Musculoskeletal Show
Musculoskeletal InjuriesSharon Sanchez, MD; Tamantha Arlata, MD; Saima Arshad, MD; Sarah Cheng, MD; Andrea Saunders, MD Musculoskeletal injury is one of the most common reasons for visiting a pediatric urgent care setting. Accidental injuries occur frequently during recreational play for toddlers and early school-aged children and more commonly during organized sports for older children. As organized sports participation increases for younger children, the prevalence of musculoskeletal-related injuries from athletic participation is shifting downward for age. This chapter outlines common injuries, evaluations, and management strategies for pediatric patients, including children and adolescents. It is important to understand that bone structure, musculature, and joint stability differ between the pediatric and adult populations. While most pediatric musculoskeletal injuries can be managed by pediatric primary/urgent care providers, having a collaborative relationship with the orthopedic specialists is advantageous. Fractures OverviewPhysical Examination
Evaluation: Imaging
Anteroposterior (AP) and lateral views are the most common. Oblique views are helpful for fully disclosing the nature and extent of many fracture patterns, especially when the injury involves the ankle, elbow, hand (especially for scaphoid fracture), or foot. Oblique views are also helpful for detecting subtle spiral fractures where the AP and lateral views are normal, yet a fracture is strongly suspected. Ankle AP mortise view is helpful since it includes distal tibia, distal fibula, talus, and proximal metatarsals.
Salter-Harris Classification SystemThis is the standard classification system for description of fractures involving the growth plate (also called physis or epiphyseal plate).
Prevalence of Fracture Types Using the Salter-Harris Classification System Fracture Patterns1. Humerus fracture 1a. Proximal humerus fracture Mechanism of Injury Proximal humerus fracture 1b. Humerus shaft fracture Mechanism of Injury Humerus shaft fracture 2. Elbow fractures 2a. Supracondylar fracture Supracondylar fractures represent half of pediatric elbow fractures and most operated pediatric fracture. Gartland Classification of Supracondylar Humerus Fracture Image Source from Wikimedia Commons: https://upload.wikimedia.org/Wikimedia/commons/f/fc/Gartland_Classification.jpg Mechanism of Injury
Associated Injuries
Radial nerve palsy is the second most common neuropraxia. On exam, patient is unable to extend wrist or digits.
Evaluation: Imaging Supracondylar humerus fracture Supracondylar humerus fracture Supracondylar humerus fracture Management
2b. Medial epicondyle fracture Mechanism of Injury Medial epicondyle fracture Physical Examination 2c. Lateral condyle fracture Medial epicondyle fracture Mechanism of Injury Physical Examination 2d. Radial head / neck fractures (of the elbow) Mechanism of Injury Physical Examination
Radial head/neck fractures 3. Radius fractures 3a. Distal metaphysis (complete fracture) Apex
volar (Colles' fracture) 3b. Distal metaphysis (incomplete fracture) Torus/Buckle fracture (typically unicortical) 3c. Diaphysis Plastic deformation: incomplete fracture with deforming force resulting in shape change of bone without clear fracture line, occurs along compression side. Buckle /Torus fracture of the dorsolateral cortex of the distal radial metaphysis
Plastic deformation (bowing deformity) of the right radius and an oblique mid-diaphyseal ulnar fracture with posterior displacement of the distal fragment (one shaft-width) 4. Femoral shaft fracture Abuse must be considered if child is less than five years of age, especially if present in a patient before walking age. Femur fractures are the second most common child abuse associated fracture after humerus fractures. (See also the section below on Non-accidental fractures.) Symptoms Mechanism of Injury Physical Examination Evaluation: Imaging X-rays:
Management
Complications
5. Tibia shaft fracture (Toddler fracture) This type of fracture is also referred to as childhood accidental spiral tibial (CAST) fractures Mechanism of Injury Physical Examination Evaluation: Imaging Tibia shaft fracture (Toddler fracture) 6. Stress fracture Stress fractures most commonly affect the long bones of the lower legs (more commonly the tibia) but can also involve the foot, hip, knee, or ankle. Mechanism of Injury Evaluation: Imaging Stress Fracture 7. Scaphoid fracture Mechanism
of Injury Physical Examination:
Evaluation: Imaging
Management
Scaphoid Fracture 8. Phalanx / Finger fractures Mechanism of Injury Physical Examination Evaluation: Imaging
Spiral Fracture on proximal phalanx of 2nd digit Management
SplintingGoals of splinting
Equipment
Applying a Distal Sugar Tong Splint Compartment SyndromeThe muscle groups are divided in compartments and bound by rigid fascial membranes. Compartment syndrome occurs when increased pressure within a closed fascial compartment (often due to bleeding and edema collection) causes neurovascular compromise and muscle ischemia. Increased pressure, exacerbated by capillary leaking, first occludes venous outflow and only later occludes arterial flow to produce the classic signs and symptoms. Compartment syndrome is defined as pressure greater or equal to 30 mm Hg. Symptoms: paresthesia and intense pain (aggravated by passive stretching of the muscles). Signs: affected area is swollen & tense, pallor, and decreased pulses. Common fractures prone to compartment syndrome
