SM_251a-252a: Peds MSK, Peds / Adult Sports Med

Question 1

Describe structural differences in pediatric bones

Answer 1

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

Question 2

Describe the anatomy of a growing bone

Answer 2

Growing bone

• Diaphysis: shaft
• Metaphysis: tapering part
• Physis: growth plate
• Epiphysis: end of bone

Question 3

In growing bone, there are ____ on the epiphyseal side and cells ____ on the metaphyseal side

Answer 3

In growing bone, there are germinal on the epiphyseal side and cells calcify on the metaphyseal side

Question 4

Describe the Salter-Harris classification

Answer 4

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

Question 5

Describe growth plate injury in the Salter-Harris classification

Answer 5

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

Question 6

Salter-Harris I fracture is ____

Answer 6

Salter-Harris I fracture is separation through the physis, usually throughb areas of hypertrophic and degenerating cartilage cell columns

Question 7

Salter-Harris II fracture is ____

Answer 7

Salter-Harris II fracture is fracture through a portion of the physis that extends through the metaphyses

Question 8

Salter-Harris III fracture is ____

Answer 8

Salter-Harris III fracture is fracture through a portion of the physis that extends through the epiphysis and into the joint

Question 9

Salter-Harris IV fracture is ____

Answer 9

Salter-Harris IV fracture is fracture across metaphysis, physis, and epiphysis

Question 10

Salter-Harris V fracture is ____

Answer 10

Salter-Harris V fracture is crush injury to the physis

Question 11

Transverse fracture occurs ____ to the long axis, is caused by ____ or ____, and involves ____ force

Answer 11

Transverse fracture occurs perpendicular to the long axis, is caused by direct blow or bending force, and involves higher force

Question 12

Comminuted fracture involves ____ force mechanism, is rare in ____, and often necessitates ____ because it is difficult to reduce

Answer 12

Comminuted fracture involves high force mechanism, is rare in children, and often necessitates operative intervention/fusion because it is difficult to reduce

Question 13

Oblique fracture is ____ to long axis, involves ____ or ____ mechanism, and can lead to ____

Answer 13

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

Question 14

Spiral fracture is caused by a ____ mechanism and often takes ____ force than a transverse fracture

Answer 14

Spiral fracture is caused by a twisting mechanism and often takes less force than a transverse fracture

Question 15

Describe fracture displacement

Answer 15

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

Question 16

Describe buckle/torus fracture

Answer 16

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

Question 17

Describe nursemaid’s elbow (radial head subluxation)

Answer 17

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

Question 18

Describe greenstick fracture

Answer 18

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

Question 19

Describe toddler’s fracture

Answer 19

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

Question 20

Describe slipped capital femoral epiphysis

Answer 20

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

Question 21

Slipped capital femoral epiphysis is described as ____ on radiograph, is treated with ____, may be complicated by ____, and should cause clinician to watch for ____

Answer 21

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

Question 22

This is a ____ fracture of the ____

Answer 22

This is a Salter-Harris II fracture of the distal radius

Question 23

Describe bone formation

Answer 23

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

Question 24

Children typically injure ____ and ____, while adults typically injure ____ and ____

Answer 24

Children typically injure physis and apophysis while adults typically injure tendons and ligaments

Question 25

Describe advantages and disadvantages of open physes

Answer 25

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)

Question 26

Sinding-Largen-Johansson syndrome is \_\_\_\_

Answer 26

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

Question 27

Osgood-Schlatter syndrome is \_\_\_\_

Answer 27

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

Question 28

Sever disease is \_\_\_\_

Answer 28

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

Question 29

Anterior superior iliac spine apophysis avulsion fracture is \_\_\_

Answer 29

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

Question 30

Little League Elbow is ____ and is primarily treated with \_\_\_\_

Answer 30

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)

