Assessing the Child’s Extremities

Tom McPartland MD FABOS,FAAP I have no financial disclosures Pediatric Assistant Clinical Professor-Rutgers Robert Wood Johnson Medical School

Goals Examining the Musculoskeletal System

• To review the anatomy of the child’s • Well child assessment musculoskeletal system. • Preventative Medicine • To develop a systematic approach to • Evaluation and Treatment of Injuries examining the child’s extremities • Assessment of Other Musculoskeletal Pathology – Infectious, Inflammatory, Neoplastic Conditions

Musculoskeletal System Nervous System Anatomy Provide Structure and Support to the Body • Muscle activation is Allow Movement of the Body initiated by the cerebral Hands manipulate the environment cortex in the brain • Nerve impulses are Feet move the individual around conducted through the Diaphragm provides for respiration spinal cord Provide Protection for Vital Organs • Peripheral nerves are stimulated and transmit Manufacture Blood the impulse to skeletal Provide a vital mineral reservoir in the body muscle

1 Muscular Anatomy Osseous Anatomy

• Skeletal muscle receives neuronal stimulus for contraction • Muscles shorten to initiate movement

Child’s Anatomy Injuries

• 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

Injury Types Fractures

• Disruption of the • Soft Tissues – Skin, Muscle, Tendon, architecture of bone – Skin • Classified as – • Abrasion Open vs. Closed – Displaced vs Non-displaced • Laceration • Fractures are a disruption in the structure of bone but – Supportive soft tissues – ligament, tendon, muscle the force required to cause • – ligament and capsules the fracture leads to soft tissue injury as well • Strains – tendon and muscle • 41% of boys and 27% of • Inflammation - “-ITIS” girls will experience a • Tears – rare in young kids but can happen fracture by age 16

2 When is an injury significant and Inflammation require greater care • First Documented by Cornelius 25 BC • Pain – Dolor • Lacerations • Redness – Rubor – Are deeper structures involved? • Swelling – Tumor • Warmth – Calor • Deformity • Immobility – Functio – Displaced fractures or laesa dislocations • Loss of function – Any neurologic change motor or sensory – Inability to bear weight on limb

Sprains Strains

• Ligament injuries – Will be tender to palpation DeLee and Drez 3rd – Can differentiate from Ed fractures based on focal location of pain – Swelling, bruising, and level of disability may be similar to fracture – Recovery can be shorter • Injuries to muscle usually occur at the or longer than fracture junction between muscle and tendon

Skin Injuries Contusions • Contusion – injury is to skin and underlying tissue without break in epidermis • Soft tissue or bony • Abrasions – superfical skin injury with impact injury with epidermal loss interstitial tissue • Lacerations – injury extends to deepest layers disruption and of skin inflammation • Avulsion – complete loss of tissue • Bruising (echmyosis) • Edema (swelling) • Pain

De Lee and Drez Textbook of Sports Medicine

3 Abrasion Lacerations

• Superficial break in skin • Injury violates skin to with epidermal loss. its basement • Does not penetrate to membrane deep subcutaneous • tissue Lacerations that gap or are > 1cm may need suture repair

Avulsion Treatment

Complete loss of tissue • R est Likely requires surgical repair • I ce • C ompression • E levation Complete Finger Tip • Splinting Amputation

Splinting History

• Immobilization reduces • The events that occurred to cause the injury – Pain may improve and speed treatment especially – Swelling in more serious injuries – Further Injury • Gather as much information as you can about • Splints include how it happened – Prefabricated splints – The child may not be able to tell you everything – Custom splints that happened – Slings – They may be focused on one injury but there may be other more important things

4 General Principles of Assessment General Principles

• Get a localizing complaint from the child • Inspection • Your exam should be focal at the site they • Range of Motion complain about but don’t ignore the rest of – Know what’s normal the limb • Palpation • Specialized Tests

When to Involve a Physician Common Playground Injuries

• Fractures • Contusions and Abrasions • Lacerations • • Injuries that are • Wrist Fracture significantly impacting function • Fracture • Suspected head injury

Examining the Extremities Regional Anatomy

• Localization • Inspection • Range of motion/Disability • Palpation

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• 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 glenohumeral motion

Shoulder ROM Shoulder Injuries

• Sprains and Strains • Fractures • Dislocation

Upper Elbow

• Injury Patterns – Little Leaguer’s Shoulder – Fractures • Humerus • Supracondylar

6 Elbow Injuries Nursemaid’s elbow

• Fractures • Nursemaids elbow • Sprains • Abrasions

DeLee and Drez Orthopedic Sports Medicine

Elbow Injuries Wrist Anatomy

• Red Flags • The wrist is a complex – Deformity joint with multiple planes of movement – Severe Pain that helps to terminally position the hand

• 8 carpal bones join the hand to the

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.