Other Complications Due to FracturesPenetrating injuries Fractures may cause penetrating injuries to surrounding structures. Any overlying bony structures, if bloody and fatty exudate is oozing, usually reflect communication with the medullary cavity of a fractured bone. In the knee joints, if serous or serosanguineous fluid flows during knee movement, this is suggestive of a penetration of the joint capsule. Air seen in the radiograph of the knee joint confirms the diagnosis. Absence does not rule out capsular penetration, but warrants exploration in the OR. Neurovascular injury Neuropraxia is a type of peripheral nerve injury that is classified as a transient conduction block of motor or sensory function. Although nerve degeneration does not occur, there can be a loss of motor function. Patients are usually able to fully recover within a period of weeks to months. Although vascular injury can occur, there is rich collateral circulation that can maintain circulation. Fractures associated with neurovascular injury include:
Additional Complications
QuickCheckSprains A sprain is an injury to a ligament which is a band of short, fibrous connective tissue that connects between two bones or bone to cartilage to stabilize a joint together with other ligaments. Ankle SprainsImage source from Wikimedia Commons: https://commons.wikimedia.org/wiki/File:Ankle_en.svg Lateral ankle sprain Mechanism of Injury
Medial ankle sprain
Syndesmotic (high-ankle) sprain
Physical Examination Anterior Drawer Test Talar Tilt Test Tibia-Fibula Squeeze Test The test identifies a syndesmotic sprain. It is a positive test when there is pain anterior and proximal to the ankle joint upon squeezing the tibia against the fibula at mid-calf. An orthopedist should be consulted for a syndesmotic sprain because surgery may be needed to maintain joint integrity and stability. External Rotation Stress Test This test also identifies a syndesmotic sprain. It is a positive test if pain is elicited in the region of the ATFL when the clinician stabilizes the leg proximal to the ankle joint, while grasping the plantar aspect of the foot and rotating the foot externally relative to the tibia. Evaluation: Imaging Ottawa Ankle Rules were created to limit unnecessary radiographs and are sensitive in children older than six years of age. An ankle series is recommended only if: Pain in the malleolar zone AND bony tenderness at the posterior edge or tip of the lateral or medial malleolus OR X-rays: in children, ligaments are stronger relative to their bones, and may need to rule out an underlying fracture first by radiography which should include antero-posterior, lateral, and oblique views. A foot series is recommended only if there is pain in mid-foot zone AND any of the following findings:
Computed tomography may be used to rule out occult fracture. MRI may be required for ankle pain not resolved after 6-8 weeks. Management a. Immobilization Grade I sprain: An elastic (ace) wrap for a few days b. Supportive Care: Immediate therapy - "RICE" treatment for the first two to three days Rest: avoid movements/activities that can reproduce pain, use crutches. c. Pain Control - Nonsteroidal anti-inflammatory drugs (NSAIDs) or non-NSAID analgesics Wrist SprainsWrist sprains involve injury to the supporting ligaments of the radiocarpal joint. Wrist sprains are rare in children but may occur in adolescent athletes who experience twisting injuries. Mechanism of Injury Image Source: https://www.sportsmd.com/sports-injuries/wrist-hand-injuries/scapholunate-ligament-tear/ Image Source: https://www.aliem.com/2013/07/ulnar-collateral-ligament-injury/ Physical Examination
Evaluation: Imaging X-ray findings may be normal or show an increased scapholunate distance. X-ray findings are usually normal in lunotriquetral sprains. Management a. Immobilization
b. Supportive Care
c. Referral to a hand specialist should be considered because untreated ligamentous injuries to the wrist may result in chronic pain and functional compromise. Orthopedic referral is recommended for scapholunate ligament injury. QuickCheckUpper Extremity Injuries Nursemaid's Elbow (Subluxation of the Radial Head)This injury is most commonly seen in children 3-5 years of age and rarely occurs after seven years of age. The lack of ossification of the proximal radial epiphysis in children less than five years of age make it more pliable and prone to slippage of the annular ligament. Mechanism
of Injury Physical Examination Evaluation: Imaging Management
Little Leaguer's ShoulderThis condition is seen mostly in adolescent pitchers or tennis players. Typically, patients present with pain when throwing but may also present with decreased velocity and control. Mechanism of Injury Physical Examination Evaluation: Imaging
Management
Little Leaguer's Elbow (Medial Apophysitis)Apophysitis is defined as irritation of a bony protuberance that is a site of tendon or ligament attachment. Little leaguer's elbow is more commonly seen in active, growing children and adolescents. It is related to overuse in skeletally immature baseball pitchers (e.g. Excessive amount of pitches per game, excessive fastball speed, and continued pitching in spite of fatigue). This is a spectrum of injuries to the medial aspect of the elbow (due to excessive tension on medial epicondyle) with secondary tendinitis. The child typically develops decreased speed, accuracy and distance of pitches. Mechanism of Injury Physical Examination Evaluation: Imaging
Management
Rest
- Return to play is done only when asymptomatic
