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Assessing the Child’s Extremities
Tom McPartland MD FABOS,FAAPPediatric Orthopedic SurgeryAssistant Clinical Professor-Rutgers Robert Wood Johnson Medical School
I have no financial disclosures
Goals
• To review the anatomy of the child’s musculoskeletal system.
• To develop a systematic approach to examining the child’s extremities
Examining the Musculoskeletal System
• Well child assessment
• Preventative Medicine
• Evaluation and Treatment of Injuries
• Assessment of Other Musculoskeletal Pathology
– Infectious, Inflammatory, Neoplastic Conditions
Musculoskeletal SystemProvide Structure and Support to the Body
Allow Movement of the Body
Hands manipulate the environment
Feet move the individual around
Diaphragm provides for respiration
Provide Protection for Vital Organs
Manufacture Blood
Provide a vital mineral reservoir in the body
Nervous System Anatomy
• Muscle activation is initiated by the cerebral cortex in the brain
• Nerve impulses are conducted through the spinal cord
• Peripheral nerves are stimulated and transmit the impulse to skeletal muscle
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Muscular Anatomy
• Skeletal muscle receives neuronal stimulus for contraction
• Muscles shorten to initiate movement
Osseous Anatomy
Child’s Anatomy
• Children’s Skeleton has features that distinguish it from an adult
– Bones are growing!
• Growth plates are inside of the bone and render it weaker
– Ossify slowly over time
– Bones are more plastic with higher water content
• More likely sustain incomplete fractures
Injuries
• Soft Tissues – Skin, Muscle, Tendon, Ligament
– Skin
• Abrasion
• Laceration
– Supportive soft tissues – ligament, tendon, muscle
• Sprains – ligament and joint capsules
• Strains – tendon and muscle
• Inflammation - “-ITIS”
• Tears – rare in young kids but can happen
Injury Types Fractures
• Disruption of the architecture of bone
• Classified as – Open vs. Closed– Displaced vs Non-displaced
• Fractures are a disruption in the structure of bone but the force required to cause the fracture leads to soft tissue injury as well
• 41% of boys and 27% of girls will experience a fracture by age 16
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Inflammation• First Documented by Cornelius 25 BC• Pain – Dolor• Redness – Rubor• Swelling – Tumor• Warmth – Calor• Immobility – Functio
laesa
When is an injury significant and require greater care
• Lacerations– Are deeper structures
involved?
• Deformity – Displaced fractures or
dislocations
• Loss of function– Any neurologic change
motor or sensory– Inability to bear weight on
limb
Sprains
• Ligament injuries
– Will be tender to palpation
– Can differentiate from fractures based on focal location of pain
– Swelling, bruising, and level of disability may be similar to fracture
– Recovery can be shorter or longer than fracture
Strains
• Injuries to muscle usually occur at the junction between muscle and tendon
DeLee and Drez 3rd
Ed
Skin Injuries
• Contusion – injury is to skin and underlying tissue without break in epidermis
• Abrasions – superfical skin injury with epidermal loss
• Lacerations – injury extends to deepest layers of skin
• Avulsion – complete loss of tissue
Contusions
• Soft tissue or bony impact injury with interstitial tissue disruption and inflammation
• Bruising (echmyosis)
• Edema (swelling)
• Pain
De Lee and Drez Textbook of Sports Medicine
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Abrasion
• Superficial break in skin with epidermal loss.
• Does not penetrate to deep subcutaneous tissue
Lacerations
• Injury violates skin to its basement membrane
• Lacerations that gap or are > 1cm may need suture repair
Avulsion
Finger TipComplete
Amputation
Complete loss of tissueLikely requires surgical repair
Treatment
• R est
• I ce
• C ompression
• E levation
• Splinting
Splinting
• Immobilization reduces
– Pain
– Swelling
– Further Injury
• Splints include
– Prefabricated splints
– Custom splints
– Slings
History
• The events that occurred to cause the injury may improve and speed treatment especially in more serious injuries
• Gather as much information as you can about how it happened
– The child may not be able to tell you everything that happened
– They may be focused on one injury but there may be other more important things
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General Principles of Assessment
• Get a localizing complaint from the child
• Your exam should be focal at the site they complain about but don’t ignore the rest of the limb
General Principles
• Inspection
• Range of Motion
– Know what’s normal
• Palpation
• Specialized Tests
When to Involve a Physician
• Fractures
• Lacerations
• Injuries that are significantly impacting function
• Suspected head injury
Common Playground Injuries
• Contusions and Abrasions
• Ankle Sprain
• Wrist Fracture
• Elbow Fracture
Examining the Extremities
• Localization
• Inspection
• Range of motion/Disability
• Palpation
Regional Anatomy
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Shoulder
• The shoulder is a complex ball and socket joint that position the hand in space.
