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91 Cards in this Set
- Front
- Back
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Common Pediatric Injuries/Diagnoses
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• Spondy’s
• Apophysitis • Knee Problems • Hip Problems • Female Athlete Triad • Salter Harris Fractures • Concussions |
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***What is this? - Spondylosis
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o Osteophyte formation (anterior lipping) and narrow IV space
• Degenerative arthritis of the disc and facet joints causing compression of the spinal cord and nerve roots |
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Where is the defect with Spondylosis
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L1-L2
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What is this? - Spondylolisthesis
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o L5 anterior on S1
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Spondylolysis
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o Scotty dog
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Physical Exam of back
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• ROM with flexion, extension, B/L side-bending and B/L rotation
• Assess for hamstring tightness and straight leg testing • Stork testing |
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• Symptoms Spondylosis
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o Exacerbation of pain with extension double leg or single leg
o May have distal neurological findings such as absence of anal reflex o Limited back motion especially with extension |
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• Studies used for Spondylosis
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o Lumbar Series: Will show osteoarthritis with evidence of spurring, disc narrowing, or neuroforaminal narrowing
o MRI is more definitive with or without contrast o CT is generally not helpful |
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• Acute Spondylosis Treatment
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o Limit standing/extension activities
o If must be on their feet, need to have established rest stops o NSAID or COX-2 Inhibitor o Short course corticosteroids for radiculopathy -30 mg for week 1, 20 mg for week 2, 10mg for week 3 |
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• Chronic Spondylosis Treatment
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o Flexion-based PT and core strengthening
o Cushioned shoes/insoles o Low impact aerobics o Bike, stairmaster, aqua-aerobics o Epidural steroid injections |
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***Spondylolisthesis
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• Anterior slippage of the spine
• Anterolisthesis involves the anterior movement of the overlying vertebral body on the affected body |
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***Grading of Spondylolisthesis
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• Grade 1 < 25% slippage
• Grade 2 25-50% • Grade 3 50-75% • Grade 4 >75% |
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• Symptoms of Spondylolisthesis
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o Pain below the waist aggravated by twisting, extension, or prolonged standing
o Waddling gait o Hamstring tightness o Hyperlordosis o Rarely neurological symptoms |
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• Studies of Spondylolisthesis
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o Lateral X-ray
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***Asymptomatic Spondylolisthesis Treatment
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o Grade 1: No restrictions; lateral X-ray every 6-12 months through growth period
o Grade 2: Restriction from collision or high risk activities with hyperextension or high impact o >50%: Surgical stabilization |
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***Symptomatic Spondylolisthesis Treatment
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o Grade 1: Activity restriction and pain control; part-time bracing with gradual wean and return to activity
o Grade 2: Rest and bracing as well as counseling against return to activities o >50%: Surgery Not different from asymptomatic Tx |
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***Spondylolysis
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• Fracture of the pars interarticularis of the lumbar spine
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Symptoms of Spondylolysis
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o Back pain aggravated by extension, usually without palpable or radicular pain
o Pain with standing single leg hyperextension Similar position to Stork Test |
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***Studies of Spondylolysis
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o Oblique X-ray demonstrates lucent line in pars (collar on Scotty Dog)
o Bone Scan may demonstrate focal signal in the pars ***SPECT (single photon emission computed tomography) done with the bone scan is very specific in identifying pars lesion o MRI may show signal and or fracture of pars Not really a good study for spondylolysis o CT will only show complete fracture |
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Treatment of Spondylolysis
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o PT for hamstring flexibility and anterior core strengthening for 3 weeks
o If no pain on stork testing after 3 weeks of PT, may start back extension strengthening exercises and continue for 3 weeks o If symptoms persist or return early, consider extending PT o If negative stork testing and pain free after 6 weeks, may return to sport without imaging Pascucci usually gets football players back to playing in 5 weeks o Bracing was previously recommended for all patients but this has proven to be ineffective (not done anymore) o Surgical consult for refractory cases |
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Scoliosis
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• Lateral curvature of the spine >10 degrees
• Progression in girls is between ages 10-16 |
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***Best test for scoliosis
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• The forward bending test is the most sensitive clinical method of documenting the problem
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• Cobb angle
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standard for quantifying the degree of curvature
o Measure an intersecting angle of perpendiculars to the upper end plate of the most superior and the lower end plate of the most inferior vertebrae in the curve |
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***Treatment of scoliosis
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o PT
o X-rays every 6 months ***Brace treatment is reserved for patients with curves in the range of 20-45 degrees ***Surgery is for curves greater than 50 degrees |
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Apophysitis
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A growth center at the insertion of tendons and ligaments into bone
• Inflammation at these sites (apophysitis) occurs during a growth spurt secondary to poor flexibility and recurrent traction of the muscle-tendon unit causing microfracture |
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***Osgood-Schlatter Disease
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• Inflammation of the apophysis of the tibial tubercle
• Most common knee complaint in children o Patellofemoral syndrome is most common problem in children |
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Pain with OS
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• Pain at tibial tuberosity with activity, relieved by rest