Clavicular FractureClavicular fractures is often seen in young, active patients. It is also the most common site of all obstetrical fractures (eg. LGA infants and those requiring instruments or special maneuvers for delivery). Associated injuries may include the scapula, the ribs, the lung (pneumothorax) and even the neurovasculature. Mechanism of Injury
Classification based on anatomic location Group I: Middle third (most common occurring 76-85%) Physical Examination Evaluation: Imaging Management
ORIF method results in faster union, improved functional outcome, better cosmetic results, and improved over all shoulder recovery. Possible complications include: hardware prominence (25-30%), neurovascular injury (3%), nonunion (1-5%), infection (4-5%), mechanical failure (1-2%) and adhesive capsulitis (4%). QuickCheckKnee Injuries Differential diagnoses may vary depending on the location of the knee pain. Osgood-Schlatter Disease(Osteochondrosis of the Knee or Tibial Tuberosity Apophysitis) Osgood-Schlatter Disease is a common cause of chronic anterior knee pain in young athletes that presents with significant pain, tenderness and swelling at the insertion point of the patellar ligament on the tibial tubercle. The patellar ligament connects the quadriceps muscles to the superior pole of the patella and then the inferior pole of the patella to the proximal tibia at the tubercle. Pain progressively worsens over time with continuous overuse eventually leading limitation of activity. Pain is aggravated by any direct trauma to knee, kneeling, squatting, climbing stairs or running and is relieved with rest and ice. Adolescents between the ages 9-14 who are experiencing a rapid growth phase and participating in activities or sports that involve running, jumping, cutting or squatting thereby increasing their risk for the development of OSD. Male prevalence but as female sports participation increases so has the incidence of OSD in females. Typically, unilateral knee affected (asymmetric) but bilateral in 25-50% of cases. Note that the location of the pain distinguishes Osgood-Schlatter (pain in the tibial tuberosity) from Sinding-Larson-Johansson (pain in the inferior pole of the patella). Both conditions are due to microtrauma to the apophysis (growth plate that provides a point of attachment for the muscle and its associated tendon or ligament) in a skeletally immature but active child. Mechanism of Injury Physical Examination Ely Test Evaluation: Imaging Image source: http://www.radpod.org/2008/03/25/osgood-schlatter-disease/ Management Non-operative treatment involves "RICE" treatment for swelling reduction and analgesic medications for pain control. Limitation of activities that exacerbate symptoms is encouraged if pain does not resolve in 24 hours or pain is not tolerated. Using a brace or padding over the knee for protection and support of knee during activities (patellar tendon strap or taping between kneecap and tibial turbercle). Strengthening and stretching exercises or physical therapy can help increase flexibility of quadriceps and hamstrings. Patients with persistent pain greater than 3 months may benefit from injection of hyperosmolar dextrose (12.5%) mixed with lidocaine by the orthopedist. Surgical intervention involves tibial tuberosity excision or ossicle resection in patients who fail conservative management. Surgery is usually not performed until the growth plates close. Quadriceps & Patellar TendinopathyThis is an overuse injury in jumping athletes. Upon presentation, they have pain localized to the superior border of the patella that worsens with activity. There is frequently associated swelling to the affected area also. Risk factors are sports that highly involve jumping (basketball, volleyball, long/high jump). Mechanism of Injury Physical
Examination Evaluation: Imaging
Management Prepatellar Bursitis (Superficial Infrapatellar Bursitis)The prepatellar bursa is a potential space that functions to enhance gliding of tissue over the patella. This injury is caused by excessive kneeling. It is generally seen in wrestlers. Aseptic bursitis occurs more commonly, but septic bursitis can also occur. Physical
Examination Evaluation: Imaging Bursal aspiration by the orthopedist is the key component of evaluation of knee bursitis to exclude septic bursitis. Management
Iliotibial Band Tendinopathy (Iliotibial Band Syndrome)Iliotibial Band Tendinopathy is a result of excessive friction between the iliotibial band (ITB) and lateral femoral condyle, subsequently causing ITB tensioning and inflammation. This injury is most commonly seen in runners, cyclists, and other athletes with repetitive knee flexion and extension. There is a localized pain over the lateral femoral condyle that is exacerbated with running. The pain is usually relieved with rest. Physical Examination Ober test assesses the tightness of ITB. It is performed with the patient lying on the unaffected side. The examiner slightly abducts and extends the affected hip and flexes the knee. The patient is then asked to allow the affected leg to fall to the table passively, without actively adducting the hip (just letting it fall with gravity), while the examiner supports the patient's lower leg. Patients with ITB syndrome are more likely to have limited adduction of the leg with this maneuver (positive Ober test). Image Source: http://indianapolisfitnessandsportstraining.com/really-band-friction-syndrome-runners/ Image source: https://www.flickr.com/photos/sportex/8076561890 Evaluation: Imaging
Management
Meniscal TearOverview The meniscus in the adolescent is comprised of three parts or thirds:
Tears are classified as longitudinal or radial based on the meniscal surface and as complete or incomplete according to the depth of the tear.
