1

Assessing the Child’s Extremities

Tom McPartland MD FABOS,FAAPPediatric Orthopedic SurgeryAssistant Clinical Professor-Rutgers Robert Wood Johnson Medical School

I have no financial disclosures

Goals

• To review the anatomy of the child’s musculoskeletal system.

• To develop a systematic approach to examining the child’s extremities

Examining the Musculoskeletal System

• Well child assessment

• Preventative Medicine

• Evaluation and Treatment of Injuries

• Assessment of Other Musculoskeletal Pathology

– Infectious, Inflammatory, Neoplastic Conditions

Musculoskeletal SystemProvide Structure and Support to the Body

Allow Movement of the Body

Hands manipulate the environment

Feet move the individual around

Diaphragm provides for respiration

Provide Protection for Vital Organs

Manufacture Blood

Provide a vital mineral reservoir in the body

Nervous System Anatomy

• Muscle activation is initiated by the cerebral cortex in the brain

• Nerve impulses are conducted through the spinal cord

• Peripheral nerves are stimulated and transmit the impulse to skeletal muscle

2

Muscular Anatomy

• Skeletal muscle receives neuronal stimulus for contraction

• Muscles shorten to initiate movement

Osseous Anatomy

Child’s Anatomy

• 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

Injuries

• Soft Tissues – Skin, Muscle, Tendon, Ligament

– Skin

• Abrasion

• Laceration

– Supportive soft tissues – ligament, tendon, muscle

• Sprains – ligament and joint capsules

• Strains – tendon and muscle

• Inflammation - “-ITIS”

• Tears – rare in young kids but can happen

Injury Types Fractures

• Disruption of the architecture of bone

• Classified as – Open vs. Closed– Displaced vs Non-displaced

• Fractures are a disruption in the structure of bone but the force required to cause the fracture leads to soft tissue injury as well

• 41% of boys and 27% of girls will experience a fracture by age 16

3

Inflammation• First Documented by Cornelius 25 BC• Pain – Dolor• Redness – Rubor• Swelling – Tumor• Warmth – Calor• Immobility – Functio

laesa

When is an injury significant and require greater care

• Lacerations– Are deeper structures

involved?

• Deformity – Displaced fractures or

dislocations

• Loss of function– Any neurologic change

motor or sensory– Inability to bear weight on

limb

Sprains

• Ligament injuries

– Will be tender to palpation

– Can differentiate from fractures based on focal location of pain

– Swelling, bruising, and level of disability may be similar to fracture

– Recovery can be shorter or longer than fracture

Strains

• Injuries to muscle usually occur at the junction between muscle and tendon

DeLee and Drez 3rd

Ed

Skin Injuries

• Contusion – injury is to skin and underlying tissue without break in epidermis

• Abrasions – superfical skin injury with epidermal loss

• Lacerations – injury extends to deepest layers of skin

• Avulsion – complete loss of tissue

Contusions

• Soft tissue or bony impact injury with interstitial tissue disruption and inflammation

• Bruising (echmyosis)

• Edema (swelling)

• Pain

De Lee and Drez Textbook of Sports Medicine

4

Abrasion

• Superficial break in skin with epidermal loss.

• Does not penetrate to deep subcutaneous tissue

Lacerations

• Injury violates skin to its basement membrane

• Lacerations that gap or are > 1cm may need suture repair

Avulsion

Finger TipComplete

Amputation

Complete loss of tissueLikely requires surgical repair

Treatment

• R est

• I ce

• C ompression

• E levation

• Splinting

Splinting

• Immobilization reduces

– Pain

– Swelling

– Further Injury

• Splints include

– Prefabricated splints

– Custom splints

– Slings

History

• The events that occurred to cause the injury may improve and speed treatment especially in more serious injuries

• Gather as much information as you can about how it happened

– The child may not be able to tell you everything that happened

– They may be focused on one injury but there may be other more important things

5

General Principles of Assessment

• Get a localizing complaint from the child

• Your exam should be focal at the site they complain about but don’t ignore the rest of the limb

