Pediatric Musculoskeletal Injuries

Sarah Bolander, MMS, PA-C

Discuss injury risks associated with playgrounds.

Correlate mechanism of injury with fracture location and pattern.

Identify pediatric fractures and be able to classify physeal injuries.

Know potential complications associated with fractures in the pediatric population.

Recognize common pediatric sports injuries based on clinical presentation and determine the appropriate diagnostic studies needed.

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CPSC3

Fall from monkey bars

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Playgrounds 2nd only to home for unintentional injury in kids

220,000 children, < 14 yo treated in the ED Average age for injuries 5-9 yo (3x more likely then 10-14 yo)

Falls (76.7%)

Majority of injuries are fractures

Upper extremity injuries (87.7%)

10% TBI, including concussion

Death is rare: strangulation > fall

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Swings are the most likely cause of TBI, and surveillance on the swings has been shown to reduce the risk of these injuries.

Monkey bars are the most common cause of fracture, and fracture is the most common cause of admission. Prevention of injury here is directed at equipment and landing surfaces.

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Splinters

Abrasions

Lacerations

Sprains

Broken Bones

Head Injuries

Spinal Injuries7

Splinters

Abrasions

Lacerations

Sprains

Broken Bones

Head Injuries

Spinal Injuries

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Metabolically more activePromotes callus formation

Remodeling ability

Thicker and more durableLess likelihood of displacement

Unique fracture presentations

Buckle/torus

Greenstick

Plastic deformation/bowing

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Fractures not initially evident on plain radiographs Toddler’s Fracture

Salter-Harris I

Some non-displaced elbow fractures

Stress fractures

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MOI: Fall onto the shoulder

Clinical Presentation: visual deformity often seen

Evaluate for open fracture or tenting of the skin

Tenderness with palpation over bone

Snapping or cracking sensation

Decreased ROM

Patient is apprehensive and guarded

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• Typically displaces superiorly and may be comminuted

70-80% occur in the middle 1/3

• May be difficult to discern from AC separation

15-30% in the distal 1/3

• Internal organ evaluation is essential

• R/O sternoclavicular dislocation or physeal fx

3-5% in the proximal 1/3

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Single AP radiograph 45° cephalic tilt view can be beneficial

Pediatric clavicle fractures rarely require fixation

POSNAFigure-8 17

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C.R.I.T.O.E. 1: Capitellum

3: Radial Head

5: Internal (Medial) Epicondyle

7: Trochlea

9: Olecranon

11: External (Lateral) Epicondyle

19Radiology Assistant

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Most common pediatric elbow fracture (>60%)

90% occur <10 yo

MOI: fall from moderate height FOOSH: Typically with hyperextension

Clinical Presentation: Swelling, pain, +/- deformity

NV exam is critical

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CC BY-SA Orthokids

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Type I Type II Type III

Diagnostics:X-ray: AP, lateral, & oblique radiographs

Anterior humeral line should intersect the capitellumCC BY-SA-NC

Management:Type I/II- Splint with light overwrap

Avoid elastic bandages when possible

Sling, NSAIDs, elevation

Refer to ortho, +/- reduction for Type II

Immobilization x 3 weeks

Type III or neurovascular concerns

Emergent ortho consult

CRPPF: Closed reduction percutaneous pin fixation

Open reduction

23Case courtesy of Dr Matt A. Morgan, Radiopaedia.org, rID: 37921

Clinical Presentation:

Soft tissue swelling concentrated

to lateral aspect of elbow

Tender to palpation over lateral condyle

Fractures may be subtle:

May only appear as a small sliver on imaging due to large cartilaginous portion

Know your anatomy!

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Diagnostics:

X-ray: AP, lateral, and internaloblique view focused on lateral condyle

MRI if needed

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 2593725

Management:Emergent referral if displacement >2 mm on

internal oblique view

Splint, sling, NSAIDs

Ortho: Casting vs surgery

Immobilization 6 weeks

Open reduction with screw fixation

High risk of complications

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MOI:1. Muscle attachment avulsion

Throwing athletes and gymnasts

2. FOOSH with arm fully extended

3. Secondary to posterior elbow dislocation

Clinical PresentationLocalized pain

Pain with resisted wrist flexion

Ulnar nerve dysfunction27

“POP”

Diagnostics:

X-Ray

AP, Lateral, and external oblique

Comparison views if needed

R/O incarceration of fragment in joint

Advance imaging may be needed

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9450

Case courtesy of Dr Levente István Lánczi, Radiopaedia.org, rID: 46853

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Management: Emergent if entrapped fragment

Nondisplaced: Splint including wrist, sling, NSAIDs

Ortho: Short term immobilization vs open screw fixation (>5 mm or associated with dislocation)