A meniscal tear may present initially with pain followed by swelling over a 24 hours period and/or pain aggravated by pivoting motions of the knee. A "tearing" or "popping" sensation may also be felt at the time of injury. Mechanical symptoms such as "catching" or "locking" coupled with a feeling of instability or the knee "giving out" may also be reported. The sensation of "locking" or "catching" is created by a portion of the torn meniscus interfering with the ability to fully extend the knee as the fragment interposes between the articular surfaces of the femur and tibia. Altered proprioception caused by the detached meniscal fragment moving around between the articular surfaces also results in perception of instability Physical Examination Three tests can be used to produce the catching or locking sensation that is associated with meniscal tears. Thessaly
Test McMurray Test Apley Compression Test Evaluation: Imaging
Evaluation: Other
Management Conservative measures: Rest the knee. Avoid maneuvers or activities that apply pressure on the knee joint until swelling subsides including squatting, kneeling, pivoting, or movements that require repetitive flexion/extension of knee joint like climbing stairs. Apply ice to the knee for 15-20 minutes every 4-6 hours with leg elevated may help reduce pain and swelling. Use crutches to reduce weight-bearing on affected knee. Utilize a knee brace that restrains patellar motion to prevent knee "giving out." Pain management, as needed. Conservative management is likely to be successful in cases where symptoms develop more slowly over 24-48 hours (rather than immediately), minimal swelling is present, full range of motion of the knee with pain is present only during full flexion or nearly full flexion of knee, or McMurray Test elicits pain only during deep flexion. Physical therapy
Orthopedic referral should be made for determining type of tear and degree of tear and whether surgical intervention is necessary. Immediate orthopedic referral should be made for large complex tears with persistent effusion, tears resulting in frequent mechanical symptoms, or "locking" of knee with extension as surgical intervention is likely necessary. Arthroscopic or open knee surgery with partial meniscectomy is preferred over total meniscectomy as it results in less recovery time and it reduces risk of developing of osteoarthritis. Osteochondritis dissecans of the lateral femoral condyle is a rare complication following partial and total meniscectomy secondary to repetitive compression of the immature chondral structures. Surgical Intervention is likely to be required when the following factors are present:
Discoid MeniscusOverview Discoid Meniscus is a term that describes an anatomic abnormality of the shape of the meniscus that results in a larger, thicker meniscus that resembles a "disc" rather than the normal "crescent" shape. It typically involves the lateral meniscus but can be bilateral in a small percentage of affected individuals. A specific cause for developing a discoid meniscus is unknown but may be a congenital anomaly or due to other contributing genetic and familial factors. Discoid menisci demonstrate a "disorganized collagen fiber scaffold" formation which increases the incidence of meniscal tears with horizontal tears being the most common. Patients with this abnormally-shaped meniscus may be asymptomatic especially in early childhood as the menisci are stable and no tearing has occurred. Older children and adolescents may present with chronic pain, an intermittent history of knee popping or clicking, effusion, quadriceps atrophy, limited ROM, as well as other mechanical symptoms such as locking or "giving way". Classification of discoid menisci is based meniscus shape and its stability based on the degree of hypermobility and peripheral rim detachment. Unstable incomplete or complete menisci can be further differentiated by location of instability (anterior, middle or posterior horn). Image source from Wikimedia Commons: https://commons.wikimedia.org/wiki/File:Scheibenmeniscus.svg
Physical
Examination Evaluation: Imaging
Source: images.radiopaedia.org
