5. Paediatrics (MSK) Flashcards
Paeds fractures - general (3)
Generally small kids’ bones bend and buckle, rather than breaking.
Repeat in 7-10 days if unsure, periosteal reaction is a sign of healing fracture.
Kids heal completely, often with no sign of fracture
Paeds fracture - involvement of physis (3)
Major concern is growth arrest, can be asked by showing a physeal bar (early bony bridge crossing the growth plate).
Can get bars from prior infection, but Hx of trauma suggests fracture.
Salter harris classification (4)
Type 1: Slipped
- Complete physeal fracture, +/- displacement
Type 2: Above (or Away from joint)
- Involves metaphysis. Most common (75%)
Type 3: Lower
- Involves epiphysis.
- Chance of growth arrest, often need surgery to maintain alignment
Type 4: Through
- Involves metaphysis and epiphysis.
- Often end up with growth arrest or focal fusion.
- Require anatomic reduction and often surgery
Type 5: Ruined
- Compression of growth plate, due to axial loading injuries.
- Poor prognosis, easy to miss and often found when looking at comparisons.
- “Bony bridge across physis”
Toddler’s fracture (3)
Oblique fracture of the midshaft of tibia, seen in child just starting to walk (new stress on bone)
If spiral fracture, sus for NAI.
Typically 9 months to 3 years.
Stress fracture in children (3)
Occurs after repetitive trauma, usually after new activity like walking.
Common site is tibia, proximal posterior cortex (Toddler fracture).
Other classic ones include Calcaneal fracture, seen after child has had cast removed and returns to normal activity.
Paeds Elbow (3)
Elevation of fat pad suggests effusion and occult fracture.
Can see thin anterior pad, but should never see posterior pad.
Commonest fracture is supracondylar (in kids, >60%), then lateral condyle (20%), then medial epicondyle (10%).
Radiocapitellar line (2)
Line through centre of radius, should intersect the middle of the capitellum on every view.
If radius is dislocated it will NOT pass through centre of capitellum
Anterior humeral line (3)
Need true lateral.
Line along anterior surface of humerus should pass through middle third of the capitellum.
Supracondylar fracture causes this line to pass through the anterior third.
Ossification centres of elbow (6)
Capitellum (age 1)
Radial head (age 3)
Internal (medial) epicondule (age 5)
Trochlea (age 7)
Olecranon (age 9)
External (lateral) epicondyle (age 11)
Lateral condyle fractures (3)
Second most common distal humerus fracture in kids.
A fracture that passes through the capitello-trochlear groove is unstable (Milch II).
Difficult to tell this, so treatment is based on displacement of the fracture fragment (>2mm or <2mm).
Trochlea (2)
Can have multiple ossification centres and therefore a fragmented appearance, NOT a fracture
Medial epicondyle avulsion (5)
Because it’s an extra-articular structure, its avulsions will not necessarily result in a joint effusion.
Can get interposed between the articular surfaces of humerus and olecranon.
Avulsed fragments can get stuck in the joint, even when there’s no dislocation
If there’s a dislocation, ask 1) is the patient 5 and 2) where is the medial epicondyle.
Should never see the trochlea without the medial epicondyle. If you can, it’s probably a displaced fragment.
Common vs Uncommon elbow fractures (4)
Common:
- Lateral condylar
- Medial epicondylar
Uncommon
- Lateral epicondyle
- Medial condyle
Nursemaids elbow (3)
When a child’s arm is pulled on, the radial head may sublux into the annular ligament.
X-rays don’t help, ulness you supinate the arm during lateral position, which often relocates the arm
Avulsion injuries (pelvis) (7)
Kids tendons tend to be stronger than their bones, unlike adults.
Iliac crest # due to Abdominal muscles
ASIS # due to Sartorius
AIIS # due to Rectus femorus
Greater trochanter # due to gluteal muscles
Lesser trochanter # due to iliopsoas
Ischial tuberosity # due to hamstrings
Symphysis # due to adductor group
Sindig-Larsen-Johansson (3)
Chronic traction injury at the insertion of the patellar tendon on the patella.
Seen in active adolescents between 10-14.
Kids with cerebral palsy are prone to it.
Osgood Schlatter (3)
Due to repeated microtrauma to the paterllar tendon on its insertion into the tibial tuberosity.
25% bilateral.
More common in boys
Distal femoral metaphyseal irregularity (6)
Cortical desmoid.
Lucency seen along the back of the posteriomedial aspect of the distal femoral epiphysis.
Lateral knee X ray with irregularity or lucency at the back of the femur is probably this.
Often bilateral.
Buzzwords include “scoop like defect” with an “irregular but intact cortex”.
Incidental finding, no clinical importance.
Blounts (5)
Tibia Vara.
Varus angulation at the medial aspect of the proximal tibia (varus bowing occurs at the metaphysis, not the knee).
Often bilateral, not seen before age of 2.
Later in disease progression, the medial metaphysis will be depressed and an osseous outgrowth classically develops.
Can see in 2 age groups, early (around age 2) and late (12).
Congenital rubella (2)
Bony changes seen in 50%, classic buzzword being “celery stalk” appearance, from generalised lucency of the metaphysis.
Usually seen in first few weeks of life
Syphillis (4)
Bony changes seen in 95% of cases.
Bony changes do NOT occur intil 6-8 weeks of life (Rubella are earlier).
Metaphyseal lucent bands and periosteal reaction along long bones.
“Wimberger sign” or destrucion of the medial portion of the proximal metaphysis of the tibia.
Caffey disease (3)
Self limiting disorder of soft tissue swelling, periosteal reaction and irritability seen in first 6 months of life.
Really hot mandible on bone scan.
Mandible is commonest location, then clavicle and ulna.
Prostaglandin therapy (3)
Prostaglandin E1 and E2, often used to keep PDA open, can cause periosteal reaction.
X-ray will show sternotomy wires or other hints of congenital heart, then periosteal reaction in arm bones
Neuroblastoma mets (1)
Only childhood malignancy that occurs in newborns and mets to bones
Physiologic growth (8)
aka physiologic periostitis of the newborn.
Name is false, doesn’t occur in newborns, seen around 3 months old, should resolve by 6.
Proximal involvement (femur) comes before distal (tibia).
Always involves the diaphysis.
NOT physiologic periosititis if
- Seen before 1 month
- Seen in tibia before femur
- does not involve the diaphysis
Langerhand cell histiocytosis (6)
Also known as eosinophilic granuloma.
Twice as common in boys.
Skeletal manifestations are highly varied, classic ones are:
Skull: most common site. Bevelled edge fron uneven distribution of the inner and outer tables. Round lucent lesion in the skill of a child - think this or neuroblastoma mets
Ribs: Multiple lucent lesions, with expanded appearance
Spine: Vertebra plana
Osteomyelitis (3)
Usually occurs in babies (30% of cases less than 2 years old).
Usually haematogenous spread (adults tends to spread directly from a diabetic ulcer)
Some changes that occur over time, potentially testable.
Osteomyelitis in newborns (2)
Open growthplates, and perforating vessels which travel from the metaphysis to the epiphysis.
Infection usually starts in metaphysis (most blood supply because it’s fastest growing) and spread via these perforators to the epiphysis
Osteomyelitis in kids (3)
Later in childhood, these perforators regress and the avascular physis stops infection from crossing over.
This creates a septic tank scenatio, where infection stays in the metaphysis.
Osteomyelitis in adults (2)
When the growth plate fuses, barrier of an avascular plate is no longer present and infection can again cross over into the epiphysis