7 Hand Hand Injuries

• Red Flags • Sprains – Malalignment • Fractures – Deep Lacerations • Dislocations • Loss of sensation • Loss of flexion or • Lacerations extension of digit • 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

• Complex Ball and Socket Joint – Highly constrained – Powerful muscles maintain balance and stabilize the trunk above and the below

8 Hip Anatomy Hip Exam

Normal ROM

Flex/Ext 100°/-20° Int Rot/Ext Rot 30°/50° Abduction/Adduction 50°/-20° Tachdijan’s Pediatric Orthopedics 5th Ed

Hip Injury Patterns Knee Injuries

• Muscular Strains • Sprains and Contusions by far the most common • Bursitis • Tendonitis • Labral Tears • Fractures • Fractures – Femur, , patella, tibial tubercle, tibial spine • – Avulsion Fracture Patella Dislocation • Ligament tears • Meniscus Injuries • Osteochondritis dissicans

Specialized Soft Tissues - Knee Assessing the Knee

• with names – Anterior Cruciate Ligament Posterior Cruciate Ligament • Is patient ambulatory? Medial Collateral Ligament • Check ROM Lateral Collateral Ligament – Full motion rules out a lot of Posterolateral Corner pathology – Normal ROM 0° to 140° • Meniscus • Check for joint effusion – Medial and lateral – Ballottement test • Ligament specific exam

9 Knee Exam Collateral Ligament Exam

• 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.

Specialized tests for Cruciate Tendonitis 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

Knee Sprains Hemarthrosis

• Mechanism 38 Pts- trauma, negative xrays, skeletally – Lateral blow with fixed (MCL) immature. Underwent – Twisting MRI – Hyperextension 13 Effusions 13 Bone Bruises 8 Patellar Disloc • Sprain may involve named ligaments and joint 1 ACL Tear capsule 1 Osteochondral Fx • Traumatic effusion usually indicative of a more 2 Tibial Spine Avulsions

significant problem Wessel et al JPO p338 2001.

10 • ACL Injuries • ACL Injuries – Diagnosis can be made clinically on – Anterior Drawer examination with Lachman’s test

Treatment of ACL injuries Case

• MRI valuable – Partial tear 12 Y/O F fell skiing – Complete tears hyperextension injury- • Most open field sports require an intact ACL in order to was able to ski to bottom tolerate frequent change of direction but painful knee. Seen • Reconstruction of the ACL with patient’s own tissue or pediatric office limping allograft tissue is definitive treatment the next day. – Results excellent PE – Long term prognosis thought to be poor whether Effusion reconstruction is performed or not but short term function and return to athletic activity is definitely improved. Mild diffuse tenderness ? Ant drawer sign

Patella Dislocation Treatment – Patella Dislocation

• • Reduce by applying medially directed force on Mechanism patella while extending knee – Patella tracks outside of – May require sedation the trochlear groove usually to lateral side • Splint in extension • Can be caused by lateral blow • Orthopedic follow-up • Can have anatomic – We evaluate for loose osteochondral fragment (?MRI) predisposition – 2-4 weeks with symptomatic treatment • Evaluate with plain film – Start PT and work on dynamic stabilization of knee Xrays – High risk of recurrent dislocation

11 Knee Summary Tibia/ • Sprains • Fractures – Splint – Nondisplaced • Knee immobilizer • Splint- knee immobilizer • Tibia fractures • Crutches • NWB with crutches – Physeal fractures • WBAT – Displaced – – Office F/U anticipate 3-6 • Consult ortho for admission Acute fractures weeks for recovery vs. elective repair – Stress fractures • Needs follow-up eval for – Many require admission ligament exam • Patella Dislocation • Tendonitis – Effusion – definitely – Reduce, splint – Achilles follow-up with ortho, – discretionary MRI Follow-up with ortho – Peroneal • Possible MRI • Ligament injury • Periostitis () – Splint – F/U ortho