Management Discoid menisci that are symptomatic generally require surgical intervention with partial meniscectomy being more common than total meniscectomy to reduce risk of osteoarthritis that often results when the entire meniscus is removed. Arthroscopic partial meniscectomy or "saucerization" involves the removal of central portion of meniscus with preservation of the stable peripheral rim with or without repair of peripheral rim detachments. This procedure effectively reshapes from disc into crescent-shape which is more anatomically correct but the remaining portion of the discoid meniscus is still prone to tears. Ligamentous InjuryKnee Ligament Anatomy Image Source from Wikimedia Commons: https://commons.wikimedia.org/wiki/File:Cruciate_Ligaments.png Grading of Ligamentous Injury ACL: Anterior Cruciate Ligament ACL tears are a common injury in adolescents participating in sports that involves running and cutting such as volleyball, soccer, basketball, skiing and football. Most common mechanism typically involves a low-energy noncontact injury that involves sudden deceleration or sudden stop combined with a twisting or pivoting motion that increased valgus stress or lateral bending of the knee. A non-contact injury can occur when running and then suddenly changing direction in effect twisting the knee or via contact injury when the foot is planted on ground and a subsequent valgus force is applied to the knee during a collision (common in football); or the athlete falls in a way that results in rotation or lateral bending of the knee. ACL injury can also be secondary to high-impact force such as in a motor vehicle collision with direct force applied to the lateral knee. Female athletes are more likely than males to sustain ACL injury due to differences in muscle strength and development, poor biomechanics, and the effects of estrogen on ligament laxity, strength, and flexibility. Patients typically present with lateral knee pain, effusion, decreased ROM, and inability to bear weight immediately after injury. Patients may report a "popping" sensation at time of injury. Pain and swelling gradually subside over after several weeks as does the ability to bear weight. However patients often report instability of the knee with episodes of knee "giving out" or "giving away" when performing pivoting or cutting motions. Physical Examination
Evaluation: Imaging
Source: emedx.com
Management Non-operative treatment is an option for those that do not plan to return to sports activities and includes physical therapy with quadriceps strengthening and neuromuscular rehabilitation. Surgical reconstruction is usually required for those desiring to return to sports activities as recurrent knee instability may interfere with ability to play sports that involve pivoting motion. PCL: Posterior Cruciate Ligament PCL injuries are less common than ACL injuries in athletic activities with injury occurring secondary to a fall with knee in flexion and foot in plantarflexion or due to a direct blow or posterior sheer force applied to the anterior knee. The PCL and the posterior capsule may also be injured with hyperextension or hyperflexion of the knee with or without a direct posterior force. PCL injury can also occur in motor vehicle accidents when a posteriorly directed force is applied to a knee in a fixed position and often due to a dashboard hitting the flexed knee. Patient may present with knee instability especially if the injury also involves other posterolateral knee structures. However, isolated PCL injuries albeit rare may be more difficult to detect when other structures not involved. A "pop" may not have been felt at time of injury as opposed to ACL injury. Patient may have mild-to-moderate effusion and a limp noted during ambulation suggesting pain with weight-bearing. Patients may also report posterior knee pain especially when kneeling down or squatting and may demonstrate loss of terminal knee flexion and unable to bend knee the last 10-20 degrees. Patient may describe generalized knee pain or that something is wrong with their knee but unable to be more specific. Isolated PCL injuries can be classified as acute or chronic. Acute injuries often present with antalgic gait as well as other gait abnormal gait patterns depending on extent of injury and patient's specific anatomy. Physical Examination
Grades of PCL injury are based on Posterior Drawer Test: Grade 1 (0-5 mm posterior displacement) – anterior border of medial tibial plateau can be posteriorly displaced but still remains anterior in relation to medial femoral condyle; few fibers are torn.