• Motion of the shoulder is produced by both scapulothoracic motion and glenohumeralmotion
Shoulder ROM Shoulder Injuries
• Sprains and Strains
• Fractures
• Dislocation
Upper Arm
• Injury Patterns
– Little Leaguer’s Shoulder
– Fractures
• Humerus
• Supracondylar
Elbow
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Elbow Injuries
• Fractures
• Nursemaids elbow
• Sprains
• Abrasions
Nursemaid’s elbow
DeLee and Drez Orthopedic Sports Medicine
Elbow Injuries
• Red Flags
– Deformity
– Severe Pain
Wrist Anatomy
• The wrist is a complex joint with multiple planes of movement that helps to terminally position the hand
• 8 carpal bones join the hand to the forearm
Wrist Hand Anatomy
• The human hand is a remarkable organ that
Manipulates
and
Senses the environment
The whole purpose of the upper extremity is to position the hand in space.
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Hand
• Red Flags
– Malalignment
– Deep Lacerations• Loss of sensation
• Loss of flexion or extension of digit
Hand Injuries
• Sprains
• Fractures
• Dislocations
• Lacerations
• Nail injuries
Neurologic Assessment of the Limb Nail Bed Injuries
• Disruptions of the nail and nail bed require precise repair of the nail bed
Lower Extremities Hip
• Complex Ball and Socket Joint
– Highly constrained
– Powerful muscles maintain balance and stabilize the trunk above and the knee below
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Hip Anatomy Hip Exam
Tachdijan’s Pediatric Orthopedics 5th Ed
Normal ROM
Flex/Ext 100°/-20°Int Rot/Ext Rot 30°/50°Abduction/Adduction 50°/-20°
Hip Injury Patterns
• Muscular Strains
• Bursitis
• Labral Tears
• Fractures
– Avulsion Fracture
• Sprains and Contusions by far the most common
• Tendonitis
• Fractures
– Femur, tibia, patella, tibial tubercle, tibial spine
• Patella Dislocation
• Ligament tears
• Meniscus Injuries
• Osteochondritis dissicans
Knee Injuries
• Ligaments with names
– Anterior Cruciate Ligament
Posterior Cruciate Ligament
Medial Collateral Ligament
Lateral Collateral Ligament
Posterolateral Corner
• Meniscus
– Medial and lateral
Specialized Soft Tissues - Knee Assessing the Knee
• Is patient ambulatory?
• Check ROM– Full motion rules out a lot of
pathology
– Normal ROM 0° to 140°
• Check for joint effusion– Ballottement test
• Ligament specific exam
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• Joint Palpation
– Assess for areas of tenderness
• Correlate with underlying structure
• Check Physes above and below the knee
• Check for active knee extension and palpate for patella tendon defect.
Knee Exam Collateral Ligament Exam
Specialized tests for Cruciate Ligaments and Meniscus
• Inflammation referable to quadriceps or patella tendon– Quadriceps
– Inferior pole patella (Sindig-Larsen-Johannsen)
– Tibial tubercle (Osgood-Schlatter)
– Very common in stop and start sports• Age related susceptibility
Tendonitis
• Mechanism – Lateral blow with fixed foot (MCL)
– Twisting
– Hyperextension
• Sprain may involve named ligaments and joint capsule
• Traumatic effusion usually indicative of a more significant problem
Knee Sprains
38 Pts- trauma, negative xrays, skeletally immature. Underwent MRI
13 Effusions13 Bone Bruises8 Patellar Disloc1 ACL Tear1 Osteochondral Fx2 Tibial Spine Avulsions
Wessel et al JPO p338 2001.
Hemarthrosis
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• ACL Injuries– Diagnosis can be made clinically on
examination with Lachman’s test
• ACL Injuries– Anterior Drawer
• MRI valuable– Partial tear
– Complete tears
• Most open field sports require an intact ACL in order to tolerate frequent change of direction
• Reconstruction of the ACL with patient’s own tissue or allograft tissue is definitive treatment– Results excellent
– Long term prognosis thought to be poor whether reconstruction is performed or not but short term function and return to athletic activity is definitely improved.
Treatment of ACL injuries
12 Y/O F fell skiing
hyperextension injury-was able to ski to bottom but painful knee. Seen pediatric office limping the next day.
