Review Of Common Pediatric Orthopaedic Problems For
Review of Common Pediatric OrthopaedicProblems for the Non-Orthopaedic ProviderThomas V Gocke, MS, ATC, PA-C, DFAAPAPresident & FounderOrthopaedic Educational Services, Inc.Blowing Rock, ducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Learning Objectives:At the end of this session participants will be able to identify thecharacteristics, initial diagnostic study findings and initialtreatment for Pediatric Proximal Humerus fractureCommon Pediatric Elbow injuriesPediatric Slater-Harris Fractures Distal Radiusand Scaphoid fracturesCommon Pediatric Hip painPediatric Knee PainCommon Pediatric Hind foot InjuriesOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Faculty DisclosuresOrthopaedic Educational Services, Inc.FinancialIntellectual PropertyNo off label product discussionsAmerican Academy of Physician AssistantsFinancialFerring PharmaceuticalsConsultant & Speakers Bureau OrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.3
Proximal Humerus FractureOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Proximal Humerus Fracture Fx defined as Physis or Metaphysis Good prognosis healing due to high remodelingpotential More common adolescent fx peak @ 15 yrs age– SH II: 12 yrs age– SH I: 5 yrs age– Metaphysis: 5-12 yrs age Mechanism– Blunt trauma– Overuse: growth plate injury 2nd to throwing l Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Proximal Humerus FracturePhysical Exam Inspection:– Swelling shoulder, Arm tucked into side Palpation:– tenderness globally Shoulder/Proximal Humerus ROM/Strength:– Limited ROM & increased pain Neurovascular: Usually no deficits Ortho -humerus-fracture--pediatricOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Proximal Humerus FractureRadiographs– Standard views: AP & lateral shoulder, Axillary, Scapular Y– Proximal Humerus Physis closes: predicts remodeling Girls - 14-17 yrs old Boys - 16-18 yrs old– Bone displacement Proximal Fragment Epiphysis– ABDucted - External rotated: 2nd RTC musclea Shaft Fragment– Anterior - ADDucted - Short: 2nd to Pectoralis & Deltoid– Treatment Based on amount of Head/physis displacement on Shaft Acceptable angulation based on remaining l Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Proximal Humerus FxPhoto courtesy TGocke, PA-COrthopaedicEducational Services, Inc.Photo courtesy TGocke, PA-C 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Proximal Humerus FractureTreatment Most respond well to non-operative therapy Acceptable angulations– 10 yrs age - any amount angulation– 10-13 yrs age - 60º angulation– 13 yrs age - 45º & 2/3 shaft displacement Immobilization– Sling vs Shoulder Immobilizer– Coaptation Splint & Sling Surgery– 2/3 displaced, 45º angulated & 2 yrs growth left - remodeling– Open Fx or Intra-articular fx– Vascular nal Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Elbow opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Elbow PainGeneral Supracondylar Humerus fx most common Pediatrics Radial head fx - most common Adults Mechanism of injury:– Fall out stretched hand (FOOSH)– Elbow Hyperextended Peak age 5-7 yrs old Nursemaids elbow - Radial head dislocation––––5% of all pediatric elbow injuriestypically seen in infancy and childhoodmechanism: isolated traumatic injurythe radial head is dislocated anteriorlyOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Elbow PainPhysical Exam Inspection:– Swelling Elbow joint /radial side proximal forearm Palpation:– tenderness globally Elbow joint/ radial head ROM/Strength:– Limited ROM & increased pain w/ pronate/supinate & Elbowflex/ext Neurovascular:– Anterior Interosseous Nerve (AIN - Median) - “OK” sign– Radial Nerve - Wrist/Finger extension– Brachial artery: spasm can mimic loss pulse Ortho dylar-fracture--pediatricOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Elbow Radiology X-ray viewsAnterior Humeral Line– AP, Lateral, Oblique Elbow injuries havecharacteristic appearances Fat Pad sign key tosuspected elbow trauma An awareness of normalelbow anatomy importantto injury detectionOrthopaedicEducational Services, Inc.Anterior Fat PadRadiocapitellar lineUlnaCapitellum 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Elbow ondyleRadial headOlecranonAnteriorFat PadHourglassTear DropUlnaPosteriorFat PadOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
