PEDIATRIC Section 13: MSK Flashcards by Gerard Pingoy

When will you get a repeat radiograph after fracture in PEDS?

7-10 days.

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Periosteal reaction is expected in how many days?

7-10 days

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What is the major concern regarding pediatric fracture?

Growth arest

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What is this?

Physeal bar

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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

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SALTER-HARRIS Classification
Complete physeal fracture, with or without displacement.

Type I: Slipped

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SALTER-HARRIS Classification

Fracture involves the metaphysis. This is the most common type (75%).

Type 2: A —Above (or “Awayfrom the Joint”)

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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)

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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

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SALTER-HARRIS Classification

Compression of the growth plate. It occurs from axial loading injuries, and has a very poor prognosis.

Type 5: R - Ruined

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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

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This is an injury which occurs after repetitive trauma, usually after new activity (walking).

Stress Fracture in Children:

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The most common fracture of the elbow

supracondylar fracture (>60%)
followed by lateral condyle (20%)
and medial epicondyle (10%).

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This is a line through the center of the radius, which should intersect the middle of the capitellum on every view (regardless of position).

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Diagnosis?

Radial dislocation

Will NOT pass through the center of teh capitellum

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A line along the anterior surface of humerus, should pass through the middle third of the capitellum.

Anterior humeral line

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Diagnosis?

supracondylar fracture

you’ll see this line pass through the anterior third.

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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)

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This is the second most common distal humerus fracture in kids.

Lateral Condyle fracture

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Lateral condyle fx criteria

If it passes through the capitello-trochlear groove

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Displacement of the lateral Condyle fracture =

surgery

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Little League EWiovi

Medial Epicondyle Avulsion

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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