SM 251a, 252a - Peds MSK, Peds/Adult Sports Med Flashcards
What is Sever disease?
Describe the presentation
Inflammation of the calcaneal aphophysis
The “childhood version of achilles tendinopaty/plantar fasciitis”
Children are more likely to have bone issues than tendon issues
- Insidious onset
- Worse with activity
- No mechanical symptoms
- May have mild weakenss with ankle dorsiflexion
- Tendernes with medial/lateral heel compresion
- Most common in children 8-11
Describe the structure of a tendon
Water
Collagen Type I
Which Salter-Harris fractures are most likely to affect bone growth?
III, IV, V
Anything that involves teh epiphysial side of the growth plate (III, IV), or crushes the growth plate (V)
What is the Salter-Harris classification of this fracture?
Salter-Harris 1
Growth plate is a bit wider than it should be
Why do tendons heal poorly comparted to muscle?
Less oxygen consumption (=> less metabolic activity/ cell turnover)
What is Sinding-Larsen-Johansson Syndrome?
What is the management?
Irritation fo the accessory growth area (apophysis) of the inferior patella
- Rest if it hurts
- Play if it feels okay
- Stretching and strengthening can help
- Patellar strap
What causes Achilles Tendinopathy?
Non-inflammatory intra-tendinous collagen type I degradation
What causes Osgood-Schlatter?
Describe the presentation and treatment
Tibial tubercle (apophysis) separates from the rest of the tibia
- Months of anterior knee pain
- Especially after activity
- Bump on tibial tubercle
- Treatment
- Activity modification, ice, NSAIDs
- Patellar strap
- Physical therapy for stretching/strengthening
- Consider immobilization
(via damage/tear in hyaline cartilage)
What is an apophysis?
Accessory growth plate
- Makes the bone wider, not longer
- Attachment points of muscles
Describe these fractures
Incomplete fracture of the radius (Greenstick fracture)
Complete fracture of the ulna
Rehabilitation after an ankle sprain is important because
- Most people do not exercise so at least they should have strengthening exercises for the ankle
- Exercise will maximize healing of the sprained ligament
- It will decrease chance of experiencing another sprain at the same ankle
- Tendons are usually injured with an ankle sprain and need to be strengthened before returning to fitness and sport activities
c. It will decrease chance of experiencing another sprain at the same ankle
Where in the tendon is achilles tendinopathy most common?
Mid-portion
What are the pathologic features of Achilles tendinopathy?
Fiber disorientation and thinning
Scattered vascular ingrowth (neovascularization)
Gray-brown, amorphous
Describe the stages of muscle strain healing
- Stage 1 - Inflammatory phase
- Neutrophils
- Proinflammatory cytokines
- Removal of necrotic material, initiation of angiogenesis
- Stage 2 - Proliferative phase
- Infiltration of myocytes
- Fibroblasts produce collagen (TIII), GAGs, elastin
- Stage 3 - Remodeling phase
- Collagen remodeling
- Consolidation, maturation
Why should Slipped Capital Femoral Epiphysis (SCFE) be treated immediately?
Treatment = immediate surgical fixation
Goal is to avoid complications
- Avascular necrosis of the hip
- SCFE of the other hip (always check for both at presentation)
In a long bone, where will you find the primary ossification center?
Where will you find the secondary ossifcation center?
- Primary ossificaiton center
- Starts in the shaft of the long bone
- Secondary ossification center
- In the epiphysis of long bones
What is the treatment for a muscle strain?
- Rest (4-7 days)
- Ice
- Compression
- Elevation
Most recover after significant sequelae
What is a muscle strain? What causes it?
Intrinsic injury to the muscle
Due to excessive intrinsic tensile force, usually occurs at myotendinous junction
How would you describe this fracture?
Salter Harris II fracture of the distal radius
Transverse fracture of the ulna
What is the Salter-Harris classification of this fracture?
Salter-Harris IV
Fracture through the metaphysis, physis, and epiphysis. Extends into the joint
What are the risk factors of slipped capital femoral epiphysis?
- M > F
- Obesity
- Endocrine dysfunction
What is the role of rehabilitation in treating an ankle sprain?
Redues risk of future sprain after first sprain
(But does not prevent 1st sprain)
Which muscles are most likely to be strained?
Muscles that span two joints
- Hamstrings (Knee and hip)
- Rectus femoris (Knee and hip)
- Gastrocnemius (Knee and ankle)
Patients with Achilles tendinopathy often have pain that is worst with
a. Sitting
b. Running
c. Walking
d. Lying down
b. Running
What is the treatment for little league elbow (Medial epicondyle apophysitis)?
REST
- Return to sport includes starting with a shorter distance, fewer throws
What is the Salter-Harris classification of this fracture?