Evaluation:
Imaging
Image source: emedx.com
Management Elective outpatient referral to orthopedic surgeon should be placed with evaluation made within 7-14 days post-injury. Non-operative treatment is an option for those that do not plan to return to sports activities and includes physical therapy with quadriceps strengthening and neuromuscular rehabilitation. For those desiring to return to sports activities, surgical reconstruction is usually required. MCL: Medial Collateral Ligament MCL tears occur when a valgus stress is applied to the lateral side of the knee suddenly forcing the knee medially into a "knocked knee" position. MCL injuries are more likely to involve other knee structures and associated meniscal tears. Patients typically present with medial knee pain following a direct contact or collision with a valgus force applied to lateral knee while the foot is planted. Noncontact MCL injury may occur due to an abrupt valgus movement the results in the "knocked knee" deformation or knee bending medially while the knee is hyperextended with some external tibial rotation. Often occurs when an athlete catches their shoe, cleat, ski, or skate on a surface as they are quickly changing direction. Patients frequently report a sensation of knee instability especially during standing or walking. Swelling and mechanical symptoms such as locking and the knee "giving out" may also be present. Physical Examination The most common finding on exam is medial knee tenderness and localized soft tissue swelling. Valgus stress may reveal a widening of the knee joint. Grades of MCL Tears Grade 1 (0-5 mm of medial knee opening) - Mild tear or sprain of the ligament with some localized tenderness but no laxity or mechanical symptoms as only a few fibers are involved. Grade 2 (6-10 mm of medial knee opening) - Partial or moderate tear of the ligament with presence of localized or diffuse tenderness along the lateral or posterolateral knee. Some swelling and mild-to-moderate laxity are present but a solid endpoint is preserved indicating some ligamentous integrity is still intact. Grade 3 (> 10 mm of medial knee opening) - Complete tear of ligament with variable amount of pain. Laxity without a solid endpoint that results in mechanical symptoms and frequently associated with injury of other ligaments. Abduction Stress Test (also known as Valgus Stress Testing) This is the most appropriate test for determining the extent of MCL injury. The clinician positions themselves such that one hand is placed on the lateral side of the knee to stabilize femur and the other hand is placed around the medial ankle. The clinician then pushes the knee medially while pulling the ankle laterally which opens the knee joint on the medial side. This maneuver is performed with the knee at both full extension and 30 degrees of flexion. Pain or a gap noted to the medial joint line at approximately 30 degrees indicates of ligamentous laxity and a partial tear of the MCL. Laxity at 0 degrees of flexion suggests possible injury to ACL, PCL, posteriomedial corner, and/or posterior oblique ligament. Evaluation: Imaging
Image source: emedx.com Management Management is determined by grade of injury Grade 1 - Crutches for up to 1 weeks and a hinged-brace
worn for 4-5 weeks for all weight-bearing as it stabilizes medial and lateral knee but allows for flexion and extension of knee. LCL: Lateral Collateral Ligament Isolated LCL injuries are the second least common knee injuries with isolated PCL tears being the least common. Isolated LCL tears occur when a varus stress is applied to the inside or medial side of the knee forcing the knee laterally LCL injuries are more likely to occur secondary to a high-energy impact injury that involves multiple knee structures such as the posterolateral corner of the knee, the lateral meniscus, the posterior cruciate ligament (PCL) and/or the anterior cruciate ligament. Patients typically present with lateral or posterolateral knee pain after sustaining a direct hit or contact to the medial or anteromedial portion of the knee while the knee is fully extended. This often occurs in football when a player is being tackled and a posterior varus force is applied to medial knee while the foot is planted and the knee hyperextended. Noncontact LCL injury may occur due to an abrupt varus movement results in the knee bending laterally while the knee is hyperextended. Therefore, a varus stress combined with some degree of hyperextension and/or external tibial rotation results in LCL injury. Patients frequently report a sensation of knee instability especially during standing or walking. Swelling and mechanical symptoms such as locking and the knee giving out may also be present. Physical Examination
Evaluation: Imaging
Management Osteochondritis Dissecans (OCD)Osteochondritis Dissecans is called Juvenile OCD in skeletally immature patients or patients with open growth plates or physes. OCD involves a lesion where a localized portion of subchondral bone and its corresponding articular cartilage become detached from the underlying bone resulting in ischemia and bone death. OCD may occur in knee, ankle, or elbow. The ischemic bone fragment is considered stable if it remains in its original position but is classified as unstable if the fragment becomes displaced and is moving freely around the joint. Occurs most often in rapidly growing active school-aged children and adolescents. Males are more likely than females to develop OCD by a ratio of 2:1. Most common region for an OCD lesion is the lateral part of the medial femoral condyle (bilateral in 25% of cases). Patient presents with knee pain and swelling with mechanical symptoms that can include catching or locking, sensation of knee instability or knee "giving out" as a displaced bone fragment interferes with normal range of motion Mechanism of Injury Physical Examination Wilson Sign: test used to diagnose OCD lesions of the lateral portion of the medial femoral condyle. The patient sits with the knee flexed over the exam table. The examiner actively extends the knee while medially rotating the tibia which elicits increasing pain as extension continues (or when knee reaches about 30 degrees of flexion). The maneuver is halted at this point and when the tibia is laterally rotated and the pain completely subsides. Evaluation: Imaging OCD lesions can be classified based on imaging findings (plain radiograph, MRI, or arthroscopy).
