Pediatrics, tumor Flashcards
Pediatrics Fractures: Greenstick Fracture vs Torus “Buckle” Fracture
Greenstick Fracture -
Incomplete fracture with cortical disruption & periosteal tearing on the convex side.
Torus “Buckle” Fracture
- Incomplete fracture at the metaphyseal-diaphyseal junction due to an axial load
🌳 Greenstick → Bone bends & breaks on one side
🪵 Torus (Buckle) → Bone compresses & buckles without breaking
Salter Haris Fracture types
● Type I: Isolated growth plate fracture (Cast or boot)
● Type II: Growth plate fx + fx of the metaphysis (most common) (Cast or boot)
● Type III: Growth plate fx + fx across the epiphysis (Often ORIF)
● Type IV: Fracture extends across the metaphysis, growth plate & epiphysis. (Needs ORIF)
● Type V: Growth plate compression. (Often ORIF)
ped: tibial shaft fracture
risk factor, MOA, sx/PE
❖ Males > Females, Approx age 8 y.o.
❖ Adolescents: 50% pedestrian vs vehicle
❖ Toddlers
➢ Low energy twist or fall
➢ Torsional forces result in spiral or oblique fracture pattern or a “toddler’s fracture”
sx/Physical Exam
● Limp or refusal to bear weight
● Tenderness
● Warmth & swelling, bruising
● Pain with ankle DORSIFLEXION
● High suspicion for compartment syndrome
“toddler’s fracture” (test)
Torsional forces result in spiral or oblique fracture pattern or a “toddler’s fracture”
= Pediatric tibial shaft SPIRAL fracture
Classification based on location - Pediatric tibial shaft fracture
Incomplete = Greenstick fracture of tibia or fibula
Complete = Complete fracture of the tibia with or without fibula fracture or plastic deformation
Tibial Spiral Fracture - “Toddler’s Fracture” = Non-displaced spiral or oblique fracture of the tibia with intact fibula in a child 3 years old or younger*******
Tibial Shaft Fractures tx and complications
Treatment
● Non-operative - Long leg casting
○ Almost all Toddler’s fractures & Greenstick fractures (Healing 3-4 weeks)
● Operative - External fixation vs ORIF (IM Nail, Plate fixation,
○ Unstable fractures
○ Poly trauma
Complications
● Compartment syndrome*
● Leg Length Discrepancy
● Angular deformity
● Physeal injury
Supracondylar fracture
overview (MC pop, moa); sx; PE - what nerves to check are intact
● MC children 5-7 y.o. - fall on outstretched hand.
● Males = Females
● Extension type (distal fragment is displaced posterior) 95-98%
● Flexion type (distal fragment is displaced anterior) <5%
Signs & Symptoms
● Pain / Refusal to move elbow
Physical Exam
● Limited ROM
● Neurovascular Exam (prior to any reduction)
○ Anterior Interosseous Nerve Neuropraxia - Unable to flex the IP joint of the thumb and the DIP joint of the index finger (Can’t make A-OK Sign) Paralysis of FPL & radial FDP.
○ Median nerve - loss of sensation over the volar aspect of index finger
○ Radial nerve neuropraxia - Unable to extend wrist, MCP joints, Thumb IP joint
○ Assess pulses & Capillary refill (palpation or doppler)
which pediatric fracture would the pt not be able to make the A-OK sign (TEST)
Supracondylar fracture!!!!!
○ Anterior Interosseous Nerve Neuropraxia - Unable to flex the IP joint of the thumb and the DIP joint of the index finger (Can’t make A-OK Sign) Paralysis of FPL & radial FDP.
Supracondylar fracture dx and tx
Dx:
● X-Rays - AP & Lateral
○ Posterior fat pad sign = highly suggestive
○ The radial head should be directed toward the
distal humerus (capitellum) on both AP & Lateral views
Treatment
● Nonoperative
○ Type I & II - Long arm casting with elbow
flexed <90 degrees ● Operative
○ Some Type II & III - Closed reduction percutaneous pinning
Nursemaid’s Elbow
Def: Subluxation of radial head with radial head becoming wedged into stretched annular ligament.
presentation:
- “Not using the arm”
- Arm flexs and refuses to use
- 2-5 years old
MOA: pull on arm upward; pulling arm/tugging arm
- Longitudinal traction with forearm pronated & extended.
- Lifting, swinging, pulling child by the extended arm.
Tx:
- Closed Reduction: HYPERPRONATION or supination with flexion.
- Obtain post-reduction x-rays to ensure no fx. Especially if child is still favoring the arm
A mother brings her 3 y.o. Daughter into the orthopedic clinic stating that since this past morning the girl has not been using her right arm. She first noticed it after dressing her. The girl holds her arm flexed and refuses to use it. On exam she cries when you palpate her elbow. X-rays are normal.
nursemaid’s elbow
- “Not using the arm”
- Arm flexs and refuses to use
Blount’s Disease
“Tibia Vara”: Abnormal proximal tibia physis that causes an abrupt varus angulation of proximal tibia.