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DX testing of OS
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• Lateral X-ray demonstrates fragmentation or irregular ossification of the tibial tubercle
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• Treatment of OS
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o Rest from aggravating activities short term
o Ice o Hamstring and quadriceps stretching o Cho-Pat brace or other patellar tendon counterforce brace for activity o Immobilization with crutches for severe pain o May return to sport as tolerated |
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***Sinding-Larsen-Johansson
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• Apophysitis of the inferior pole of the patella
• Happens in preteen boys o Not very common |
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S/S of Sinding-Larsen-Johansson
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• Pain, swelling and tenderness of the inferior pole of the patella with high impact activities
o May also have hamstring tightness |
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X-Ray of Sinding-Larsen-Johansson
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may be normal or show calcification or elongation of the inferior pole of the patella or demonstrate bipartite patella (in 2 pieces)
• Treatment similar to that of Osgood-Schlatter |
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Sever’s Disease
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• Apophysitis at the calcaneus, specifically at the insertion of the Achilles tendon
• 9-12 year-olds in high impact sports present with posterior heel pain |
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xray of Sever’s Disease
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may show irregular contour of the apophysis and you may need a bone scan or MRI to evaluate for a stress fracture
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tx of Sever’s Disease
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o Rest, ice, NSAID’s PRN
o Heel cord stretching by physical therapist o Heel cups or shoe inserts |
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Os Trigonum
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• Accessory ossicle of the posterior talus
• Osteochondral lesion of the talus |
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Accessory Navicular
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• Secondary center of ossification develops at the medial navicular
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Navicular Osteonecrosis (Kohler disease)
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• Children 4-8, usually boys
• Patients limp and turn out their foot while walking |
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***xray of Navicular Osteonecrosis (Kohler disease)
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dense, fragmented, ***thin navicular
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tx of Navicular Osteonecrosis
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• Cast, boot or activity modifications for 1-2 months
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***Freiberg Infarction
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• Osteonecrosis of the second metatarsal most commonly in adolescents
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xray of Freiberg Infarction
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looks “chewed up”
o Not round and crisp |
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tx of Freiberg Infarction
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• Treat with a boot or post-op shoe for 3-4 weeks
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***What is common with Medial Elbow Apophysitis (Little Leaguer’s Elbow)
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• Usually will have medial epicondyle fragmentation and avulsion or delayed or accelerated apophyseal growth
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***What is the term Little League Elbow
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blanket term that also includes osteochondritis dessicans of the capitellum, osteochondrosis of the radial head, flexion contracture of the elbow, and olecranon stress fractures
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Who normally presents with Little League Elbow
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• Usually pitchers that present with medial elbow pain, but also occurs in gymnasts
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What should be assessed with LLE
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• Assess for ROM and strength at the elbow, wrist, shoulder and back
• Assess for laxity or pain at the elbow and compare it to the other side • Tinel’s test will help discover an ulnar nerve subluxation |
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Studies for LLE
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• X-rays need to be done bilaterally for comparison
• May need CT to evaluate for loose bodies |
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***Treatment of LLE
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o Send it to someone who knows how to treat it and treats it often!
o 4-6 weeks of rest with no throwing o A strengthening and light throwing program may begin after 6-8 weeks of rest |
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***Typical Elbow Dislocation
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Posterior
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***What can be associated with an elbow dislocation
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• Medial epicondyle fractures
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***What is another name for Subluxation of the Radial Head. What age is it most common in children
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• Nursemaid’s elbow is the most common elbow injury in children < 5 years of age
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***What causes Nursemaid’s elbow
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• Associated with increased ligamentous laxity
• Cause is by pulling on the forearm when the elbow is extended and the forearm is pronated |
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***What is injured with Nursemaid’s elbow
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• The annular ligament which wraps around the neck of the radius, slips proximally and lies between the radius and ulna
• Reduce by placing your thumb on the radial head and supinating the elbow |
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***Patellofemoral Pain Syndrome
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• Most common cause of anterior knee pain in the young athlete
• Caused by overuse secondary to malalignment and VMO weakness |
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S/S of Patellofemoral Pain Syndrome
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• Symptoms are worse with stairs, running or sitting with knee flexed for extended period of time
• Subpatellar crepitus, snapping, popping or grinding are often described |
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Dx findings for PFPS
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• Diagnosis by positive patellar grind test and lateralization and patellar tilt on X-ray
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Tx of PFPS
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Physical Therapy to strengthen and stretch VMO, quadriceps, hamstrings and iliotibial band usually successful within 3-4 weeks
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***Osteochondritis Dessicans of the Knee
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• Partial or complete separation of a segment of hyaline cartilage
