Transcript Lecture-4-kafp-peds-msk-lecture-november-2016

Pediatric Musculoskeletal Review
Wade M. Rankin, DO, CAQSM
Kelly Evans-Rankin, MD, CAQSM
UK Department of Family and Community Medicine &
Orthopedic Sports Medicine
Objectives
• Review and discuss usual pediatric
outpatient MSK conditions.
• Formulate workup and treatment options
for pediatric outpatient MSK conditions.
• Improve the MSK education for common
conditions for outpatient practitioners.
Growth Plate Injuries
Growth Plate Injuries
• Osteochondroses-self-limiting deraignment of
normal bone growth involving the centers of
ossification in the epiphysis, aseptic ischemic
necrosis
• Epiphysitis-inflammation of an epiphysis or of
the cartilage joining the epiphysis to a bone
shaft
• Apophysitis-secondary ossification center
that serves as the attachment site for a
muscle-tendon unit.
Ossification Centers
Common Osteochondrosis
Osteochondrosis
• Hip
– Femoral Head Epiphysis – Legg-Calve-Perthes
• Knee
– Inferior Pole Patella- Sindling-Larsen-Johansson (10-13)
– Tibial Tuberosity- Osgood-Schlatter (10-14)
• Foot
– Calcaneal Epiphysis- Sever’s Disease
– Metatarsal Head- Freiburg Disease (Infracture)
– Navicular bone- Kohler bone disease (2-8)
• Elbow
– Medial condyle epiphysitis- Little League Elbow
– Humeral capitellum- Panner’s Disease (<10)
• Back
– Anterior vertebral endplates- Scheuermann’s Disease (10-12)
– Pars Interarticularis- Spondylolysis
Osgood Schlatter
Sinding-Larsen-Johansson Disease
Osteochondrosis of the
growth plate of the inferior
pole of the patella
Sever’s Disease
• Traction apophysitis of
the Achilles insertion to
the calcaneous
• Calcaneal apophysitis
• Most common cause of
heel pain in children
between ages of 5-11
• Bones grow faster than
the muscles/tendon
causing traction of the
apophysis
Sever’s Disease
• Diagnosis
– Swelling and
tenderness noted
around the Achilles
insertion
– Passive dorsiflexion
can increase pain
– Radiographs are
usually normal and
does not aid in the
diagnosis –SORT C
Sever’s Disease
• Decrease paininducing activities
• NSAIDS/Tylenol
• Ice, stretching and
strengthening of the
gastroc-soleus
complex
• ?orthotic devices
Little League Shoulder
Little League Shoulder
• Little League Shoulder
– Salter Harris I Fx of
proximal humerus
(osteochrondrosis)
– Repetitive overuse injury in
pitchers/throwers
– “Dead arm”
– Pain with overhead
throwing
– Widening of physis on Xray
– Txt-conservative, “shut
down”, PT when pain free,
instruction on proper
mechanics
Little League Shoulder
• Insidious onset of symptoms that have
been present for months and often delay
seeking consultation until the pain
increases or until there is a decrease in
throwing velocity or control
• Up to 70 percent of patients with little
leaguer’s shoulder have tenderness over
the proximal and lateral portion of the
humerus
Little League Shoulder
• Imaging
– Classic findings include widening of the proximal
humeral physis with or without physeal
fragmentation, sclerosis, and demineralization
– Bone scan and magnetic resonance
imaging(MRI) usually are unnecessary but may
be considered if initial radiographs are negative
and suspicion for the diagnosis is high, or if there
is clinical suspicion for other pathology
Little Leaguer’s Shoulder
Little Leaguer’s Shoulder
Little League Shoulder
• Treatment
– relative rest from throwing for an average of
three months, icing, and analgesic
medications as needed for pain
– begin strengthening exercises when they are
comfortable and an interval throwing program
when they are pain free. Evaluation of
throwing mechanics also should be
considered.
Little Leaguer’s Elbow
Little Leaguer’s Elbow
• An apophysitis of the medial epicondyle in
athletes between nine and 12 years of age
• Most patients experience pain in the medial
aspect of the elbow during throwing, and they
may have decreased pitch velocity or control
• diagnosis of little leaguer’s elbow is made
clinically and should be considered in
throwers with medial elbow pain, even if
symptoms are minimal
Little Leaguer’s Elbow
• Imaging
– Radiographs may be normal or may reveal
hypertrophy of the medial epicondyle, bony
fragmentation, apophyseal widening or avulsion
(medial epicondyle), loose cartilaginous bodies,
or osteochondral lesions
– MRI and nerve conduction studies may be useful
for patients with normal radiographs and clinical
suspicion for other conditions such as ulnar
collateral ligament injury or radiculopathy.
Little Leaguer’s Elbow
Little Leaguer’s Elbow
• Treatment
– complete rest from throwing or pitching for at
least four to six weeks
– ice packs and analgesic medications may be
used for swelling and pain.
– General conditioning, stretching, and core
strengthening should be encouraged
– A gradual and progressive (interval) throwing
program may begin after the initial rest period.