Complications: Ulnar nerve injury/palsy

Nonunion

Decreased ROM 29AO Foundation

MOI: FOOSH- with valgus stress

Posterior elbow dislocations

Clinical Presentation Tenderness to palpation over radial

head/neck

Pain with supination/pronation >> flexion/extension

Young children may complain of wrist pain

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Diagnostics X-Rays

AP, lateral, and external oblique (flatten head of radius)

Clinical if radial head not ossified (~3-5 yo) 31

Management: Immobilize including the wrist

Sling

NSAIDs

Ortho: cast vs surgery

Complications: Premature physeal closure

Loss of ROM

Nonunion

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Subluxation of radial head

>80% occur between 1-3 years of age

MOI: Sudden pull of pronated arm

Clinical Presentation: Arm either fully extended or slightly flexed and

pronated

Overall refusal to use arm but may use fingers

Mild pain over radial head

Pain increases with attempts to supinate

Evaluate entire extremity

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Imaging typically not required

Management:

Reduction by either:

1. Hyperpronation with pressure over the radial head

2. Supination, Flexion with pressure over radial head

“Lollipop/Popsicle Test”

34Orthobullets

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Evaluate for two injuries Radius and ulna act like a ring with the

radioulnar joints proximal and distal

Consider two fractures or a fracture with a dislocation

MOI: direct impact

Clinical presentation: Localized pain, swelling, +/- wrist or elbow pain

Often clinical deformity or may be more subtle in kids (bowing, greenstick)

ROM restricted: supination and pronation

Evaluate for possible open fracture (including small puncture)

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AP/Lat radiographs

Fully visualize the wrist and the elbow

If only one fractures is seen, look for another and fully assess the joints

Case courtesy of Dr Yair Glick, Radiopaedia.org, rID: 6165937

Monteggia Fracture Ulnar (or radial and ulnar) shaft fracture with dislocation of radial

head

R/O with “Isolated” ulnar shaft fractures

Diagnosis with X-Ray

Include elbow in forearm films

38Case courtesy of Radswiki, Radiopaedia.org, rID: 12222

Nondisplaced: splint and refer for casting NSAIDs, elevation, sling, ice

Immobilization 6-8 weeks

Sports activity 4-6 months

Displaced: Emergent reduction ORIF: IM rods

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MOI: Fall

FOOSH

Direct Trauma

Most common:

Distal radius typically involved at metaphysis

+/- ulnar involvement

Clinical Presentation:

Point tenderness, swelling, ecchymosis, +/- deformity

Assess neurovascular function

Physeal injuries may be subtle

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“Dinner Fork Deformity”

Diagnostics: X-ray: AP/Lat +/- obliq

SH I often clinical diagnosis without initial radiographic finding

42Torus or Buckle Fracture

Management: Emergent with significant clinical deformity or

neurovascular compromise

Splint and NSAIDS

Ortho: cast, +/- reduction vs surgery

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Exos

Today's Parent

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MOI: Ball sports, crush injury, caught in playground

equipment

Clinical Presentation: Pain, swelling, ecchymosis

Nail hematoma

Skin disruption

Physical Exam Assess for open fracture including bleeding under

nailbed

Evaluate for angulation or rotational concerns

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Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 30373

Radiographs differentiate dislocations and physeal displacements

Radiographs: AP, lateral, and oblique

Treatment:

Splinting, bracing, or buddy taping

Ortho referral for open fracture, displacement or physeal injuries

Hand surgeon: rotational concerns, phalanx neck fracture, tendon/nerve injury

Rotation46

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MOI: jumping, high energy sports, slides with valgus force Trampoline: littlest one is at highest risk

Clinical Presentation: Localized pain, swelling, difficulty with ambulation

KarliFeder48

Imaging: AP/Lat Complete or incomplete fractures

Buckle fractures are common jumping injury in younger patients

Child abuse should be considered with “corner fractures”

Treatment: Splint, ice, elevations, NSAIDs, non-

weightbearing

Ortho referral for long leg cast

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MOI: falling while running/twisting mechanism SLIDES!

Clinical Presentation: Limp or refusal to weight bear

Often mistaken for a foot injury

Pain with palpation along tibia typically mid to distal diaphysis

Evaluate joints above/below and unaffected side first

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Fox News51

Diagnostics:

X-ray: AP, lateral, and obliques

May be occult fx on initial films

Management:

Immobilize (splint/wee walker)

NWB, NSAIDs, elevate if possible

Ortho: Wee walker vs cast

52Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 23981

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Fibula is the most commonly injured bone in the ankle Considered an extension injury of lateral

ligament complex injury

Pediatrics at risk for either Salter-Harris or avulsion injuries

MOI: inversion +/- rotation Running

Transferring between one playground equipment to another

54Case courtesy of Dr Dalia Ibrahim, Radiopaedia.org, rID: 33862

Clinical Presentation: Localized pain, swelling, and

ecchymosis

WB status varies

Location! Location! Location!

