Pediatric Musculoskeletal Injuries Flashcards
How do children’s bones differ from adult bones? What kinds of injury does this lead to?
children’s bones are more porous and pliable, which results in a greater number of incomplete fractures - due to decreased mineral content and responds to forces differently resulting in unique fracture patterns
ligaments are also relatively stronger and less likely to get injured, making younger children more likely to experience fractures than sprains or dislocations
What are the four anatomic aresa of pediatric long bones?
epiphysis
physis (growth plate)
metaphysis
diaphysis
What are the structural differences in pediatric bones?
periosteum is thick, strong, and metabolically active, holds fracture fragments in alignment and aids in reduction, healing and remodeling
extensive remodeling corrects large degrees of angulation and displacement (age < 8 yrs)
nonunion is rare
Salter-Harris Classification system
used to describe the location of a fracture in relation to the growth plate
fractures are graded as a scale from 1 to 5, with a higher classification indicating an increased risk for affecting further bone growth
type I Salter-Harris Physeal injury
separation through the physis, usually through areas of hypertrophic and degenerating cartilage cell columns
radiograph appears normally initially
diagnosed based on injury (usually shear injury), swelling, pain, and tenderness over growth plate
growth is rarely affected
type II Salter-Harris Physeal injury
fracture through a portion of the physis that extends through the metaphyses
most common fracture pattern involving growth plate
most common fracture pattern involving growth plate
type III Salter-Harris Physeal injury
fracture through a portion of the physis that extends through the epiphysis and into the joint
may interfere with growth
involves articular surface, may affect joint
type IV Salter-Harris Physeal injury
fracture across the metaphysis, physis, and epiphysis
may interfere with growth
involves articular surface, may affect joint
type V Salter-Harris Physeal Injury
crush injury to the physis/growth plate
from severe axial loading
worst prognosis with possible growth arrest
What details should be included when describing fractures?
the bone involved
the location within the bone
the fracture pattern
any displacement
age of the fracture
Does it take more force to cause a transverse fracture, spiral fracture, or spiral fracture?
transverse fracture
transverse fracture
perpendicular to long axis
complete fracture
usually higher force mechanism
direct blow or bending force
often easy to reduce
comminuted fracture
when the bone fractures in multiple places
usually takes a great amount of force
rare in young children and difficult to reduce
often require operative intervention fixation
oblique fracture
oblique to long axis of bone
twisting force or compression/bending mechanism
can have significant displacement, may be difficult to maintain alignment when reduced
spiral fracture
caused by a twisting mechanism
often takes less force than transverse fracture
What is displacement?
when parts of a fracture is moved out of normal alignment
a fragment may be moved laterally, angulated, rotated, or shortened in relation to its normal position
translation - lateral movement
angulation - measure through mid-axial line
rotation - may be difficult to tell
What is a torus or buckle fracture?
one of the most common fracture patterns seen in children, especially the distal forearm - occurs at the junction of metaphysis and diaphysis in distal forearm, radius +/- ulna
results from a compressive load, such as a fall onto an outstretched hand
the bony cortex of the metaphysis buckles in a small area
these are stable fractures that heal quickly with simple immobilization - use premade splint for 3-4 weeks
as the skeletal system matures and the metaphyseal region becomes stiffer, the incidence of these fractures decreases
What are greenstick fractures?
the most common fracture pattern in children
result of compression or bending force and bone on convex side fails
considered incomplete fractures since the bony cortex remains intact on one side
fracture line does not propagate to the concave side (incomplete)
these fractures usually occur at the junction of the diaphysis and the metaphysis
if reduction needed, need to make break complete to maintain alignment, and casting is needed
What are bowing fractures (plastic deformation)?
compression force causes microscopic failure in bone, resulting in a bending or bowing - up to a 20 degree curve in a child <4 yrs
occur when bone bends without a clear single fracture line - usually ulna +/- radius
though often not a clear cortical defect, the deformity can still be significant and reduction may be needed
also occurs in children due to the pliability and porous nature of pediatric bones - almost unique in children
What is a toddler’s fracture?
usually refers to an oblique, non-displaced fracture in the distal tibia of an ambulating child younger than 5 years old
occurs in an oblique or spiral patterns from a twist in the lower leg while running or falling
sometimes the child’s leg gets caught in something and the fracture occurs when the child twists the leg in trying to free it
fractures may be subtle or not able to be visualized on initial radiograph
What is the treatment for toddler’s fracture?