Image source: learning radiology.com
Management Stage I – Small compressed, non-displaced bone fragment Non-Surgical Interventions. Conservative management is usually adequate for stage I - III OCD lesions. Non-displaced fragments can be treated non-operatively through conservative measures that include NSAIDs/analgesics and no sports participation with resumption of activities only after symptoms completely resolve or imaging demonstrates complete healing of lesion. Immobilization with casting or hinged braces with limited weight-bearing for 6-12 weeks dependent on duration of healing. Physical Therapy for strengthening and increasing joint mobility after evidence of healing and weight-bearing with ambulation; swimming and cycling are often used for rehabilitation as these activities as they build muscle strength with low impact on joint. Surgical Intervention. Indications for surgical intervention include: Stage IV lesions which indicates a detached and displaced bony fragment Arthroscopy or arthrotomy can be uses to remove displaced fragments if non-weight bearing surface is not involved. Surgical replacement or reattachment of the fragment to the adjacent bed with a pin is required when the weight-bearing surface is involved. Prognosis Patellar Instability and DislocationPatellar instability and patellar dislocation may occur from a direct blow, tight lateral structures (ilitobial band or vastus lateralis), or ligamentous laxity (Ehlers-Danlos). It presents with knee instability with anterior knee pain. Mechanism of Injury Direct blow is a less common mechanism. Examples include knee to knee collision in basketball, or football helmet to the side of the knee. Physical Examination
Evaluation: Imaging
Views:
Increased Q angle: increased angle between the force vector of the quadriceps and the patellar tendon.
Management
QuickCheckImage source from Widimedia Commons: https://commons.wikimedia.org/wiki/File:818_Femur_Q_Angle.jpg Muscle Injuries/Strain Muscle strain occurs when a muscle is stretched too much, too quickly, or works too hard. Sudden or excessive forceful eccentric contraction (muscle lengthens as it contracts) of the muscle causes overstretching which results in tearing of the muscle fibers.This sometimes makes the muscle tear. Muscles that are commonly strained include those in the back, neck, and back of the leg. Symptoms of muscle strain include muscle spasms or tightness, swelling, bruising, muscle weakness, or inability to move the muscle. Physical Examination
Evaluation: Imaging
Management
Refer to Orthopedic team for suspicions of muscle tear. Pain Control Over-the-Counter Medications. Non-prescribed analgesics may be used for mild pain.
Prescription Medications Acetaminophen with Codeine - schedule III controlled substance and does not require triplicate to prescribe Tramadol - schedule IV controlled substance and does not require triplicate to prescribe. This is a weak opioid related to codeine and is less likely to be associated with respiratory depression than stronger opioids. It is not recommended for patients under 17 years of age. Tramadol can also lower seizure threshold. It should not be used in patients on antidepressants. Oxycodone or Hydrocodone - schedule II narcotics which require triplicate to prescribe. These are stronger opioids related to codeine and contain acetaminophen. Trade names Vicodin (Hydrocodone/Acetaminophen) Liquid formulations available Lortab elixir (7.5mg hydrocodone/325mg acetaminophen) Opioids - If opioids are needed for breakthrough pain, continue for 72 hours. Re-evaluation is warranted. Non-Accidental Musculoskeletal Injuries In a clinical setting where musculoskeletal injury is the chief complaint, it is imperative to maintain a threshold of suspicion for physical abuse as the primary cause of an injury. Non-accidental injuries may be difficult to recognize since caretakers rarely disclose maltreatment, some children cannot provide a history, and signs and symptoms of physical abuse may be subtle or confused with other common pediatric diagnoses. Signs & Symptoms
a. Corner fracture, also known as bucket handle fracture, is a metaphyseal fracture that is pathognomonic of non-accidental trauma. (see below) Image source: Radiology Assistant b. Scapula fractures
Image source: Radiology Assistant 4. Seeking medical care at different facilities for repeat events. There are medical conditions which can predispose children to have bony abnormalities making them more prone to fractures. These conditions warrant further work-up. It is important to consider these as etiology of the fracture and not exclusively from abuse.
