Pediatric Musculoskeletal Injuries Flashcards

1
Q

How do children’s bones differ from adult bones? What kinds of injury does this lead to?

A

children’s bones are more porous and pliable, which results in a greater number of incomplete fractures - due to decreased mineral content and responds to forces differently resulting in unique fracture patterns

ligaments are also relatively stronger and less likely to get injured, making younger children more likely to experience fractures than sprains or dislocations

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2
Q

What are the four anatomic aresa of pediatric long bones?

A

epiphysis

physis (growth plate)

metaphysis

diaphysis

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3
Q

What are the structural differences in pediatric bones?

A

periosteum is thick, strong, and metabolically active, holds fracture fragments in alignment and aids in reduction, healing and remodeling

extensive remodeling corrects large degrees of angulation and displacement (age < 8 yrs)

nonunion is rare

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4
Q

Salter-Harris Classification system

A

used to describe the location of a fracture in relation to the growth plate

fractures are graded as a scale from 1 to 5, with a higher classification indicating an increased risk for affecting further bone growth

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5
Q

type I Salter-Harris Physeal injury

A

separation through the physis, usually through areas of hypertrophic and degenerating cartilage cell columns

radiograph appears normally initially

diagnosed based on injury (usually shear injury), swelling, pain, and tenderness over growth plate

growth is rarely affected

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6
Q

type II Salter-Harris Physeal injury

A

fracture through a portion of the physis that extends through the metaphyses

most common fracture pattern involving growth plate

most common fracture pattern involving growth plate

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7
Q

type III Salter-Harris Physeal injury

A

fracture through a portion of the physis that extends through the epiphysis and into the joint

may interfere with growth

involves articular surface, may affect joint

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8
Q

type IV Salter-Harris Physeal injury

A

fracture across the metaphysis, physis, and epiphysis

may interfere with growth

involves articular surface, may affect joint

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9
Q

type V Salter-Harris Physeal Injury

A

crush injury to the physis/growth plate

from severe axial loading

worst prognosis with possible growth arrest

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10
Q

What details should be included when describing fractures?

A

the bone involved

the location within the bone

the fracture pattern

any displacement

age of the fracture

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11
Q

Does it take more force to cause a transverse fracture, spiral fracture, or spiral fracture?

A

transverse fracture

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12
Q

transverse fracture

A

perpendicular to long axis

complete fracture

usually higher force mechanism

direct blow or bending force

often easy to reduce

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13
Q

comminuted fracture

A

when the bone fractures in multiple places

usually takes a great amount of force

rare in young children and difficult to reduce

often require operative intervention fixation

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14
Q

oblique fracture

A

oblique to long axis of bone

twisting force or compression/bending mechanism

can have significant displacement, may be difficult to maintain alignment when reduced

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15
Q

spiral fracture

A

caused by a twisting mechanism

often takes less force than transverse fracture

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16
Q

What is displacement?

A

when parts of a fracture is moved out of normal alignment

a fragment may be moved laterally, angulated, rotated, or shortened in relation to its normal position

translation - lateral movement

angulation - measure through mid-axial line

rotation - may be difficult to tell

17
Q

What is a torus or buckle fracture?

A

one of the most common fracture patterns seen in children, especially the distal forearm - occurs at the junction of metaphysis and diaphysis in distal forearm, radius +/- ulna

results from a compressive load, such as a fall onto an outstretched hand

the bony cortex of the metaphysis buckles in a small area

these are stable fractures that heal quickly with simple immobilization - use premade splint for 3-4 weeks

as the skeletal system matures and the metaphyseal region becomes stiffer, the incidence of these fractures decreases

18
Q

What are greenstick fractures?

A

the most common fracture pattern in children

result of compression or bending force and bone on convex side fails

considered incomplete fractures since the bony cortex remains intact on one side

fracture line does not propagate to the concave side (incomplete)

these fractures usually occur at the junction of the diaphysis and the metaphysis

if reduction needed, need to make break complete to maintain alignment, and casting is needed

19
Q

What are bowing fractures (plastic deformation)?

A

compression force causes microscopic failure in bone, resulting in a bending or bowing - up to a 20 degree curve in a child <4 yrs

occur when bone bends without a clear single fracture line - usually ulna +/- radius

though often not a clear cortical defect, the deformity can still be significant and reduction may be needed

also occurs in children due to the pliability and porous nature of pediatric bones - almost unique in children

20
Q

What is a toddler’s fracture?