RadiologyFat Pad SignNORMALSynovial spaceABNORMALEffusionFat padFat padOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Elbow Radiology Normal anterior fat pad -small The posterior fat pad is notvisible - soft tissue of thetriceps muscle is notseparated from the posterioredge of the humerus More than one third of thecapitellum lies in front of theanterior humerus line “True Lateral” Elbow X-rayHourglassTear Drop– hourglass sign or ‘figure-ofeight’OrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Non-displaced Supracondylar Humerus fxPhoto courtesy TGocke, PA-CPhoto courtesy TGocke, PA-COrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Elbow PainTreatment Initial recognition important– Suspect fx pattern/Nondisplaced fx pattern– Posterior Splint vs. Sling: immobilization helps with pain control– 8 yrs old consider Long arm cast/sling– 8 yrs old consider Posterior splint/sling F/U 10-14 days Minimal Increased stiffness with prolongedimmobilization Good long-term results majority cases identified early– ALL displaced fx need to be seen same dayOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Take Home message Positive Fat Padsign Kids: thinkSupracondylarHumerus fracture Positive Fat Padsign Adults: thinkRadial Head fracture Immobilize kids insplint or castPicture courtesy TGocke, PA-COrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Medial EpicondylitisOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Medial Epicondylitis Medial elbow pain w/ orw/o neuro changes Occupational hazards– Grounding golf club (TFCC)– Power tools/drills– Gripping– Throwing Pain usually radiates down forearm Active & resistive wrist flexioncontribute to medial elbow pain Prolonged ME 2nd to failure oftendon healingOrthopaedicEducational Services, Inc.MedialepicondyleIncisionSite 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Medial Epicondylitis Increased stress medial elbow– Ligament laxity Ulnar collateral ligament & capsule– Ulnar nerve stretched Exhibit peripheral neuropathy symptoms– Muscle weakness CFT 2nd to overuse Peripheral ulnar neuropathy Physical Exam– General elbow exam– Ulnar collateral stress test– Ulnar nerve Tinel – look for associated cubital tunnel symptomsOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Medial Epicondylitis Diagnostic Studies– X-ray not always indicated– U/S can look at tendon integrity– MRI – not necessary to make diagnosis Treatment RICE Support strap CFT region elbow NSAIDS Physical Therapy Corticosteroid Injection Surgery– Recalcitrant tendonitis that has failedconservative therapyOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Fractures Wrist/ForearmFlynn JM, Wilson RH: Overtreatment a cause of complications with pediatric distal radius fracturesOrthopedics Today, September ics/./both-bone-forearm-fracture-- pediatricOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Distal Radius FracturesGeneral: Distal Radius & Ulna fx: 40% all pediatric fxs Younger patients - high energy (sports) Peak occurrence– Girls 10-12 yrs– Boys 12-14 yrs Injury Mechanism:– Most common: Fall On Out Stretched Hand– Abuse fx: Hx inconsistent with MechanismMultiple Injuries/bone healing various stagesChild affectPatterns of EcchymosisOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Distal Radius FracturesFracture - Bone location Physis: Slater-Harris growth plate fx Metaphysis - Distal Radius– Colles fx: apex volar– Smith’s fx: apex dorsal– Torus/Buckle fx: Unicortical bone deformity Diaphysis- Shaft– Both bone Forearm fx– Radius/Ulna fxs: distal 1/3 shaftFlynn JM, Wilson RH: Overtreatment a cause of complications with pediatric distal radius fracturesOrthopedics Today, September ics/./both-bone-forearm-fracture-- pediatricOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Distal Radius FracturesFracture - Bone location Diaphysis– Both Bone Forearm Fracture– Radius Shaft - mid-shaft– Ulna Shaft: mid-shaft (“night stick”)– Plastic/Greenstick fx Plastic deformity: deforming force reshapes bone (no fx) Greenstick: bending deformity of bone with bone fracture– Monteggia - Ulna shaft fx with Radiocapitellar joint dislocation– Galeazzi - Distal 1/3 Radius fx with DRUJ injuryFlynn JM, Wilson RH: Overtreatment a cause of complications with pediatric distal radius fracturesOrthopedics Today, September ics/./both-bone-forearm-fracture-- pediatricOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Salter-Harris Fracture ClassificationS 1- Separation physisA 2- Fx ABOVE physisL 3 - Fx BELOW physisT 4 - Fx THRU physisR 5 - Fx CRUSH physisLittle JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Physis FracturesSalter-Harris 1Little JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Physis Fractures Salter-Harris 1 vs 2PhysisEpiphysisOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Physis FracturesSalter-Harris 2Little JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Physis FractureSalter-Harris 3Little JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Physis FractureSalter-Harris 4Little JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Metaphysis FracturesTorus Fracture Aka: “Buckle fx”Skeletally immatureFOOSH mechanismSame symptoms adult fxOften overlooked on x-rayUnicortical Bone deformity– Radius and/or UlnaLittle JT et al: Pediatric Distal Forearm and Wrist Injury: AnImaging Review, March/April opaedicEducational Services, Inc.X-ray courtesy Tom Gocke, PA-C Library 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Pediatric Diaphysis dicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Distal 1/3 Radius FracturesTreatment: Non-displaced fx No closed reduction required– Extra-articular, non-displaced– Minimal radial shortening– Dorsal angulation 5 – Well padded sugartong vs.volar splint vs. Commercialsplint– Arrange for same day or nextday F/U Ortho appt Displaced Fx - hopaedicEducational Services, Inc.Picture courtesy T Gocke, PA-C 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Carpal Scaphoid FractureLittle JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Carpal Scaphoid Fracture Carpal bones have no periosteumNO periosteal reaction seen with bone injury/FxAnatomic Snuff box tenderness hallmark clinical signMechanism of injury - FOOSH– Crush/compression injury distal radius and proximal pole Scaphoid Peds Scaphoid fx– Distal pole fx most common location kids– Waist fx becoming more prevalent 2nd to higher BMI kids Blood supply– Solitary dorsal & volar branch from Radial artery Complications:– Nonunion fx healing vs. Avascular necrosisLittle JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Anatomic Snuff BoxRadial side Wrist Borders– ABD Pollicis longus– Extensor PollicisBrevis– Extensor PollicislongusOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Carpal Scaphoid FractureDistal PoleX-ray Posterioanterior (PA), Lateraland Scaphoid view Distal Pole fx most common Fx not usually seen on initialradiograph MRI:– Most sensitive detect occultScaphoid fx– Bone Contusion, TFCC &Intercarpal Ligament injuryProximal PoleLittle JT et al: Pediatric Distal Forearm and WristInjury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Carpal Scaphoid FractureTreatment: Recognition/Suspicion keytreatment Immobilize Thumb Spica Splintvs Thumb Spica Cast Initial X-ray MRI scan for ? Occult fx Needs ortho referral 1 week Limit sports/aggressive activityPhoto courtesy TGocke, PA-CLittle JT et al: Pediatric Distal Forearm and Wrist Injury: An Imaging Review, March/April opaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Back PainOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Back Pain General– MSK injury : most common form back injury– Isolated to muscle injury– Complaints along various levels Thoracolumbar spine– Affects all ages– Worse with movement & better with rest– Sit-Stand-Lie: varied response– Sports & Labor job: repetitive motion– NO radicular symptoms (beyond gluteal)– NO pain--introductionOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Back PainTreatment: Musculoskeletal:– 90% of low back pain resolves within one year– Depends on patient response NSAIDS vs. Steroid dose pack Muscle Relaxer Analgesics Physical therapy vs. Home Exercise Program (HEP) Limit activity– Recreation– Work F/U exam 1-2 weeks– Duration: varies 1-4 weeks Fragile period 6 weeksOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Common Orthopaedic ProblemsPediatric Spondylolysis/Spondylolisthesis Common cause Low back pain (LBP) kids Pars stress reaction/fracture Sclerosis with incomplete bone healing vs. disputation Spondylolysis– Anatomic defect in Pars Interarticularis – bone sclerosis– Defects not present at birth– Usual injury mechanism – repetitive hyperextension– High prevalence in gymnasts, weight lifters, footballlinemenMoore D: Pediatric Spondylolysis/Spondylolisthesis –spine – OrthobulletsCavalier R: Spondylolysis and Spondylolisthesisin Children and Adolescents: Diagnosis, Natural Historyand Nonsurgical Management, J Am Acad Ortho Surg 2006;14: 417-424OrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Common Orthopaedic ProblemsPediatric Spondylolysis/Spondylolisthesis Symptoms– Spondylolysis asymptomatic– Activity onset Low Back Pain and buttock pain– L5 radiculopathy– Hamstring tightness (Quad, Hip Flexor, Achilles)– Lumbar extension exacerbates symptomsMoore D: Pediatric Spondylolysis/Spondylolisthesis –spine – OrthobulletsCavalier R: Spondylolysis and Spondylolisthesisin Children and Adolescents: Diagnosis, Natural Historyand Nonsurgical Management, J Am Acad Ortho Surg 2006;14: 417-424OrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Common Orthopaedic ProblemsPediatric Spondylolysis/Spondylolisthesis Physical exam––––Low Back Pain: worse with extensionPoor flexibilityParaspinal muscle spasm/tenderness (unilateral vs. bilateral)Frequently no neurologic deficit Straight Leg Raise – positive vs. false positive (tight hamstrings)– Lumbar radiculopathy 2nd to anterior slip or compression/traction at foramen L5 most common Ankle dorsiflexion weakness & L5 radiculopathyMoore D: Pediatric Spondylolysis/Spondylolisthesis –spine – OrthobulletsCavalier R: Spondylolysis and Spondylolisthesisin Children and Adolescents: Diagnosis, Natural Historyand Nonsurgical Management, J Am Acad Ortho Surg 2006;14: 417-424OrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Lumbar ExamPhysical Examination Neurologic– Sensory Lumbar distribution L3 distal thigh L4 medial low leg and ankle L5 Anterior low leg & dorsal ankle S1 Lateral ankle– Reflexes Patellar: L4 distribution Achilles: S1 distribution Babinski:– negative test: down going toes– positive test: toes flare upOrthopaedicEducational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved.
Common Orthopaedic ProblemsDiagnostic Imaging Spo
Orthopaedic Educational Services, Inc. 2017 Orthopaedic Educational Services, Inc. all rights reserved. Review of Commo
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