Evaluation: Imaging
Management It is important to know the law and resources specific to your state. The Texas Abuse Hotline, via Texas Department of Family & Protective Services. www.txabusehotline.org 1-800-252-5400 QuickCheckReferences and Sources Atanda, Alfred, Deepak Reddy, Jaime A. Rice, and Michael A. Terry. "Injuries and Chronic Conditions of the Knee in Young Athletes." Pediatrics in Review Nov 2009, 30 (11) 419-430; DOI: 10.1542/pir.30-11-419. Beaty, James et al. Rockwood and Wilkins Fractures in Children 7th edition. PA: 2010. Canares, Theree, Lockhart, Gregory."Sprains." Pediatrics in Review Jan 2013, 34 (1) 47-49. Cardone, Dennis A., DO & Jacobs,
Bret C., DO, MA (2016). Meniscal Injury of the knee. In T.W. Post, K. Fields & J. Grayzel (Eds.), UptoDate. Diab, Mohammad. Practice of Paediatric Orthopaedics. New York: 2016. Friedberg, Ryan P., MD (2016). Anterior cruciate ligament injury. In T.W. Post, K. Fields & J. Grayzel (Eds.), UptoDate. Available from https://www.uptodate.com/contents/anterior-cruciate-ligament-injury?source=search_result&search=anterior%20cruciate%20ligament%20injury&selectedTitle=1~29 Grogan, Dennis P., and John A. Ogden. "Knee and Ankle Injuries in Children."Pediatrics in Review Nov 1992, 13 (11) 429-434; DOI: 10.1542/pir.13-11-429. Hergenroeder, Albert C., MD & Harvey, Brian S., DO (2016). Osteochondritis dissecans (OCD): Clinical manifestations and diagnosis. In T.W. Post, R. Bachur & J. Wiley (Eds.), UptoDate. Available from https://www.uptodate.com/contents/osteochondritis-dissecans-ocd-clinical-manifestations-and-diagnosis?source=search_result&search=osteochondritis%20dissecans&selectedTitle=2~26 Kienstra, Andrew J., MD & Macias, Charles G., MD, MPH (2014). Osgood-Schlatter disease (tibial tuberosity avulsion). In T.W. Post, P. Williams, J. Singer & J Wiley (Eds.), UptoDate. Available from https://www.uptodate.com/contents/osgood-schlatter-disease-tibial-tuberosity avulsion?source=search_result&search=osgood%20schlatter&selectedTitle=1~57 Kim, Jae-Gyoon, Seung-Woo Han, and Dae-Hee Lee. Diagnosis and Treatment of Discoid Meniscus. Knee Surgery & Related Research 28.4 (2016): 255-262. PMC. Web. 23 Jan. 2017. Knee Pain and Osgood-Schlatter Disease. healthychildren.org. American Academy of Pediatrics. 20 Nov. 2015. Web. 12 Jan. 2017. Available from https://www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/Knee-Pain-and-Osgood-Schlatter-Disease.aspx King, Christopher. Textbook of Pediatric Emergency Procedures. New York: 2008. Martin, Sean N., DO & deWeber, Kevin, MD, FAAFP, FACSM (2016). Lateral collateral ligament injury and related posterolateral corner injuries of the knee. . In T.W. Post, K. Fields & J. Grayzel (Eds.), UptoDate. Available from https://www.uptodate.com/contents/lateral-collateral-ligament-injury-and-related-posterolateral-corner-injuries-of-the-knee?source=search_result&search=lateral%20collateral%20ligament%20injury&selectedTitle=1~19 McDonald, James, MD, MPH, FAAFP, FACSM & Rodenberg, Richard, MD (2016). Posterior cruciate ligament injury. In T.W. Post, F. OConnor & J. Grayzel (Eds.), UptoDate. Available from https://www.uptodate.com/contents/posterior-cruciate-ligament-injury?source=search_result&search=posterior%20cruciate%20ligament%20injury&selectedTitle=1~19 Orthopaedic Review. (n.d.). Retrieved January 22, 2017, from http://www.orthobullets.com/. Therese L. Canares and Gregory Lockhart S. Sprains. Pediatrics in Review. 2013;34;47 Wolf, Michael. Knee Pain in Children, Part III: Stress Injuries, Benign Bone Tumors, Growing Pains. Pediatrics in Review Mar 2016, 37 (3) 114-119; DOI: 10.1542/pir.2015-0042. Print. Zitelli, B., McIntire, S. C., & Nowalk, A. J. (2017). Atlas of Pediatric Physical Diagnosis. St. Louis, MO: Elsevier. Image sources Wikimedia Commons, the free media repository. Retrieved 14:24, June 1, 2018 from https://commons.wikimedia.org/w/index.php?title=File:Gartland_Classification.jpg&oldid=223733480. Unless otherwise noted: All unspecified computer graphics/drawings were created by Pablo Lopez and used with his permission. All unspecified photographs by Sharon Sanchez, MD University of Texas Medical Branch and used with her permission. All unspecified radiographic images were created by Leonard Swischuk MD, University of Texas Medical Branch and used with his permisson. How do we assess an injured extremity?The following are the primary signs and symptoms of extremity injuries: Pain at the injury site.. Pulse. Feel the pulse distal to the point of injury. ... . Capillary refill. Test the capillary refill in a finger or toe of any injured limb. ... . Sensation. ... . Movement.. Which of the following bones is most vulnerable to injury?The clavicle, more commonly called the “collarbone”, is one of the most frequently fractured bones in the body. In fact, it's the most common site for a fracture in children.
Which of the following is typically the first complaint in a patient who is developing compartment syndrome?Pain is usually the initial complaint and should trigger the workup of acute compartment syndrome. All patients at risk should have early and frequently repeated physical examinations to assess for pain in the muscle compartments.
When assessing a patient with a possible spinal injury you should?If you suspect someone has a spinal injury:. Get help. Call 911 or emergency medical help.. Keep the person still. Place heavy towels or rolled sheets on both sides of the neck or hold the head and neck to prevent movement.. Avoid moving the head or neck. ... . Keep helmet on. ... . Don't roll alone.. |