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Diagnostics:

X-Ray: AP, mortise, lateral, internal and external oblique

Consider occult fractures in kids

Ottawa Ankle Rules

Malleolar tenderness AND

Posterior fibula pain

Posterior distal tibia pain

Inability to WB (at injury & current)

Include foot films if:

Midfoot pain AND

Navicular bone pain

5th MT base pain

Inability to WB (at injury & current)Rosh Reviews

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Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 9645

Case courtesy of Dr Jeremy Jones,

Radiopaedia.org, rID: 27766 57

Fracture or ankle sprain: initial treatment is the same Posterior vs stirrup splint

Elevation, NWB, NSAIDs

Ortho consult for NWB, bony pain, concerns on imaging

Most pediatric ankle injuries are referred

Reconditioning following and ankle sprain or fracture is critical in preventing recurrence PT and home exercise program

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Juvenile idiopathic osteonecrosis of the femoral head

Peak incidence 4-8 years of age, M>F 5:1

Bilateral in 10-20%

Risk Factors: Family History

Caucasian>>East Asian or African American

Maternal smoking/second hand smoke

Associated with hyperactivity (ADHD)

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Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 7983

Painless limp or insidious onset of pain: hip, groin, thigh, or knee Limp or pain is often activity related and worsens by the end of the day

Pain relieved with rest

Muscle spasticity may be present

May have history of minor trauma

*Diagnosis often by high clinical suspicion

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Gait disturbance: Antalgic limp / Trendelenburg gait

Limited internal rotation or abduction of hip

Limb length discrepancy presents later in the course of the disease

(+) Galeazzi AAFP

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Radiographs (AP and frog laterals) are mainstay for diagnosis and monitoring condition

Plain radiographs are often initially normal

Bone scan or MRI if needed

Fragmentation and remodeling present on radiographs with disease progression

Talal Ibrahim, and David G. Little JBJS Reviews 2016;4:e463

Stages of LCP

StagesInitial Phase (necrosis)

Fragmentation

Re-ossification

Healed (remodeling)

*Multiple ways to classify further64

Age of onset best prognostic factor Younger age at presentation = better outcome

Goal: Symptomatic control and preserve hip function

Treatment recommendations are controversial

Literature supports early surgical intervention but overall improvement is modest and number needed to treat is high

Nonsurgical Options: Observation, activity restrictions, PT65

Courtesy of Texas Scottish Rite Hospital

for Children

Inflammation and irritation of patellar tendon insertion on tibial tubercle (osteochondritis)Traction at tibial tubercle apophysis

Clinical Presentation:Focal tenderness to tibial tubercle

Enlargement or bony protrusion of tibial tubercle

66AAOS

Diagnostics:

Lateral x-rays used to r/o avulsion

Management:

Will have good days and bad

Occasional rest, NSAIDs, ice

Quad exercises and hamstring stretches

Chopat strap

Pain flares around time of rapid growth

Girls age 10-11

Boys age 13-14

67Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 10135

Irritation, inflammation of calcaneal apophysisOveruse syndrome

Pull of achilles' tendon

Children age 6-12 most commonly affectedCommon in soccer players and gymnasts

Clinical: pain at calcaneal apophysis

Treatment: Stretches, Ice, NSAIDs68

CPSC69

Always complete a thorough physical exam Asses joint above and below

Check bilaterally

MOI can often guide your exam and ddx

Don’t be afraid to repeat imaging Consider obliques and evaluate the entire bone

including joints

Compare with unaffected side when needed

Caution with splinting Avoid tight ACE bandages/Coban

Educate parents on neurovascular concerns and how to adjust bandaging

Provide skin barrier if using foam splints

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When in doubt, Refer!

Befriend your local pediatric orthopaedic provider

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POSNA: https://posna.org

AAOS: https://www.aaos.org

AAP: https://www.aap.org/

AAFP: https://www.aafp.org/

PAOS: https://paos.org

Raediopaedia: https://radiopaedia.org

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Naeini HS, Lindqvist K, Jafari HR, Mirlohi AH, Dalal K. Playground injuries in children. Open Access J Sports Med. 2011; 24: 61-68.

Adelson SL, Chounthirath T, Hodges NL, Collins CL, Smith GA. Pediatric playground-related injuries treated in hospital emergency departments in the United States. Clin Pediatr (Phil.). 2018; 57(5): 584-592.

Slongo TF, Audige L, AO Pediatric Classification Group. Fracture and dislocation classification compendium for children: the AP pediatric comprehensive classification of long bone fractures (PCCF). J Orthop Trauma. 2007; 12(10 Suppl): S135-160.

McKinnis LN. Fundamentals of musculoskeletal imaging. Philidelphia, PA: F.A. Davis Company; 2014.

Smith JR, Kozin SH. Identifying and managing physeal injuries in the upper extremity. JAAPA. 2009; 22(9): 39-45.

Nguyen JC, Markhardy BK, Merrow AC, Dwek JR. Imaging of pediatric growth plate disturbances. Radiographics. 2017; 37(6): 1791-1812.

Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963; 45: 587-622.

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