MSK Injuries in Children and Adolescents Flashcards
Anatomical differences vs adults
Epiphyseal plates and its junctions Growth spurts Bone malleability Apophysites Articular cartilage Muscle development Frequency and variety of sports
Relevance of epiphysis
Epiphyseal plates in growing skeleton
site of weakness not seen in adults; susceptible to sheer forces
Relevance of metaphysis
Softer part of bone
bone malleability => absorbs greater energy => less brittle
more susceptible to fractures
most common = Greenstick
Relevance of diaphysis
main section of long bone made up of cortical bone
Growth plates and Growth spurts
Growth plates = between epiphyses and metaphysis - fracture lines
Growth spurts are a result of the changes in the balance of bone and muscle causing altered biomechanics, co-ordination and energy levels
Apophysites (function and relevance)
Boney attachment sites of muscle tendon
in maturing skeleton => area of weakness because bone is softer
Apophysites examples of the pelvis
ASIS - sartorius
AIIS - rectus femoris
PUBIC SYMPHYSIS - rectus abdominus via ing ligament
ILIAC CREST - gluteals, Tensor fascia latae
ISCHIAL TUBEROSITY - adductor magnus, biceps femoris, semitendinosus, semimembranosus
GREATER TROCHANTER - gluteus medius and minimus
LESSER TROCHANTER - psoas/iliacus
Features of articular cartilage in kids
thicker and greater ability to remodel
thus more likely to get osteochondritis diseccans; blood supply more easily modified
Factors of joint stability
muscle development
ligament laxity
core stability
Principles of Management of Sporting child
Manage physiological processes
identify causes and emphasise rehabilitation based on this
address biomechanics
do not forget
- inflammatory conditions and other medical conditions
- cardiovascular changes
- nutrition
- psychosocial factors
- environmental factors; greater body SA
- autonomy, beneficence, confidentiality, do not harm, equity
- player development
Growth plate fractures
Salter harris classification (5 types)
can be complicated
Rx depends on type
healing depends on severity, age, which growth plate and type
Salter Harris Classification
Type I - straight through growth plate
Type II - extends through metaphysis (chip)
Type III - extends through epiphysis (T shaped)
Type IV - through both epiphysis and metaphysis
Type V - compression fracture
Greenstick fracture
one side broken and other is bent
reduced
casted for 6 wks
usually in metaphysis
Buckle fracture
‘torus’ fracture
FOOSH - fallen on outstretched hand
incomplete fracture of one side buckles without disrupting the other side
5-11yo
Groin pain in football
4th most common injury affecting footballers (10%)
3rd longest absence from sport
incorporates abdo, adductors, lumbar spine and SIJ, hip
Sx - pain in lower abdo, groin and testicles; weakness; running/cutting/side-steps, sit ups, coughing/sneezing
Groin pain in football - Mechanism of injury
- torque with opposing forces
- stronger leg muscles compared to abdominals
- conjoint tendon pulls up and rotates the trunk
- adductor pulls down and rotates upper leg
- opposing forces disruption of muscles at their insertion
Avascular necrosis of the hip
disrupted blood supply to neck of the femur due to damage to joint => collapse flattening of femoral head
pain on WB
Ax - NOF fracture (apophyseal injury), dislocation, ETOH, systemic cortisone
Ix - XR, Bone scan, MRI
Rx - conservative or surgical if needed (decompressing)
Perthe’s disease
Rare childhood disease of femur
temporarily disrupted blood supply to head of femur
during revascularisation the bone is soft => painful hip, limp
boys, 5-12yo
Dx - XR, bone scan, MRI
Slipped Upper Femoral Epiphysis
Traumatic cause of hip and groin pain
weakness of growth plates causes posterior translation of femoral head during periods of accelerated growth
develops gradually - pain, stiffness, instability
antalgic gait, leg short, ER
boys, pre-teens and teens
Spondylolysis
Defect in pars interarticularis due to hyperextension
most common in L4-L5 and L5-S1
6% of general population and 50% of athletic back pain
daily activity-related pain and rest pain
ask about: morning stiffness, multiple joint pain/swelling, night pain, neuro Sx, systemic Sx
O/E - ROM, Stork test, Fitch-catch (variation of stork with rotation), palpation, leg length, SLR, Slump test
Ix - XR, SPECT, CT, MRI
