1. Pediatric Musculoskeletal Review
Wade M. Rankin, DO, CAQSM
Kelly Evans-Rankin, MD, CAQSM
UK Department of Family and Community Medicine & Orthopedic Sports Medicine

2. 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.

3. Growth Plate Injuries

4. 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.

5. Ossification Centers

6. Common Osteochondrosis

7. 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

8. Osgood Schlatter

9. Sinding-Larsen-Johansson Disease
Osteochondrosis of the growth plate of the inferior pole of the patella

10. 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

11. 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

12. Sever’s Disease Decrease pain-inducing activities NSAIDS/Tylenol
Ice, stretching and strengthening of the gastroc-soleus complex
?orthotic devices

13. Little League Shoulder

14. 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

15. 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

16. 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

17. Little Leaguer’s Shoulder

18. 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.

19. Little Leaguer’s Elbow

20. 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

21. 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.

22. Little Leaguer’s Elbow

23. 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

24. 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)

25. Spondylolysis

26. 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

27. 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.

28. 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

29. 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”

30. Scotty Dog

31. 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

32. Questions on Growth Plates?

33. Pediatric Disorders Septic Joint Pediatric Fractures Intoeing
Nursemaid’s Elbow
“Growing Pains”

34. 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)

35. Septic Joint/Arthritis
SA Knee

36. 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%

37. Septic Arthritis If several risk factors exist
-Ultrasound or fluoroscopic guided aspiration
-Aspirate usually cloudy
-50, ,000 cells/mL
-Aspirate culture gold standard

38. Pediatric Fractures

39. Types of Pediatric Fractures

40. Most Common Fracture Sites

41. Salter-Harris Fracture Types

42. Salter-Harris Fracture Types
S- “slipped” “Straight”
A- “above”
L- “lower”
T- “through”
R- “rammed or ruined”

43. 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

44. Common X-rays Tested
Child Abuse Fx

45. Intoeing

46. 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

47. Nursemaid’s Elbow

48. 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

49. Nursemaid’s Elbow
Nursemaid's Elbow Reduction

50. “Growing Pains”

51. “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

52. “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

53. The End
Questions?