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

Tibia shaft fractures Toddler’s Fracture • Fractures of tibial diaphysis are caused by axial load or • Very common in three point bending forces – Lateral blow with fixed foot, young children – Direct blow (soccer) • Accidental – Fall • Goal is to restore alignment • Stable – Stable fracture pattern may be treated in long leg cast with close • Can WBAT follow-up Most children under 12 can be treated with a cast • Heals in 3-4 weeks Consider surgery in older children or unstable fracture patterns Surgical options are flexible intramedullary rods or external • Usually age 3 or less fixation

12 Tibial Stress Fracture Summary

• Function of frequent • Tibia fractures running – Toddler 3 or younger • Patient reports symptoms • Stable pattern worsen with physical – Cast or boot and may bear weight activity. Often no – Nondisplaced > 3 years symptoms at rest • Cast 4-6 weeks • Plain films can be useful – Return to activity 2-3 months – “the dreaded black line” Displaced • MRI if clinical suspicion high Closed reduction and casting and plain films negative Surgery only if • Treatment is rest 2-3 open fracture months stable reduction cannot be held in cast

Ankle Injuries Specialized Soft Tissues Ankle Two parts to ankle • Sprains • Tibiotalar joint • Fractures • Distal tibiofibular joint (Syndesmosis) – Stable lateral malleolar patterns – Unstable Bimalleolar fractures Named Ligaments – Growth Plate Injuries • Tibiotalar – Anterior Talofibular Ligament – Transitional ankle fractures (ATFL) – Calcaneofibular Ligament • Tendonitis – Posterior Talofibular ligament – Deltoid ligament • Syndesmosis – Anterior and Posterior tibiofibular ligaments

Ankle Sprains

• Most common cause of lower extremity pain – 25,000 ankle sprains per day • Inversion most frequent mechanism

13 High Ankle Sprain Treatment

• A high ankle sprain is an • Treatment in ED injury to the ligaments – Splint that hold the distal tibia – CAM boot and fibula together • Office F/U – Anterior tibiofibular – Necessary if medial and ligament lateral tenderness with – negative Xray or high ankle Posterior tibiofibular sprain ligament – Recovery variable – Interosseous ligament • A couple days to several – Collectively called the weeks syndesmosis • PT if recurrent sprains – Retrain proprioception

Salter I Distal Fibula – typical “goose egg” swelling over distal fibula with tenderness over distal fibular physis Thank You

Foot Injuries Fractures

• Fractures • Fifth Metatarsal Base Fracture • Sprains • Toe and Metatarsal Fractures – 1st Metatarsal Midfoot Sprains • Calcaneal fractures – Turf toe metatarsal fractures 90% • Plantar Fasciitis phalangeal fractures 18% navicular fractures 5% talar fractures 3% • Tendonitis calcaneal fractures 3% • Punctures and Lacerations cuboid fractures 2%

14 Tendonitis Sprains of the Foot

• Most common cause of “foot” pain • Midfoot • Ankle extensors • Intermetatarsal ligaments • Achilles Tendon • Peroneals • Treat with boot or cast • Crutches • Treat with rest, ice, boot if needed – WBAT

Spinal Cord Injury Midfoot Sprain • Spinal Cord Injuries are extremely serious • Ligaments of the midfoot maintain the longitudinal arch of the foot • Important Lisfranc ligament spans medial cuneiform and 2nd metatarsal

Kids on the Go Youth Sports

• More children playing sports now than ever before • The amount of time we dedicate to sports is – 41 million kids engage in some form of youth sports also changing • 17.5 million play soccer (2 million more since 1987) – • 220,000 play Pop Warner football (doubled in last 20 yrs Kids play more sports • 2.2 million play Little League Baseball – Kids play on more teams • Lacrosse increased from 82,000 in 2001 to 220,000 in 2005 – Rec league • – School team 69% of girls and 75% of boys will participate in an – Travel team organized sport – Summer team

15 Differences in Children

• We are seeing more sports related injuries • Strength to Weight Ratio constantly changing – 3.5 million sports-related injuries per year in children less than 15 years old – Most children achieved balanced running and – Children under 10 more likely to be injured in unorganized setting jumping by 6-7years – During pubertal growth spurt, increase in weight and lengthening of bone levers outstrips the • We are seeing more overuse injuries than ever before growth of muscle – Kids playing on multiple teams – No rest between seasons – The growing skeleton was not intended for this much – Children will intermittently master and then stress struggle with certain skills

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