PEDIATRIC Section 13: MSK Flashcards
When will you get a repeat radiograph after fracture in PEDS?
7-10 days.
Periosteal reaction is expected in how many days?
7-10 days
What is the major concern regarding pediatric fracture?
Growth arest
What is this?
Physeal bar
What is a physeal bar?
“early” bony bridge crossing the growth plate after physeal involvement of the fracture or pior infection
Trauma is a classic way to ask it
SALTER-HARRIS Classification
Complete physeal fracture, with or without displacement.
Type I: Slipped
SALTER-HARRIS Classification
Fracture involves the metaphysis. This is the most common type (75%).
Type 2: A —Above (or “Awayfrom the Joint”)
SALTER-HARRIS Classification
Fracture involves the epiphysis. These guys have a chance of growth arrest, and will often require surgery to maintain alignment
Type 3: L - Lower
(3 is the backwards “E”for Epiphysis)
SALTER-HARRIS Classification
Fracture involves the metaphysis and epiphysis. These guys don’t do as well, often end up with growth arrest, or focal fusion. They require anatomic reduction and often surgery.
Type 4: T - Through
SALTER-HARRIS Classification
Compression of the growth plate. It occurs from axial loading injuries, and has a very poor prognosis.
Type 5: R - Ruined
SALTER-HARRIS Classification
These are easy to miss, and often found when looking back at comparisons (hopefully ones your partner read).
The buzzword is “bony bridge across physis”.
Type 5: R - Ruined
This is an injury which occurs after repetitive trauma, usually after new activity (walking).
Stress Fracture in Children:
The most common fracture of the elbow
supracondylar fracture (>60%)
followed by lateral condyle (20%)
and medial epicondyle (10%).
This is a line through the center of the radius, which should intersect the middle of the capitellum on every view (regardless of position).
Diagnosis?
Radial dislocation
Will NOT pass through the center of teh capitellum
A line along the anterior surface of humerus, should pass through the middle third of the capitellum.
Anterior humeral line
Diagnosis?
supracondylar fracture
you’ll see this line pass through the anterior third.
ELBOW Ossification Centers in order
CRITOE
Capitellum (Age I)
Radius (Age 3)
Internal (medial) epicondyle (Age 5)
Trochlea (Age 7)
Olecranon (Age 9)
External (Lateral) epicondyle (Age 11)
This is the second most common distal humerus fracture in kids.
Lateral Condyle fracture
Lateral condyle fx criteria
If it passes through the capitello-trochlear groove
Displacement of the lateral Condyle fracture =
surgery
Little League EWiovi
Medial Epicondyle Avulsion
The last plate in the elbow to fuse
medial epicondyle
Because medial epicondyle is an extra-articular structure, its avulsions will NOT necessarily result in
Joint effusion
Medial epicondyle avulsion fracture can get interposed between this two structures
Articular surface of the humerus and olecranon
Anytime you see an elbow dislocation - ask yourself
Is teh patiend 5 y.o.? where is the medial epicondyle?
The importance ofIT (crIToe) -
You should never see the trochlea and not see the internal (medial epicondyle), if you do it’s probably a displaced fragment
When a child’s arm is pulled on, the radial head may sublux into the annular ligament.
Nursemaids Elbow
Obvious Ulnar Shaft Fracture + Subtle Radial Head Dislocation
Monteggia fracture- dislocation
Why are avulsion fractures more common in kids?
Kids tendons tend to be stronger than their bones, so avulsion injuries are more common (when compared to aduUs).
Pelvic Avulsion fracture muscle attechments
Iliac crest =
ASIS -
AIIS -
Greater Trochanter -
LEsser Trochanter -
Ischial Tuberosity -
Symphysis -
Iliac crest = Abdominal muscles
ASIS - Sartorius, Tensor Fascia lata
AIIS - Rectus femoris
Greater Trochanter - Gluteal muscles
LEsser Trochanter - Iliopsoas
Ischial Tuberosity - Hamstrings
Symphysis - ADDuctor Group
This an acute avulsion of the inferior patellar pole.
Patellar Sleeve Avulsion Fracture
Diagnosis?
Patellar Sleeve Avulsion Fracture
The classic look is a fragment of bone at the inferior patella with associated soft tissue swelling.
Patellar Sleeve Avulsion vs Sinding-Larsen-Johansson
- Patellar Sleeve Avulsion is acute
- SLJ is chronic
Age 10-14 + chronic traction injury at the insertion of the patellar tendon on the patella. + Cerebral palsy
Sinding-Larsen-Johansson
This is due to repeated micro trauma to the patellar tendon on its insertion at the tibial
Sinding Larsen Johansson
Schlatter
tuberosity. It’s bilateral 25% of the time, and more common in boys.
Osgood-Schlatter
“Celery Stalk”
Congenital Rubella
DIagnosis?
Celery stalk in Congenital rubelaoral metaphysis
Diagnosis?
Syphillis
destruction of the medial portion of the proximal metaphysis of the tibia.
“Wimberger SIng”
In Syphillis, Bony changes do NOT occur until when?
6-8 week sof life (Rubella changes are earlier)
Soft tissue swelling + periosteal reaction + irritability + Self limiting =
Caffey Disease
Caffey disease is seen within
first 6 months of life
really hot mandible on bone scan
Caffey Disease (hot cAffey>) hehe
Prostaglandin E l and E2 (often used to keep a PDA open) can cause
Periosteal reaction
Sternotomy wires in CXR (Congenital heart) + Periosteal reaction
Prostaglandin Therapy
This is really the only childhood malignancy that occurs in newborns and mets to bones.
Neuroblastoma Mets
“Physiologic Periostitis of the Newborn”
Physiologic Growth
Physiologic periostitis inovlement.
Proximal involvement (femur) comes before distal involvement (tibia). It always involves the diaphysis.
It is N O T physiologic periostitis if:
You see it before 1 month
You see it in the tibia before thefemur
It does not involve the diaphysis.
LAngerhans Cell Histiocystosis (LCH)
Also known as EG (eosinophilic granuloma).
x2 common in boys
Skeletal manifestations are highly variable,
Most common site of LCH
Sull
LCH
Uneven destruction of the innter and outer tables
“Beveld Edge”
Round lucent lesion in the skull of a child =
Think:
Neuroblastoma mets or LCH
Appearance of LCH in the ribs and spine
Ribs: Multiple lucent lesions
Spine: Vertebra plana
Osteomyelities usullay occurs in?
babies (30% of cases < 2 y.o.)
usually hematogeneous (adults it direcly spreads - typically from a dibetic ulcer)
Describe osteomyelitis in the newborns vs kids vs Adults
Newborn: Open growth plates + perforating vesells - travel from metaphysis to epiphysis
Infection starts @metaphysis (most blood supply, growing the fastest) then spread from the perforaties to the epiphysis
Kids
- perforators regress - Epiphysial plate is avasular
- stops infection from crossing over
- “septic tank” scenario - Infection smolders.
- 75% involves metaphyses of long bones (Femur most common)
Adults
- Growth plates fuse
- avasscular plate barrier absent
- infection AGAIN cross over to theepiphyses to caus mayhem
Boney changes in osteomyelitis don’t occur on x-ray for how many days?
around 10 days