General Principles

• Inspection

• Range of Motion

– Know what’s normal

• Palpation

• Specialized Tests

When to Involve a Physician

• Fractures

• Lacerations

• Injuries that are significantly impacting function

• Suspected head injury

Common Playground Injuries

• Contusions and Abrasions

• Ankle Sprain

• Wrist Fracture

• Elbow Fracture

Examining the Extremities

• Localization

• Inspection

• Range of motion/Disability

• Palpation

Regional Anatomy

6

Shoulder

• 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 glenohumeralmotion

Shoulder ROM Shoulder Injuries

• Sprains and Strains

• Fractures

• Dislocation

Upper Arm

• Injury Patterns

– Little Leaguer’s Shoulder

– Fractures

• Humerus

• Supracondylar

Elbow

7

Elbow Injuries

• Fractures

• Nursemaids elbow

• Sprains

• Abrasions

Nursemaid’s elbow

DeLee and Drez Orthopedic Sports Medicine

Elbow Injuries

• Red Flags

– Deformity

– Severe Pain

Wrist Anatomy

• The wrist is a complex joint with multiple planes of movement that helps to terminally position the hand

• 8 carpal bones join the hand to the forearm

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.

8

Hand

• Red Flags

– Malalignment

– Deep Lacerations• Loss of sensation

• Loss of flexion or extension of digit

Hand Injuries

• Sprains

• Fractures

• Dislocations

• Lacerations

• 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 Hip

• Complex Ball and Socket Joint

– Highly constrained

– Powerful muscles maintain balance and stabilize the trunk above and the knee below

9

Hip Anatomy Hip Exam

Tachdijan’s Pediatric Orthopedics 5th Ed

Normal ROM

Flex/Ext 100°/-20°Int Rot/Ext Rot 30°/50°Abduction/Adduction 50°/-20°

Hip Injury Patterns

• Muscular Strains

• Bursitis

• Labral Tears

• Fractures

– Avulsion Fracture

• Sprains and Contusions by far the most common

• Tendonitis

• Fractures

– Femur, tibia, patella, tibial tubercle, tibial spine

• Patella Dislocation

• Ligament tears

• Meniscus Injuries

• Osteochondritis dissicans

Knee Injuries

• Ligaments with names

– Anterior Cruciate Ligament

Posterior Cruciate Ligament

Medial Collateral Ligament

Lateral Collateral Ligament

Posterolateral Corner

• Meniscus

– Medial and lateral

Specialized Soft Tissues - Knee Assessing the Knee

• Is patient ambulatory?

• Check ROM– Full motion rules out a lot of

pathology

– Normal ROM 0° to 140°

• Check for joint effusion– Ballottement test

• Ligament specific exam

10

• 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.

Knee Exam Collateral Ligament Exam

Specialized tests for Cruciate 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

Tendonitis

• Mechanism – Lateral blow with fixed foot (MCL)

– Twisting

– Hyperextension

• Sprain may involve named ligaments and joint capsule

• Traumatic effusion usually indicative of a more significant problem

Knee Sprains

38 Pts- trauma, negative xrays, skeletally immature. Underwent MRI

13 Effusions13 Bone Bruises8 Patellar Disloc1 ACL Tear1 Osteochondral Fx2 Tibial Spine Avulsions

Wessel et al JPO p338 2001.

Hemarthrosis

11

• ACL Injuries– Diagnosis can be made clinically on

examination with Lachman’s test

• ACL Injuries– Anterior Drawer

• MRI valuable– Partial tear

– Complete tears

• Most open field sports require an intact ACL in order to tolerate frequent change of direction

• Reconstruction of the ACL with patient’s own tissue or allograft tissue is definitive treatment– Results excellent

– Long term prognosis thought to be poor whether reconstruction is performed or not but short term function and return to athletic activity is definitely improved.

Treatment of ACL injuries

12 Y/O F fell skiing

hyperextension injury-was able to ski to bottom but painful knee. Seen pediatric office limping the next day.

