Radial sublux/OSD/Sever's/ankle Flashcards
Radial Head Subluxation
general
Age of incidence
Also known as Nursemaid’s Elbow
Subluxation of the radial head under the annular ligament due to a sudden longitudinal traction on theforearm
Epidemiology
Most commonly occurs in children aged 1–4 years; rare after 5 years of age
Most common upper limb injury in children < 5 years of age
Girls are more commonly affected
Radial head subl
patho and other mechanisms
Axial traction mechanism:
Pronatedforearm undergoes axial traction while the elbow is extended
Withaxialtraction, the head of theradiusslips under the annular ligament
Theannularligament becomes interposed between the capitellum and the radial head
As children age, theannularligament thickens and nursemaid’s elbow becomes less likely to occur
Other possible mechanisms:
Falling onto an outstretched arm
Twisting ofa forearm
radial head subluxation
clin man
History andpresentationoften lead to the diagnosis:
Young toddler refusing to usearm
Often associated with history of longitudinal traction:
Young child moves suddenly in opposite direction while holding adult’shand
Young child is lifted up by arms
A click may be heard or felt by the person pulling the child’s arm
radial head subluxation
PE
The entire affected upper limb/clavicleshould be examined
Patient is often anxious and protective of injuredarm
Injured upper limb is held in slightly flexed, pronated position
Patientsare unable or unwilling to supinate theirarm
Pain and tenderness localized to the lateral aspect of the elbow
Signs of trauma (ecchymosis,edema, warmth) or neurovascular compromise are absent
If present, other diagnoses should be considered
If radial head spontaneously reduces prior to examination, patients may be asymptomatic
radial head subluxation
Dx
History and physical examination with typical findings are sufficient to diagnose
Plain film x-ray:
Rarely indicated with typical presentation
Useful with atypical presentations or unknown history
Useful in evaluation of other diagnoses (fracture,congenitalelbow dislocation, infectiousetiology)
radial head subluxation
Tx
Supination/flexiontechnique
Closed reduction of a nursemaid’s elbow is the procedure of choice
Must be certain there are no fractures prior to manipulation
Supination/flexiontechnique:
Warn caregivers that the maneuver will hurt and the child will likely cry
Child can be seated in parent’s or caregiver’s lap
Fully extend and supinate elbow and then take elbow intoflexion
This procedure is done while maintaining slight pressure over the radial head; often, the provider will feel a “click” in the elbow
Typically, the child will be moving the arm normally within 15 minutes
Immobilizationis unnecessary after first episode
radial head subluxation
Tx
Hyperpronation technique
Warn caregivers that the maneuver will hurt and the child will likely cry
Child can be seated in parent’s or caregiver’s lap
While applying mild pressure over the radial head, the provider holds the elbow in a flexed position and hyperpronates theforearm
A click may be felt whendisplacementis reduced
Typically, the child will be moving thearmnormally within 15 minutes
radial head subluxation
Management & Prognosis
Patientswho fail the initial reduction maneuver:
Reconsider the diagnosis
If there are no signs offracture, reduction attempt may be repeated
If unable to reduce or if diagnosis is in question, consider a splint and orthopedic referral
Prognosis
Excellent when reduced in a timely manner
Recovery is immediate after reduction
Recurrence rate: approximately 20%
Higher likelihood of recurrence if the child is younger than 3 years
Osgood-Schlatter Disease & Sever’s Disease
Apophysis
Normal secondary ossifications center
Located in the non-weight bearing part of the bone
Site of tendon or ligament attachment
Referred to as a “traction epiphysis”
Eventually fuses with the major portion of the bone (2nd decade of life)
Osgood-Schlatter Disease (OSD)
general and RF
MOA?
Also known as Tibial Tubercle Apophysitis
Common cause of anterior knee pain in adolescents
Inflammation of the patellar ligament at the tibial tuberosity as the result of repetitive extension stress
♂>♀
Boys: 12-15 years
Girls: 8-12 years
Risk factors:
Participation in athletics, especially running and jumping sports
Osgood-Schlatter Disease (OSD)
clin man and PE
Test?