Salter-Harris V
Crush injury to the physis
Most likely to result in premature closure of the growth plate and growth arrest
Describe the grading system for muscle strains
- Grade 1 = microscopic tear
- Grade 2 = partial tear
- Grade 3 = full tear
What is a greenstick fracture?
What causes it?
An incomplete fracture; one side appears normal, and the other is fractured
Caused by compression or bending forces
This x-ray shows a greenstick fracture of the radius, and a complete fracture of the ulna
What is the treatment for Achilles tendinopathy?
- No running - cross-training is ok
- Heel lift if significant pain with walking
-
Physical therapy
- Eccentric exercise program
- Heavy slow resistance training
- Limited role of injections and surgery
Rest alone will not cure the tendinopathy
Most patients make a full recovery
In pediatric bones, where is the germial layer?
Epiphysial side of the long bone
New chondrocytes migrate to the metaphysial side, where they are calcified
Describe the management of a buckle (torus) fracture
Simple immobilization (pre-made splint)
Heals well
A hip x-ray of a 12 year old male child shows “ice ream falling off of the cone.”
He walks with a slight limp, and the affected leg is externally rotated
What is the most likely diagnosis?
What is the treatment?
Slipped Capital Femoral Epiphysis (SCFE)
M>F, obesity, endocrine disorder = risk factors
Immediate surgical fixation to prevent further slippage
What are the structural differences in pediatric vs. adult bone?
Compared to adult bones, pediatric bones have different:
- Periosteum
- Thick, strong, metabolically active
- Holds fracture fragments in alignment
- Aids in reduction, healing, remodeling
- Extensive remodeling
- Can self-correct large degrees of angulation and displacement
What is a toddler’s fracture?
What causes it?
- Oblique, non-displaced fracture of distal tibia
- Child must be walking and <5 years old
- Usually a twist while running or falling, or while trying to free the leg
- ex: Lands funny at the end of the slide
Treatment = full immobilization! Important not to bear weight
Describe the history and physical exam consistent with Slipped Capital Femoral Epiphysis (SCFE)
- Sub-acute or chronic pain with acute worsening
- Vague pain to groin, thigh, knee
- Limp w/leg externally rotated at the hip
- Pain an limitation with flexion and internal rotation
Why are sprains uncommon in young children?
Pediatric ligaments are strong compared with pediatric bone; the bone is the weak point, and is more likely to fracture than the ligament is to sprain (tear)
A 3 year old girl has leg pain and a limp after falling and twisting her leg. Is she more likely to have a fracture or a sprain?
Fracture
Childrens bones are weak compared with tendons
2 year-old girl with left arm pain and refusing to move her left arm
Her teenaged cousin was swinging her around by the arms when she began to cry and have pain in her left elbow
Physical exam:
- Holding left arm at side, won’t move it
- No swelling or deformity
- No tenderness to palpation (check bony landmarks)
- Cries with movement of elbow
What is the most likely diagnosis?
Dislocated elbow (radial head subluxation)
- History of tracion to the arm
- Pulls radial head distally, annular ligament gets trapped in the joint space
- Comfortable at rest, pain with movement
- No swelling, deformity, or bony tenderness
- Treatment
- Hyperpronation or supination + flexion
X-ray for fracture if H&P does not fit
Are children more likely to sustain fractures or sprains?
Fractures, often incomplete
Ligaments are strong compared to the bone; the bone is more likely to sustain injury than the ligament
How are ankle sprains treated?
- Rest
- Ice
- Compression
- Elevation
- Rehab
- Prevents recurrence (but does not prevent 1st sprain)
Which structure is affected in Sinding-Larsen-Johansson Syndrome?
Which structure is affected in Osgood-Schlatter Syndrome?
- Sinding-Larsen-Johansson: inferior patella
- Osgood-Schlatter: tibial tuberosity
What causes a sprain?
Injury to a ligament
What is the difference in appearance between a Bowing fracture and a Greenstick fracture?
Bowing = cannot see clear fracture line anywhere
Greenstick = Can only see clear fracture line on one side of the bone
Both are much more likely to occur in pediatric vs. adult bone
Where in the muscle do most muscle strains occur?
Why?
Myotendinous junction
Weakest point of the muscle beacause the tendon is not a fully formed muscle
Name the kind of fracture in each picture
From left to right
- Transverse
- Oblique
- More likely to slip out of place than transverse, may require fixation
- Spiral
- Comminuted
What is the Salter-Harris classification of this fracture?
Salter-Harris II
Fracture through a portion of the physis, extends through the metaphysis
What is the Salter-Harris classification of this fracture?
Salter-Harris III
Fracture through a portion of the physis that extends through the epiphysis and into the joint
