SM_251a-252a: Peds MSK, Peds / Adult Sports Med Flashcards
Describe structural differences in pediatric bones
Structural differences in pediatric bones
- More porous and pliable: unique fracture patterns, incomplete fractures
- Ligaments stronger than bone: more likely to fracture, less likely to sprain
- Periosteum: holds fracture fragments in alignment
- Extensive remodeling: corrects large degrees of angulation and displacement, nonunion is rare
Describe the anatomy of a growing bone
Growing bone
- Diaphysis: shaft
- Metaphysis: tapering part
- Physis: growth plate
- Epiphysis: end of bone
In growing bone, there are ____ on the epiphyseal side and cells ____ on the metaphyseal side
In growing bone, there are germinal on the epiphyseal side and cells calcify on the metaphyseal side
Describe the Salter-Harris classification
Salter-Harris classification
- Salter I: separation through physis usually through areas of hypertrophic and degenerating cartilage cell counts
- Salter II: fracture through a portion of the physis that extends through the metaphysies
- Salter III: fracture through portion of the physis that extends through the epiphysis and into the joint
- Salter IV: fracture across metaphysis, physis, and epiphysis
- Sater V: crush injury to the physis
Describe growth plate injury in the Salter-Harris classification
Growth plate injury in the Salter-Harris classification
- Salter I: initially normal or subtle widening radiograph, diagnosis based on hx of trauma and symptoms, repeat XR shows healing callus, growth rarely affected
- Salter II: most common growth plate fracture pattern, growth rarely affecte
- Salter III and V: may interference growth, involves articular surface and may affect joint
- Salter V: crush injury of growth plate, from severe axial loading, worst prognosis with possible growth arrest
Salter-Harris I fracture is ____
Salter-Harris I fracture is separation through the physis, usually throughb areas of hypertrophic and degenerating cartilage cell columns
Salter-Harris II fracture is ____
Salter-Harris II fracture is fracture through a portion of the physis that extends through the metaphyses
Salter-Harris III fracture is ____
Salter-Harris III fracture is fracture through a portion of the physis that extends through the epiphysis and into the joint
Salter-Harris IV fracture is ____
Salter-Harris IV fracture is fracture across metaphysis, physis, and epiphysis
Salter-Harris V fracture is ____
Salter-Harris V fracture is crush injury to the physis
Transverse fracture occurs ____ to the long axis, is caused by ____ or ____, and involves ____ force
Transverse fracture occurs perpendicular to the long axis, is caused by direct blow or bending force, and involves higher force
Comminuted fracture involves ____ force mechanism, is rare in ____, and often necessitates ____ because it is difficult to reduce
Comminuted fracture involves high force mechanism, is rare in children, and often necessitates operative intervention/fusion because it is difficult to reduce
Oblique fracture is ____ to long axis, involves ____ or ____ mechanism, and can lead to ____
Oblique fracture is oblique to long axis, involves twisting force or compression/bending mechanism, and can lead to be difficult to maintain alignment due to significant displacement
Spiral fracture is caused by a ____ mechanism and often takes ____ force than a transverse fracture
Spiral fracture is caused by a twisting mechanism and often takes less force than a transverse fracture
Describe fracture displacement
Fracture displacement
- Fracture fragment is moved out of normal bony alignment
- Translation: lateral movement, describe as percentage
- Angulation: in degrees, measure through mid-axial line
- Rotation: may be difficult to tell
Describe buckle/torus fracture
Buckle/torus fracture
- Result of compression force on bone: FOOSH injury
- Common forearm fracture in children: junction of metaphysis and diaphysis of distal forearm
- Stable fracture
- Heals well with simple immobilization: premade splint for 3-4 weeks, rapid return to function
Describe nursemaid’s elbow (radial head subluxation)
Nursemaid’s elbow (radial head subluxation)
- Typical history: traction to arm, pain initially / comfortable at rest, will not use arm
- Physical exam: no swelling, deformity, or bony tenderness; pain with movement of elbow
- Most common elbow injury at 2-5 years old
- Traction to radius pulls radial head distally and annular ligament (which attaches radius to ulna) gets trapped in joint space
- Treat with supination and flexion or with hyperpronation
Describe greenstick fracture
Greenstick fracture
- Compression or bending force
- Bone on convex side fails
- Fracture does not propagate to other side (incomplete)
- Plastic deformity of concave side
- If reduction is needed, need to make break complete to maintain alignment
Describe toddler’s fracture
Toddler’s fracture
- Oblique, non-displaced fracture of distal tibia
- Child must be walking and < 5 years old
- MechanismL twist while running or falling and trying to free leg
- Clinical picture: limp or refusal to bear wright, minimal to no swelling, fracture line may be subtle on x-ray
- Treatment: cast, no weight bearing
Describe slipped capital femoral epiphysis
Slipped capital femoral epiphysis
- Occurs in adolescents (10-16 years)
- Growth plate instability during periods of rapid growth
- Salter I fracture w/ slippage of epiphysis: slips inferior and posterior
- Risk factors: male, obesity, endocrine disorders