Mechanism unknown
Treatment
● Under 3.yo. Observe
● Knee Ankle Foot
Orthosis
● Older than 3 with
severe deformity - hemiepiphysiodisis
Sever’s disease -> what is it (TEST)
CACANEAL APOPHYSITIS = Aka Sever’s disease -> Pain along the POSTERIOR HEEL**
* Inflammation of the growth plate (apophysis) at the posterior calcaneus (heel)
* Affects prepubertal, active children (<9 y.o. In females, <11 y.o. In males)
* Caused by repetitive stress & microtrauma
* Signs & Symptoms: Pain and tenderness at posterior heel with activity.
Treatment
● Modification of activity
● 1⁄4 inch heel lift
● Achilles and calf stretching
Scoliosis def and screening (Test)
Lateral & rotational curvature of the spine.
Common in girls and with family hx. Most common 10 y.o. With Cobb angle >10 degrees.
Screening:
● Adams forward bending test. Look for asymmetry with a prominence on one side.
● Scoliometer - > or equal to 7 degrees is +.
● Leg length, waistline asymmetry, skin defects, abnormal reflexes,
Scoliosis dx, tx, surgical correction
Radiographs
X-Ray: Cobb angle > or equal to 10 degrees
MRI: if rapid progression, abnormal reflexes
Treatment
● Observation: Cobb angle <25deg. Risser Grade 0-2 **
○ F/U: 6-9mo. Bracing if angle increases >5deg. In 3-6mo.
Surgical correction
● >40 deg Cobb angle **
● Risser grade 0-2**
● Skeletally immature
Scoliosis - Bracing: when would you brace vs CI
● Skeletally immature
● Cobb angle increases >5deg in 3-6mo.
● Cobb angle 30-39 deg
Contraindicated:
- skeletally mature
- Cobb angle >/= 50 deg
- Or <20deg.
most common benign tumor? what imaging? tx? (test)
OSTEOCHONDROMA
- xray: Pedunculated (narrow stalk). Grows away from the growth plate **
- definitive dx: BIOPSY
- tx = observation
Osteochondroma
● Bony overgrowth with cartilage capped over it.
● Located at an area of tendon insertion, often
on long bones.
● Most common benign tumor (10% lead to
chondrosarcoma).
● Males > Females. 10-20y.o.
● Can grow until reach skeletal maturity.
Signs & Symptoms
● Painless
● Palpable mass
● Neurologic symptoms if nerve compression
Radiographs
X-Ray:
- Pedunculated (narrow
stalk). Grows away from the growth plate.
Biopsy is definitive.
Treatment
● Observation
● Marginal resection if painful.
● Marginal resection if located in pelvis (m.c location to progress to malignancy).
Enchondroma
- Second most common benign bone tumor***
- Most common tumor of the hand***
- Painless***
- Often found incidentally “Incidentaloma”
- Round/Oval radiolucent lesion near epiphysis
- Sharp margins, thin intact cortex
Osteoid Osteoma
● BENIGN bone tumor**
● Male > Female. 10-20 y.o.
● Proximal femur m.c., tibia, femur, spine.
● Characterized by high levels of
prostaglandins
Signs & Symptoms
● Pain that is worse at night.
● Relieved with NSAIDs (prostaglandin
inhibition)
● Limp, decreased ROM, tenderness.
X-Rays:
● Small round radiolucent
nidus with a sclerotic margin
● CT & MRI more sensitive
Unicameral (Solitary) Bone Cyst
➔ Most common cystic lesion of bone.*
➔ #1 cause of pathologic fractures in children.
➔ Males>Females, 5-15 y.o.
➔ Painless. Fracture usually
first sign.
Proximal Humerus #1, proximal femur
X-Rays
● “Fallen leaf” sign, Intact cortices.***
● Epiphysis usually spared
Treatment
Corticosteroid injections
(85-90% success rate)- decrease prostaglandin.
● Prostaglandin is believed to reduce the cyst’s ability to reabsorb into the bone.
Surgical: Curettage and bone grafting
1 cause of pathologic fractures in children: what is it, xray, tx
Unicameral (Solitary) Bone Cyst
➔ Most common cystic lesion of bone.
-
X-Rays
● “Fallen leaf” sign,
Treatment
Corticosteroid injections
Osteosarcoma - important facts (test); sx, PE
❖ Malignant tumor characterized by a production of new bone or immature bone by malignant cells.
❖ MC primary bone malignancy**
❖ Distal Femur m.c.**
❖ METS to lung m.c.**
❖ 80% occur <20y.o.
❖ 50-60 y.o. With hx of Paget’s &/or radiation
Signs & Symptoms
❖ Bone pain, Worse @ night
❖ Joint swelling
Physical Exam
❖ +/- tender mass
Osteosarcoma dx and tx
Diagnosis
● X-Rays:
○ Classic-“Hair on End” or “Sunburst Appearance”*
○ Sclerotic & lyticlesions
○ Codman’s Triangle: Ossification of raised periosteum*
● Biopsy: Definitive
● Labs: Increased Alkaline Phosphatase (used for diagnosis, prognosis, treatment response, & recurrence).
○ Increases with osteoblastic
(formation of new bone) activity.
● CT to evaluate for METS (lungs most common).
● Bone Scan to evaluate for METS
tx:
- Neovascular: Chemotherapy/Surgical removal/Amputation
- Not Neovascular: Limb-sparing resection