PE
Effusion
Mild diffuse tenderness
? Ant drawer sign
Case
• Mechanism
– Patella tracks outside of the trochlear groove usually to lateral side• Can be caused by lateral
blow
• Can have anatomic predisposition
• Evaluate with plain film Xrays
Patella Dislocation
• Reduce by applying medially directed force on patella while extending knee– May require sedation
• Splint in extension
• Orthopedic follow-up– We evaluate for loose osteochondral fragment (?MRI)– 2-4 weeks with symptomatic treatment– Start PT and work on dynamic stabilization of knee– High risk of recurrent dislocation
Treatment – Patella Dislocation
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Knee Summary• Sprains
– Splint• Knee immobilizer• Crutches• WBAT
– Office F/U anticipate 3-6 weeks for recovery• Needs follow-up eval for
ligament exam
– Effusion – definitely follow-up with ortho, discretionary MRI
• Ligament injury– Splint– F/U ortho
• Fractures– Nondisplaced
• Splint- knee immobilizer• NWB with crutches
– Displaced• Consult ortho for admission
vs. elective repair– Many require admission
• Patella Dislocation– Reduce, splint– Follow-up with ortho
• Possible MRI
• Tibia fractures
– Physeal fractures
– Acute fractures
– Stress fractures
• Tendonitis
– Achilles
– Peroneal
• Periostitis (Shin Splints)
Tibia/Fibula
Proximal Tibia Salter I Fracture Proximal Tibia Physeal Fractures
• Open reduction for irreducible Salter I and II, displaced Salter IV
• Observe closely for vascular compromise or compartment syndrome in first 24 hours
• Follow for growth disturbance, angular deformity
Toddler’s Fracture
• Very common in young children
• Accidental
• Stable
• Can WBAT
• Heals in 3-4 weeks
• Usually age 3 or less
• Fractures of tibial diaphysis are caused by axial load or three point bending forces– Lateral blow with fixed foot,– Direct blow (soccer)– Fall
• Goal is to restore alignment– Stable fracture pattern may be treated in long leg cast with close
follow-upMost children under 12 can be treated with a castConsider surgery in older children or unstable fracture patternsSurgical options are flexible intramedullary rods or external fixation
Tibia shaft fractures
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• Function of frequent running
• Patient reports symptoms worsen with physical activity. Often no symptoms at rest
• Plain films can be useful – “the dreaded black line”
• MRI if clinical suspicion high and plain films negative
• Treatment is rest 2-3 months
Tibial Stress Fracture
• Tibia fractures– Toddler 3 or younger
• Stable pattern– Cast or boot and may bear weight
– Nondisplaced > 3 years• Cast 4-6 weeks
– Return to activity 2-3 months
DisplacedClosed reduction and castingSurgery only if
open fracturestable reduction cannot be held in cast
Summary
• Sprains
• Fractures
– Stable lateral malleolar patterns
– Unstable Bimalleolar fractures
– Growth Plate Injuries
– Transitional ankle fractures
• Tendonitis
Ankle InjuriesTwo parts to ankle• Tibiotalar joint• Distal tibiofibular joint
(Syndesmosis)
Named Ligaments• Tibiotalar
– Anterior Talofibular Ligament (ATFL)
– Calcaneofibular Ligament– Posterior Talofibular ligament– Deltoid ligament
• Syndesmosis– Anterior and Posterior
tibiofibular ligaments
Specialized Soft Tissues Ankle
• Most common cause of lower extremity pain
– 25,000 ankle sprains per day
• Inversion most frequent mechanism
Ankle Sprains
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• A high ankle sprain is an injury to the ligaments that hold the distal tibia and fibula together– Anterior tibiofibular
ligament
– Posterior tibiofibular ligament
– Interosseous ligament
– Collectively called the syndesmosis
High Ankle Sprain
• Treatment in ED– Splint
– CAM boot
• Office F/U– Necessary if medial and
lateral tenderness with negative Xray or high ankle sprain
– Recovery variable• A couple days to several
weeks
• PT if recurrent sprains– Retrain proprioception
Treatment
Thank You
Salter I Distal Fibula –typical “goose egg” swelling over distal fibula with
tenderness over distal fibular physis
• Fractures
• Sprains
– 1st Metatarsal Midfoot Sprains
– Turf toe
• Plantar Fasciitis
• Tendonitis
• Punctures and Lacerations
Foot Injuries
• Fifth Metatarsal Base Fracture
• Toe and Metatarsal Fractures
• Calcaneal fractures
Fractures
metatarsal fractures 90%phalangeal fractures 18%navicular fractures 5%talar fractures 3%calcaneal fractures 3%cuboid fractures 2%
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• Most common cause of “foot” pain
• Ankle extensors
• Achilles Tendon
• Peroneals
• Treat with rest, ice, boot if needed
– WBAT
Tendonitis
• Midfoot
• Intermetatarsal ligaments
• Treat with boot or cast
• Crutches
Sprains of the Foot
Midfoot Sprain
• Ligaments of the midfoot maintain the longitudinal arch of the foot
• Important Lisfranc ligament spans medial cuneiform and 2nd metatarsal
Spinal Cord Injury
• Spinal Cord Injuries are extremely serious
• More children playing sports now than ever before
– 41 million kids engage in some form of youth sports
• 17.5 million play soccer (2 million more since 1987)
• 220,000 play Pop Warner football (doubled in last 20 yrs
• 2.2 million play Little League Baseball
• Lacrosse increased from 82,000 in 2001 to 220,000 in 2005
• 69% of girls and 75% of boys will participate in an organized sport
Kids on the Go
• The amount of time we dedicate to sports is also changing
– Kids play more sports
– Kids play on more teams– Rec league
– School team
– Travel team
– Summer team
Youth Sports
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• We are seeing more sports related injuries– 3.5 million sports-related injuries per year in children less than 15
years old
– Children under 10 more likely to be injured in unorganized setting
• We are seeing more overuse injuries than ever before– Kids playing on multiple teams
– No rest between seasons
– The growing skeleton was not intended for this much stress
• Strength to Weight Ratio constantly changing
– Most children achieved balanced running and jumping by 6-7years
– During pubertal growth spurt, increase in weight and lengthening of bone levers outstrips the growth of muscle
– Children will intermittently master and then struggle with certain skills
Differences in Children