– Most athletes are able to return to competitive
pitching and throwing at 12 weeks
Prevention
• Little League Shoulder and Little
Leaguer’s Elbow
– American Academy of Pediatrics recommends
limiting the number of pitches to 200 per week
or 90 pitches per outing
– USA Baseball Medical and Safety Advisory
Committee recommends more conservative
pitch counts (i.e., 75 to 125 pitches per week
or 50 to 75 pitches per outing, depending on
age)
Spondylolysis
Spondylolysis
• Vertebral defect (unilateral or bilateral) of
the pars interarticularis is thought to be
secondary to repetitive hyperextension of
the posterior elements of the spine,
leading to stress injury or fracture
Spondylolysis
• Presentation
– occurs in approximately 6 percent of the general
population but may contribute to nearly 50
percent of cases of back pain in athletes
– activity-related back pain that is exacerbated by
hyperextension of the lumbar spine
• lineman blocking, volleyball serving, gymnastic or
cheerleading tumbling
– progressing to pain during rest and daily
activities.
Spondylolysis
• Examination
– hyperlordotic posture,
limited range of
motion, and hamstring
tightness with
tenderness or pain in
the affected region
during single-leg
hyperextension,
commonly called the
“stork” test
Spondylolysis
• Imaging
– lumbar spine
radiographs with
anteroposterior,
lateral, and bilateral
oblique views
– The classic
appearance on the
oblique view has been
described as the
“Scotty dog” with a
“collar appearance”
Scotty Dog
Spondylolysis
• Treatment
– relative rest from the offending activity,
analgesic medications, physical therapy, and
possibly bracing (for symptomatic patients
after two to four weeks of rest).
– Bracing continues until the lesion is shown to
be healed on radiographs or until the athlete
is completely asymptomatic, which may take
up to nine to 12 months
• Questions on Growth Plates?
Pediatric Disorders
•
•
•
•
•
Septic Joint
Pediatric Fractures
Intoeing
Nursemaid’s Elbow
“Growing Pains”
DDx for Toddler (1-3yo) Refuses to Walk
•
•
Painful
– Septic arthritis/osteomyelitis
– Transient synovitis
– Intervertebral discitis
– JRA
– Occult fracture
– Neoplasia (leukemia,
metastatic)
– Foreign body in the Foot
Painless
– Developmental dysplasia of
the hip
– Leg-length discrepancy
– Neuromuscular disease (CP)
Septic Joint/Arthritis
• SA Knee
Septic Joint/Arthritis
• Highly likely if:
– Fever of 38.7 degrees Celsius
– Refuses to bear weight on one leg
– WBC count >12,000 cells/mm
– ESR >40 mm/hr
• Likelihood of being septic arthritis
– Zero factors: 0.2%
– One factor: 3.0%
– Two factors: 40%
– Three factors: 93.1%
– Four factors: 99.6%
Septic Arthritis
If several risk factors exist
-Ultrasound or fluoroscopic
guided aspiration
-Aspirate usually cloudy
-50,000-100,000 cells/mL
-Aspirate culture gold
standard
Pediatric Fractures
Types of Pediatric Fractures
Most Common Fracture Sites
Salter-Harris Fracture Types
Salter-Harris Fracture Types
•
•
•
•
•
S- “slipped” “Straight”
A- “above”
L- “lower”
T- “through”
R- “rammed or
ruined”
Salter-Harris Fracture
• If xray findings are negative
(need comparison views),
but patient TTP over the
physis
– Treat like a Salter-Harris
Type 1
• Splint if reliable, cast if
not
• Reassess in 2 weeks, if
still tender, 2 more
weeks
• Patient remain
immobilized until no
longer TTP over physis
Common X-rays Tested
Child Abuse Fx
Intoeing
Intoeing
• Internal tibial torsion
• Believed to be caused by
sleeping in the prone position
and sitting on the feet
• 90% resolve without
intervention by age 8
• Treatment includes avoiding
sleeping in the prone position
and not sitting on feet
• Night splints, orthotics and
shoe wedges are ineffective
• Surgery associated with high
complication rate so not
recommended before age 8
Nursemaid’s Elbow
Nursemaid’s Elbow
• Radial head subluxation
– Most common in ages 1-4, can happen up to age
6-7 yo
– “pulled elbow”, usually happens when a child arm
is pulled to avoid a dangerous event or when
child is swung with play by the arms/wrist
– Child usually presents with holding arm at side
and unwillingness to move the elbow
– Radiographs usually not needed unless trauma or
swelling
Nursemaid’s Elbow
• Nursemaid's Elbow Reduction
“Growing Pains”
“Growing Pains”
• Benign nocturnal limb pains of childhood
– Cramping pains of thigh/shin/calf usually following an
active day
– Affect 35% of children 4-6 yo, may occur up to age 19
– Pathophysiology is unknown
– May be associated with growth in general but not
associated with pubertal growth spurt
– Pain occurs in evening/night, may awaken the child at
night, disappears by morning
– Not associated with a limp
“Growing Pains”
• Treatment
– If classic presentation is present in the
absence of inflammatory or chronic signs,
benign nature should be enforced
– PE is normal in these children
– No further diagnostic tests are needed
– Reassurance should be given to parents
– No long-term sequelae
The End
• Questions?