Rx - relative rest, analgesia, rehab [core, hamstring stretch, flexion activities, aerobic fitness, sports-specific], bracing
Other causes of back pathology in young athletes
spondylolisthesis lumbrosacral sprain scoliosis scheuermann's osteomyelitis congenital abnormalities ankylosing spondylitis juvenile RA malignancy
Traction apophysitis
Inflammation of tendinous attachment site
potential avulsion fractures
- Osgood Schlatters (patella)
- Sever’s diseases (achilles)
- Sinding Larsen Johansson (inf. pole patella)
- Little league elbow ( med. epicondyle; wrist flex)
- Iselin (5th metatarsal; peroneus brevis
Mx - relative rest, Rx inflammation, address biomechanical factors, improve movement patterns
Osgood Schlatters
Inflammation of the patella tendon insertion at the tibial tubercule
TOP and protruted tib tubercule, pain on resisted knee extension/ squatting and on passive knee flexion, restricted hams flexibility
BIOMECH - Poor quads and hams flexibility, growth spurt, increased q angle, patella alta, ovepronated feet, knee valgus
Boys - due to q angle and type of sports; related to running and jumping
associated with growth and load
Severs Disease
Inflammation of achilles tendon insertion on the calcaneous growth plate
TOP calcaneal growth plate, pain and restriction on DF, pain on resisted PF/calf raise
BIOMECH - overprontation/ valgus at the ankle, stiff forefoot
Patello-femoral instability (Joint laxity)
Younger population Mechanism - patellar alignment - lateral pull vs medial - subluxation = partial loss - dislocation = complete loss of congruity
BIOMECH - shallow femoral trochlea, hypoplastic lateral femoral condyle, patella shape, patella altam poor VMO strength
Rx - XR and ortho review, +/- brace, progressive knee flexion, strengthening VMO whilst limiting tension of lat structures
Patella Dislocation
Most commonly one of the medial structures fails and patella moves laterally
medial patella femoral ligament detaches at femoral attachment
avulsion fracture at chondro-osseous junction
Patellofemoral dislocation Protocol
W1 - knee extension brace + crutches, RICE, statuc quads, gluteal, grastroc strengthening
W2 - Same but no crutches + bilateral calf raises
W3 - No brace. No AROM exercises, but statuc. Bilat squats 30degrees. SL balance
W4 - SL calf raises. Static proprioception. Standing hip theraband strengthening
W5 - AROM exercises to 90 in supine. BL squats 45 degrees. Step ups. Static proprioception + wobble board. Hamstring bridging. Glut med strengthening
W6 - SL Squat to 45 degrees (rest same as W5)
W7 - Start bike. SL squat to 60
W8 - X-trainer. pool running. Fwds/bwds 1/2 lunges. Squats to 75 degrees
W9 - Start Trampette running. Progress to mat running. Fwds/bwds lunges
W10 - Running, keep ups, 1-2 volleys, technical volleys, accelerations
W11 - Slalom running, increase speed and CoD, dribble with ball , passing 5-10M
W12 - Increase technical sessions
W13 - Train 3x45 mins, no game
W14 - Train 3x60 mins, no game
W15 - Train 3x75 mins, game 45mins
Osteochondritis Dissecans
Separation of articular cartilage from subchondral bone
85% on medial femoral condyle posteriorly
RF - trauma (50%), M, Overuse, familial (10%), ligamentous weakness, genu valgum/varus, meniscal lesions in the knee
Sx - Vague Hx of pain, effusion, locking (loose body), wilson sign (pain at 30degree flexion and IR of knee) children usually full ROM, tender joint line
Ix - XR (weight bearing , tunnel view), MRI (size of lesion, loose bodies)
Prognosis better if younger, on medial side, no synovial fluid on MRI
Osteochondritis Dissecans - Stages
STAGE 1 - Depressed OD; intact cartilage, small area
STAGE 2 - Partially detached OD
STAGE 3 - Completely detached OD but not displaced; most common
STAGE 4 - Completely detached OD but displaced; avascular fragment = loose body
Injury Prevention Concepts
- Anthropometric Measurements
- Load management (FITT principle)
- Generic warm up
- Functional movement screening (7 fundamental movement patterns)
- Injury prevention exercise programmes (strengthening and recovery)
Recommended daily activity for 1-5yo
> = 180mins /d
Recommended daily activity for 5-18yo
> =60mins/ d spread across the week
Normal lower limb variants
Newborn = Genu varum
1.5-2 yo = Straight
3-8 yo = Genu valgum (knock knees)
>6-8 yo = Straight
Transverse Plane Deformities of Hip
Normal = 12-15 degrees Retroversion = <12 Anteroversion = >15