Question 31

Little League Shoulder is ____ and treated with \_\_\_\_

Answer 31

Little League Shoulder is proximal humerus epiphysiolysis and treated with rest

Question 32

Describe the two paradigms of inflammation and tendinopathy

Answer 32

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

Question 33

Describe tendons

Answer 33

Tendons * Structure: white w/ fibroelastic texture, 70% water, collagen type I is 65-80%, oxygen consumption 7.5x lower than muscle * Function: connects muscle to bone, strengthr elated to thickness and collagen content

Question 34

Describe risk factors for Achilles tendinopathy

Answer 34

Achilles tendinopathy risk factors * Systemic (intrinsic): advancing age, obesity, diabetes, dyslipedomia, HTN, increased waist circumference, genetic * Nonsystemic (intrinsic): abnormal biomechanics, muscle inflexibility, muscle weakness, malalignment, joint laxity * Extrinsic: excessive mechanical load, training errors, improper equipment, medications (BCP, floroquinolones, NSAIDs, statins)

Question 35

Describe Achilles tendinopathy pathology

Answer 35

Achilles tendinopathy pathology * Non-inflammatory intratendinous collagen degeneration * Fiber disorientation and thinning * Scattered vascular ingrowth (neovascularization) * Gray-brown and amorphous

Question 36

Describe clinical presentation, diagnosis, treatment, and prognosis of Achilles tendinopathy

Answer 36

Achilles tendinopathy clinical presentation, diagnosis, treatment, and prognosis * Presentation: generally occurs w/o sudden injury, pain w/ vigorous activity not rest, localized pain to mid-portion or insertion, generally not warm or erythematous, strength normal * Diagnosis: based on H&P, imaging to assess for tear or calcification * Treatment: relative rest, heel lift if pain with walking, physical therapy * Prognosis: most recover completely with treatment

Question 37

\_\_\_ was spared from injury

Answer 37

Short head of biceps femoris was spared from injury

Question 38

Muscle strain pathology results from ____ and includes injury at ____ and \_\_\_\_

Answer 38

Muscle strain pathology results from excessive intrinsic tensile force and includes injury at myotendinous junction and soft tissue bleeding

Question 39

Muscle strain healing of injured soft tissue includes \_\_\_\_, \_\_\_\_, and ____ phases

Answer 39

Muscle strain healing of injured soft tissue includes inflammatory, proliferative, and remodeling phases 1. Inflammatory phase: RBCs and WBCs infiltrate, initiation of angiogenesis, removal of necrotic material 2. Proliferative phase: infiltration of myocytes, production of collagen (Type III) 3. Remodeling phase: consolidation phase, maturation phase

Question 40

Describe presentation, diagnosis, treatment, and prognosis of muscle strain

Answer 40

Muscle strain presentation, diagnosis, treatment, and prognosis * Presentation: sudden onset of pain, deceleration or acceleration injury, stops sports play, impaired function, pain ± weakness, TTP at site of injury * If gradual onset, consider other causes * Treatment: rest for 4-7 days, RICE, progress from strengthening and stretching to agility and trunk stab exercises * Prognosis: most recover without significant sequelae, more severe strain necessitates longer recovery

Question 41

\_\_\_ ligament is most likely to be injured

Answer 41

Anterior talofibular ligament is most likely to be injured

Question 42

Ankle sprain risl factors include \_\_\_\_, \_\_\_\_, \_\_\_\_, and \_\_\_\_

Answer 42

Ankle sprain risl factors include decreased strength, decrease proprioception / balance, limited ankle ROM, and landing after a jump

Question 43

\_\_\_ ligament is most common site of ankle sprain

Answer 43

Anterior talofibular ligament is most common site of ankle sprain

Question 44

Describe clinical presentation, diagnosis, treatment and prognosis of ankle sprain

Answer 44

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

Question 45

Ankle sprain rehab \_\_\_\_, \_\_\_\_, and \_\_\_\_

Answer 45

Ankle sprain rehab prevents recurrence via training for coordination and balance, reduces functional ankle instability, and reduces risk of future sprain after 1st sprain but does not prevent 1st sprain (does not prevent 1st sprain)