Symptoms
Painon anterior aspect of knee
Exacerbated by kneeling
Physical Examination
Inspection
Enlarged tibial tubercle
Palpation
Tenderness over tibial tubercle
Provocative test
Pain on resisted knee extension
Osgood-Schlatter Disease (OSD)
Dx
Based on history and clinical findings
Radiographs
Lateral radiograph of the knee
Irregularityand fragmentation of the tibial tubercle
Can help to rule out tibial tubercle fracture and patellar tendonitis (Jumpers knee)
Osgood-Schlatter Disease (OSD)
Tx
Conservative management
90% of patients have complete resolution
Rest/activity modification
Ice
NSAIDs
Strapping/sleeves to decrease tension on the apophysitis
Quadriceps stretching
Surgery
Ossicle excision
Performed inskeletally maturepatients with persistent symptoms
Sever’s Disease
general
Also known as apophysitisof the calcaneus
Common inflammatory condition of the growth plate in the heel
Due to traction apophysitis and repetitive microtrauma
Commonly seen in adolescent athletes(♂>♀) participating in running & jumping sports
Often presents just before or during peak growth
Severs disease
PE and clin man
Symptoms
Pain in the area of the calcaneal apophysis in an immature athlete
Bilateral involvement 60% of cases
Increased pain with activity or impact
Stretching of the gastrocnemius and the soleus exacerbates heel pain
May have associated warmth, erythema, and/or swelling
Physical examination
Tight Achilles tendon
Positive squeeze test (pain with medial-lateral compression over the tuberosity of the calcaneus)
Pain over the calcaneal apophysis
Severs disease
Dx
Based on history and clinical findings
Radiographs
Sclerosis can be present
Fragmentation is common
Helpful to rule out other causes of heel pain (osteomyelitis, calcaneal bone cysts)
Severs disease
Tx
Conservative management
Rest/activity modification
Ice (before and after activity)
NSAIDs
Gastroc-soleus stretching
Ankle dorsiflexor strengthening
Heel cups or heel pads
Orthotics
Strain v Sprain
Strain: an injury in which a muscle is stretched too much and tears
Sprain: an injury to a ligament caused by tearing of the fibers of the ligament
Bones of the Ankle
Ligaments of the Ankle
Deltoid (the strong, medial ligament)
Anterior and posterior talofibular (lateral ligaments)
Calcaneofibular (lateral ligaments)
Ankle Sprain
general
Common injury
Result from:
Inversion injury
Turning of the foot inward
Tears the lateral ligaments – most often the anterior talofibular ligament
Can have an associated talar dome fracture
Eversion injury
Turning the foot outward
More often causes an avulsion fracture of the medial malleolus than a ligament sprain due to the strength of the deltoid ligament
Ankle Sprain
High ankle sprain
MOI
ligaments involved
Results form a forceful external rotation of the foot and ankle
Tear of the ligaments that connect the fibula and tibia
Anterior tibiofibular ligament
Posterior tibiofibular ligament
Interosseous ligament/membrane
Ankle Sprain
S/Sx
Audible “pop” at the time of injury
Pain
Location is variable with the type of injury
Inversion – maximal at the anterolateral ligament
Eversion – maximal over the deltoid ligament
Swelling
Ecchymosis
Ligament injury: tenderness is maximal over the damaged ligaments rather than over bone
Fracture: tenderness is maximal over bone rather than over ligaments
Degrees of Lateral Ankle Sprains
1st degree – mild ankle sprain
Minimal pain and swelling
Ankle is weakened and prone to reinjury
Healing: 5-14 days
Degrees of Lateral Ankle Sprains
2nd degree – moderate to severe ankle sprain
Swelling often associated with ecchymosis
Walking produces pain and is often difficult
Healing: 14-21 days
Degrees of Lateral Ankle Sprains
3rd degree – severe ankle sprain
Diffuse swelling and ecchymosis
Unable to bear weight
Ankle instability
Nerve damage may be present
Healing: 6-8 weeks
Ankle vs foot radiograph
An ANKLE radiograph should be performed if there is pain in the malleolar region with any of the following:
Bone tenderness at the posterior edge of the distal 6 cm or tip of the lateral malleolus
Bone tenderness at the posterior edge of the distal 6 cm or the tip of the medial malleolus
Inability to bear weight for at least 4 steps both immediately after injury and at the time of evaluation
A FOOT radiograph should be performed if there is pain in the midfoot region with any of the following:
Bone tenderness at the navicular bone
Bone tenderness at the base of the 5th metatarsal
Inability to bear weight for at least 4 steps both immediately after injury and at the time of evaluation
ankle sprain
Dx
Based on history and physical examination
Ankle anterior drawer test
Performed to evaluate the stability of the anterior talofibular ligament (differentiate between 2nd and 3rd degree lateral ankle sprains)
Positive test: anterior movement of the foot = 3rd degree tear
Plain-film radiographs to exclude fractures
AP, lateral, and oblique
Ankle sprain
Tx
PRICE
Protection, rest, ice, compression, and elevation
Splinting alleviates pain
Aircast or orthotic boot for mild sprain
Posterior splint for 2nd, 3rd, and high ankle sprains
Crutches should be used until gait is normal
Early mobilization for mild sprains
Ice: applied for 15-20 minutes every 4-6 hours for the first 24-28 hours
Orthopedic referral
Evaluate for surgical repair for moderate to severe sprains