A

usually refers to an oblique, non-displaced fracture in the distal tibia of an ambulating child younger than 5 years old

occurs in an oblique or spiral patterns from a twist in the lower leg while running or falling

sometimes the child’s leg gets caught in something and the fracture occurs when the child twists the leg in trying to free it

fractures may be subtle or not able to be visualized on initial radiograph

21
Q

What is the treatment for toddler’s fracture?

A

cast, no weight bearing

22
Q

What is the clinical picture of toddler’s fracture?

A

limp or refusal to bear weight

often minimal to no swelling

fracture line may be subtle on x-ray

23
Q

What is nursemaid’s elbow?

A

radial head subluxation, which can occur in children younger than 6 years of age (25% of all elbow injuries) as a result of a pull on the child’s extended arm

the typical history is an adult pulling a falling child up by the hand

the traction on the radius moves the radial head distally from the elbow joint and part of the annular ligament gets trapped between the radial head and the capitellum

treat by suppination and flexion - one hand at wrist and other hand on elbow to “pop” of relocation

24
Q

What would be a typical history referring to nursemaid’s elbow?

A

traction to the arm

patient has pain initially, then comfortable as long as the arm is held still

not using the arm

25
Q

What is found on physical exam for nursemaid’s elbow?

A

elbow slightly flexed and arm held against body, not moving

no swelling, deformity, or bony tenderness

pain with movement of elbow

if history or physical exam does not fit or is concerning, consider radiographs to rule out fracture

26
Q

What is the clinical presentation of nursemaid’s elbow?

A

concern of not using the affected arm

no pain at rest, no tenderness to palpation, and holds the affected arm at the side, pronated or partially flexed

movement is painful

reduction is accomplished by hyperpronation or supination flexion method

child will begin using the arm normally within minutes of successful reduction

27
Q

What happens in slipped capital femoral epiphysis?

A

occurs as aresult of instability of the proximal femoral growth plate, resulting in slippage of the epiphysis relative to the femoral neck (Salter Harris Type I fracture through the physis) - inferior and posterior slips

occurs in adolescents (10-16yrs), often during periods of rapid growth

bilateral in up to 40%

28
Q

What is the clinical presentation of a slipped capital femoral epiphysis?

A

chrinic knee, thigh or groin pain with a limp

the hip is externally rotated with limited flexion and internal rotation

radiographs show a widened growth plate with epiphyseal slippage

on radiographs - widened growth plate

29
Q

What are the risk factors for SCFE?

A

males > females

obesity

endocrine disorders

30
Q

What are the physical exam findings of SCFE?

A

limited internal rotation

when hip is flexed, it externally rotates

pain with flexion and internal rotation

gait - limp with leg externally rotated at hip

31
Q

What is the treatment for slipped capital femoral epiphysis? What are some possible complications?

A

immediate surgical fixation (within 24 hrs) to prevent further slippage until the physis closes

complications are avascular necrosis of the hip and increased risk with longer time to diagnosis/intervention and large amount of slip

watch for SCFE of other hip

32
Q

What are the factors that increase the likelihood that injuries occurred from abuse?

A

no explanation or a vague explanation for a significant injury

an important detail of the explanation changes dramatically

an explanation is inconsistent with the pattern, age, or severity of the injuries

an explanation is inconsistent with the child’s physical and/or developmental capabilities

different witnesses provide markedly different explanations for the injuries

a delay in seeking care with a significant injury

33
Q

What kinds of fractures are highly suggestive of abuse?

A

skull fractures and long bone fractures are most common fractrues in abusive trauma

rib fractures and metaphyseal fractures also very suggestive

34
Q

What do rib fractures indicate in a child?

A

an infant’s chest is more malleable than that of an older child and as a result the ribs deform rather than break, unless a major force is exerted - high specificty for abuse

most non-accidental rib fractures are thought to occur from anterior-posterior compression of the chest and are associated with intracranial injuries due to shaking of the infant

35
Q

What is the clinical presentation of a rib fracture in a child/infant?

A

patients often do not present with a history of trauma, but with irritability and respiratory or gastrointestinal complaints - usually not suspected clinically

rib fractures may not be apparent radiographically until the healing callus is seen, 7-10 days after the injury

36
Q

What are the common features of a metaphyseal fracture in children?

A

also known as a “corner fracture” or “bucket-handle fracture” - highly specific for abuse

occurs in the metaphysis of long bones as a result of tensile or shearing forces - area of immature bone and thin plate of bone separates

the metaphysis in infants is vulnerable to injury and can separate when a child is pulled, twisted, or yanked forcefully by an extremity

this type of force is unlikely to occur from accidental causes in this age group

these fractures often don’t have any external signs of injury, typically are not seen well on radiographs until healing and remodeling

heals quickly and no treatment is needed