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***Demographics of Osteochondritis Dessicans of the Knee
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• Males:Females 2:1
• Ages 13-21 most commonly |
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Stages of Osteochondritis Dessicans (4)
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• Stage 1: Compression fracture, normal X-ray
• Stage 2: Partially detached, osteochondral fragment • Stage 3: Defect is detached but within underlying cartilage • Stage 4: Detached defect with migration |
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S/S of Osteochondritis Dessicans
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• Symptoms include vague, diffuse knee pain that is worse with activity and may produce an effusion
• Loose bodies may produce locking, popping and instability |
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Studies used for Osteochondritis Dessicans
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• If X-rays are indeterminate, MRI or bone scan may be helpful
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Tx of Osteochondritis Dessicans
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• Stage 1 and 2 may do well with immobilization, whereas Stage 3 and 4 need to see orthopedics
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Bipartite Patella. What is it and where is it most common
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• Failure of an ossification center of the patella to fuse
• Most common at the superior lateral corner |
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S/s of Bipartite Patella
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• May be asymptomatic or present with tenderness and swelling
• Pain with jumping and running in chronic cases |
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What should be looked at in a xray of Bipartite Patella
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• If you see separation from posterior X-ray, you want to see X-ray of the anterior knee to make sure there is no fracture
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What does bleeding in the knee indicate
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It is likely tendon, ligament, or bone that was injured
Cartilage (meniscus) is usually not the culprit if there is bleeding |
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***SCFE (Slipped Capital Femoral Epiphysis)
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• Shearing failure of proximal femoral epiphysis usually from impact activity
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***Who gets SCFE
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• Males:Females 2:1
• 9-16 y.o. • Obese or tall and thin |
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Pain of SCFE
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• Painful weight-bearing or limp with pain in anterior groin, thigh or knee with limited internal rotation
o If a kid picks up his leg to move it, they probable have SCFE |
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What xrays to get with SCFE
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: AP and frog-leg lateral with contralateral comparison views
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TX of SCFE
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• Treat with non-weight-bearing and referral to orthopedics for pinning
• Return to sport after months of inactivity, hardware removal and most often physeal closure |
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***Legg-Calve-Perthes
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• Interrupted blood supply to femoral epiphysis
• Patient will have a limp and pain from anterior groin to knee |
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***Who gets Legg-Calve-Perthes
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• 4-8 y.o.
• Males > females |
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Studies for Legg-Calve-Perthes
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• X-rays and possibly bone scan or MRI
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Tx of Legg-Calve-Perthes
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• Refer to Orthopedics
• Treatment options include observation, bed rest, bracing or casting and surgery • Return individualized, decided by Orthopedics |
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***Avulsion Fractures
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• Usually caused at an apophysis from a forceful muscle contraction
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***commmon sites of avulsion
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• ASIS: Sartorius and tensor fascia lata
o Usually from soccer pre-season - on the plant leg • AIIS: Rectus femoris • Ischial Tuberosity: Hamstrings, most likely biceps femoris • Lesser Trochanter: Iliopsoas |
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What pts normally get avulsion Fx
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o Football linemen from pushing off
o Soccer players on plant foot while kicking o Weight lifters o Runners |
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Tx of avulsion
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NWB for 4 weeks, then repeat X-ray, re-evaluate and consider PT
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***Toxic (Transient) Synovitis
Where is it seen |
• Males:Females 2:1
• Most common cause of hip pain in children <10 years old |
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***S/s of Toxic Synovitis
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• Symptoms include recent URI, low-grade fever and painful limp or inability to walk
• ESR and WBC count may be slightly elevated • Self-limiting with rest and NSAID’s |
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***Female Athlete Triad
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• (1) Menstrual disturbances/amenorrhea, (2) bone loss/osteoporosis, and (3) energy deficit disordered eating
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What is needed for dx of triad
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• Need to obtain PMHx, menstrual history, psychosocial history, exercise history, nutritional assessment, current medications and physical exam
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Lab studies for triad
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• Laboratory studies include pregnancy test, UA, CBC, ESR, CMP, thyroid panel, FSH, LH, prolactin, testosterone, DHEAS, and direct estradiol
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Who should you consult reguarding triad
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• May need consultation with psychiatrist or psychologist, gynecologist, orthopedic surgeon, sports nutritionist, cardiologist and if available athletic trainer
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***Studies for triad
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• DEXA scan and EKG depending on severity
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***Salter Harris Mnemonic - In relation to the growth plate
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• S (Type 1) Same
• A (Type 2) Above • L (Type 3) Lower • T (Type 4) Through • E (Type 5) Everywhere |
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Salter Harris 1 Fractures
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• Difficult to diagnose with X-rays alone
• Diagnose by tenderness over the growth plate • Immobilize for 3-4 weeks, then re-evaluate |
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most common cause of concussions in pediatrics
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• Most commonly caused by bicycle accidents in pediatrics!
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