cast, no weight bearing
What is the clinical picture of toddler’s fracture?
limp or refusal to bear weight
often minimal to no swelling
fracture line may be subtle on x-ray
What is nursemaid’s elbow?
radial head subluxation, which can occur in children younger than 6 years of age (25% of all elbow injuries) as a result of a pull on the child’s extended arm
the typical history is an adult pulling a falling child up by the hand
the traction on the radius moves the radial head distally from the elbow joint and part of the annular ligament gets trapped between the radial head and the capitellum
treat by suppination and flexion - one hand at wrist and other hand on elbow to “pop” of relocation
What would be a typical history referring to nursemaid’s elbow?
traction to the arm
patient has pain initially, then comfortable as long as the arm is held still
not using the arm
What is found on physical exam for nursemaid’s elbow?
elbow slightly flexed and arm held against body, not moving
no swelling, deformity, or bony tenderness
pain with movement of elbow
if history or physical exam does not fit or is concerning, consider radiographs to rule out fracture
What is the clinical presentation of nursemaid’s elbow?
concern of not using the affected arm
no pain at rest, no tenderness to palpation, and holds the affected arm at the side, pronated or partially flexed
movement is painful
reduction is accomplished by hyperpronation or supination flexion method
child will begin using the arm normally within minutes of successful reduction
What happens in slipped capital femoral epiphysis?
occurs as aresult of instability of the proximal femoral growth plate, resulting in slippage of the epiphysis relative to the femoral neck (Salter Harris Type I fracture through the physis) - inferior and posterior slips
occurs in adolescents (10-16yrs), often during periods of rapid growth
bilateral in up to 40%
What is the clinical presentation of a slipped capital femoral epiphysis?
chrinic knee, thigh or groin pain with a limp
the hip is externally rotated with limited flexion and internal rotation
radiographs show a widened growth plate with epiphyseal slippage
on radiographs - widened growth plate
What are the risk factors for SCFE?
males > females
obesity
endocrine disorders
What are the physical exam findings of SCFE?
limited internal rotation
when hip is flexed, it externally rotates
pain with flexion and internal rotation
gait - limp with leg externally rotated at hip
What is the treatment for slipped capital femoral epiphysis? What are some possible complications?
immediate surgical fixation (within 24 hrs) to prevent further slippage until the physis closes
complications are avascular necrosis of the hip and increased risk with longer time to diagnosis/intervention and large amount of slip
watch for SCFE of other hip
What are the factors that increase the likelihood that injuries occurred from abuse?
no explanation or a vague explanation for a significant injury
an important detail of the explanation changes dramatically
an explanation is inconsistent with the pattern, age, or severity of the injuries
an explanation is inconsistent with the child’s physical and/or developmental capabilities
different witnesses provide markedly different explanations for the injuries
a delay in seeking care with a significant injury
What kinds of fractures are highly suggestive of abuse?
skull fractures and long bone fractures are most common fractrues in abusive trauma
rib fractures and metaphyseal fractures also very suggestive
What do rib fractures indicate in a child?
an infant’s chest is more malleable than that of an older child and as a result the ribs deform rather than break, unless a major force is exerted - high specificty for abuse
most non-accidental rib fractures are thought to occur from anterior-posterior compression of the chest and are associated with intracranial injuries due to shaking of the infant
What is the clinical presentation of a rib fracture in a child/infant?
patients often do not present with a history of trauma, but with irritability and respiratory or gastrointestinal complaints - usually not suspected clinically
rib fractures may not be apparent radiographically until the healing callus is seen, 7-10 days after the injury
What are the common features of a metaphyseal fracture in children?
also known as a “corner fracture” or “bucket-handle fracture” - highly specific for abuse
occurs in the metaphysis of long bones as a result of tensile or shearing forces - area of immature bone and thin plate of bone separates
the metaphysis in infants is vulnerable to injury and can separate when a child is pulled, twisted, or yanked forcefully by an extremity
this type of force is unlikely to occur from accidental causes in this age group
these fractures often don’t have any external signs of injury, typically are not seen well on radiographs until healing and remodeling
heals quickly and no treatment is needed
