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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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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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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Splinters
Abrasions
Lacerations
Sprains
Broken Bones
Head Injuries
Spinal Injuries7
Splinters
Abrasions
Lacerations
Sprains
Broken Bones
Head Injuries
Spinal Injuries
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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 12
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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
14Radiology 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
18Case 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 internal oblique view focused on lateral condyle
MRI if needed
Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 2593720
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 dysfunction22
“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 24AO 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) 26
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”
29Orthobullets
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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: 6165932
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
33Case 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
37Torus 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
Rotation41
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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
KarliFeder43
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 News46
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
47Case 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
49Case 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 52
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:e458
Stages of LCP
StagesInitial Phase (necrosis)
Fragmentation
Re-ossification
Healed (remodeling)
*Multiple ways to classify further59
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, PT60
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
61AAOS
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
62Case 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, NSAIDs63
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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