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 Knee Foot Elbow Back 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 pain-inducing activities NSAIDS/Tylenol Ice, stretching and strengthening of the gastroc-soleus complex ?orthotic devices

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 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?