- History: often sub-acute or chronic, acute worsening, vague pain to groin / thigh / knee, limp
- Physical exam: pain and limitation with flexion and internal rotation, gait is limp w/ leg externally rotated at hip
- Radiograph: widening growth plate, ice cream falling off cone
- Treatment: immediaten surgical fixation to prevent further slippage
- Complications: avascular necrosis of hip
- Watch for SCFE of other hip
Slipped capital femoral epiphysis is described as ____ on radiograph, is treated with ____, may be complicated by ____, and should cause clinician to watch for ____
Slipped capital femoral epiphysis is described as “ice cream falling off the cone” on radiograph, is treated with immediate surgical fixation, may be complication by avascular necrosis of hip, and should cause clinician to watch for SCFE of other hip
This is a ____ fracture of the ____
This is a Salter-Harris II fracture of the distal radius
Describe bone formation
Bone formation
- Cartilage skeleton is transformed to a bony skeleton
- Endochondral ossification: process of bone formation from cartilage in long bones
- Primary ossification center: calcification starts in long bone shaft
- Secondary ossification center: at ends of bone in the epiphyses
- Physis: growth plate (between ossification centers)
- Apophysis: accessory growth plate, where muscles attach
Describe advantages and disadvantages of open physes
Advantages and disadvantages of open physes
- Advantages: tremendous potential for bone healing and remodeling, fractures are often easier to heal
- Disadvantages: can fracture through the physes (risk of growth arrest / angulation), irritation of physis or apophysis (juvenile epiphyseolysis or apophysitis)
Sinding-Largen-Johansson syndrome is ____
Sinding-Largen-Johansson syndrome is inferior patella apophysitis
- Irritation of accessory growth area (apophysis) of inferior patella
- Age 11-12 most common b/c infrapatellar apophysis is active
- Clinical diagnosis
- Symptomatic treatment
- Stretching
- Patellar strap
Osgood-Schlatter syndrome is ____
Osgood-Schlatter syndrome is inflammation of patellar ligament at tibial tuberosity (apophysitis)
- Boys 12-15 yo, girls 10-13 yo
- Adolescents participating in sports
- Bilateral sometimes
- Aggravated by running, jumping, kneeling
- Treatment: activity modification, icing, NSAIDs, patellar strap, PT (but avoid quadriceps strengthening), consider immobilization
- Waxing/waning symptoms for 1-2 years - 10% with persistent symptoms
Sever disease is ____
Sever disease is calcaneal apophysitis
- Age 8-11
- Often children have mild weakness w/ ankle dorsiflexion and tight calf muscles
- Clinical diagnosis
- Differential includes stress fracture and infection
- Childhood version of Achilles tendinopathy / plantar fasciitis
Anterior superior iliac spine apophysis avulsion fracture is ___
Anterior superior iliac spine apophysis avulsion fracture is when bone is pulled away from apophysis at anterior superior iliac spine
- Treatment: rest, slow progression of PT (RICE, gentle ROM, resistance exercise, stretching / strengthening, sports-specific drills), return to sports 6 weeks - 4 months, surgery is rarely indicated
Little League Elbow is ____ and is primarily treated with ____
Little League Elbow is medial epicondyle apophysitis and is treated primarily with rest
- Also use physical therapy / biochemical analysis
- Prevent with proper pitch progression, pitch counts, and proper rest
(medial epicondylitis / golfer’s elbow is seen in adults)
Describe the two paradigms of inflammation and tendinopathy
Inflammation and tendinopathy
- Mechanical overload (failed healing response): repeated microdamage with inadequate healing, features of a failed healing response, elevated inflammatory markers
- Proinflammatory environment (continuum model): sedentary individuals have high levels of proinflammatory cytokines, low levels of COL-1 (which usually improves state of inflammation), no inflammation-mediated change
___ was spared from injury
Short head of biceps femoris was spared from injury
Muscle strain pathology results from ____ and includes injury at ____ and ____
Muscle strain pathology results from excessive intrinsic tensile force and includes injury at myotendinous junction and soft tissue bleeding
Muscle strain healing of injured soft tissue includes ____, ____, and ____ phases
Muscle strain healing of injured soft tissue includes inflammatory, proliferative, and remodeling phases
- Inflammatory phase: RBCs and WBCs infiltrate, initiation of angiogenesis, removal of necrotic material
- Proliferative phase: infiltration of myocytes, production of collagen (Type III)
- Remodeling phase: consolidation phase, maturation phase
___ ligament is most likely to be injured
Anterior talofibular ligament is most likely to be injured
Describe clinical presentation, diagnosis, treatment and prognosis of ankle sprain
Ankle sprain clinical presentation, diagnosis, treatment and prognosis
- Presentation: sudden onset, inversion and plantarflexion, often w/ impaired function, mild focal to diffuse generalized lateral ankle swelling, may have a laxity
- Diagnosis: H&P, plain films for fracture or intra-articular pathology, may have concomittant peroneal tendon or muscle injury, MRI if pain not improving during first few weeks
- Treatment: rice, immobilize briefly, taping / bracing reduces recurrence, rehab
- Prognosis: most have fully recovery but 1/3 have recurrence/pain at 1 year
