kg/day daily IV × 14–28 days Cefotaxime 180 mg/kg/day q8h IV × 14–28 days
Apophysis - what is. this?
cartilaginous structure on growing bones serving as a site for tendon insertion
How much weakner does an apophysitis tend to be than its surrounding structures?
2-5x
What increases tension at the apophysis ?
rapid bone growth before adequate lengthening
What causes apophysitis?
traction injury to cartilage and bony att of tendons
most often as overuse
What is the pathophysiology of Osgood-Schlatter?
condition where patellar tendon insertion on tibial tubercle ossification center becomes inflamed due to repetitive tensile stress
Who commonly gets Osgood-Schlatter?
boys 10-15y
girls 8-12y
Sx usually resolve when the physis closes for OGS but what occurs in 10% of pt?
nonunion
typically ++ pain anterior knee after kneeling
OGS - pain where and with what activity?
bony prominence and pain over tibial tuberosity
What may a OGS xray show?
lateral: blurred margins of patellar tendon acute stage
afte 3-4mo can get bone fragmentation and later fuse at chronic stage
Management OGS in ED
reduction pain and swelling
subside activities
nsaid
ice
improve str quad/ham/gastroc
Sever disease - what is this?
calcaneal apophysitis
Squeeze test for severs
squeeze heel if painful = +
Tx calcaneal apophysitis/severs
nsaid
ice
activity decr
stretch
heel cup
*stretching to achilles sp
What is little league elbow?
describe a group of elbow injuries, including apophysitis, medial epicondylitis, and osteo- chondritis dissecans of the radial head and capitellum.
Little league elbow findings
localized tender
swel over medial epicondyle
pain with resisted wrist flexion and forearm pronation
What may radiographs of medial epicondyltis show?
focal lucency or sclerosis at the subchondral bone in the anterior aspect of the capitellum. Images may demonstrate fragmentation at the condyle, apophyseal avulsion, or widening at the medial epicondyle ossification center.
Operative indications for medial epicondylitis?
displaced # >5mm
incarcerated fragment
assoc with elbow disloc
Where will apophysitis of the hip occur?
muscle oringation or insertion: iliac crest
asis, aiis, gr trochanter, less troch, ischial tuberosity, pubic symphisis
who is at greatest risk for apophysitis/avulsion # of hip?
distance runner
dancer
kocking sport
Tx for hip apophysitis
activity restriction and stretching of associated muscles because this is a self-limited disorder that resolves by improving flex- ibility or when the apophyseal centers fuse when skeletal growth is complete.
When is surgery recommended for avulsion fracture of the hip?
fragment displaced >2cm or rapid rehab
What is gymnast wrist?
distal radial epiphysitis
Why do people get gymnast wrist?
compressive loading and shearing forces cause physeal microfractures at the hypertrophic zone. This leads to temporary ischemia which inhibits normal physeal calcification, causing physeal widening and metaphyseal irregularity. Th
Adverse effects of gymnast wrist
bony deterioration
instability
chronic arthritis