PE

Effusion

Mild diffuse tenderness

? Ant drawer sign

Case

• Mechanism

– Patella tracks outside of the trochlear groove usually to lateral side• Can be caused by lateral

blow

• Can have anatomic predisposition

• Evaluate with plain film Xrays

Patella Dislocation

• Reduce by applying medially directed force on patella while extending knee– May require sedation

• Splint in extension

• Orthopedic follow-up– We evaluate for loose osteochondral fragment (?MRI)– 2-4 weeks with symptomatic treatment– Start PT and work on dynamic stabilization of knee– High risk of recurrent dislocation

Treatment – Patella Dislocation

12

Knee Summary• Sprains

– Splint• Knee immobilizer• Crutches• WBAT

– Office F/U anticipate 3-6 weeks for recovery• Needs follow-up eval for

ligament exam

– Effusion – definitely follow-up with ortho, discretionary MRI

• Ligament injury– Splint– F/U ortho

• Fractures– Nondisplaced

• Splint- knee immobilizer• NWB with crutches

– Displaced• Consult ortho for admission

vs. elective repair– Many require admission

• Patella Dislocation– Reduce, splint– Follow-up with ortho

• Possible MRI

• Tibia fractures

– Physeal fractures

– Acute fractures

– Stress fractures

• Tendonitis

– Achilles

– Peroneal

• Periostitis (Shin Splints)

Tibia/Fibula

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

Toddler’s Fracture

• Very common in young children

• Accidental

• Stable

• Can WBAT

• Heals in 3-4 weeks

• Usually age 3 or less

• Fractures of tibial diaphysis are caused by axial load or three point bending forces– Lateral blow with fixed foot,– Direct blow (soccer)– Fall

• Goal is to restore alignment– Stable fracture pattern may be treated in long leg cast with close

follow-upMost children under 12 can be treated with a castConsider surgery in older children or unstable fracture patternsSurgical options are flexible intramedullary rods or external fixation

Tibia shaft fractures

13

• Function of frequent running

• Patient reports symptoms worsen with physical activity. Often no symptoms at rest

• Plain films can be useful – “the dreaded black line”

• MRI if clinical suspicion high and plain films negative

• Treatment is rest 2-3 months

Tibial Stress Fracture

• Tibia fractures– Toddler 3 or younger

• Stable pattern– Cast or boot and may bear weight

– Nondisplaced > 3 years• Cast 4-6 weeks

– Return to activity 2-3 months

DisplacedClosed reduction and castingSurgery only if

open fracturestable reduction cannot be held in cast

Summary

• Sprains

• Fractures

– Stable lateral malleolar patterns

– Unstable Bimalleolar fractures

– Growth Plate Injuries

– Transitional ankle fractures

• Tendonitis

Ankle InjuriesTwo parts to ankle• Tibiotalar joint• Distal tibiofibular joint

(Syndesmosis)

Named Ligaments• Tibiotalar

– Anterior Talofibular Ligament (ATFL)

– Calcaneofibular Ligament– Posterior Talofibular ligament– Deltoid ligament

• Syndesmosis– Anterior and Posterior

tibiofibular ligaments

Specialized Soft Tissues Ankle

• Most common cause of lower extremity pain

– 25,000 ankle sprains per day

• Inversion most frequent mechanism

Ankle Sprains

14

• A high ankle sprain is an injury to the ligaments that hold the distal tibia and fibula together– Anterior tibiofibular

ligament

– Posterior tibiofibular ligament

– Interosseous ligament

– Collectively called the syndesmosis

High Ankle Sprain

• Treatment in ED– Splint

– CAM boot

• Office F/U– Necessary if medial and

lateral tenderness with negative Xray or high ankle sprain

– Recovery variable• A couple days to several

weeks

• PT if recurrent sprains– Retrain proprioception

Treatment

Thank You

Salter I Distal Fibula –typical “goose egg” swelling over distal fibula with

tenderness over distal fibular physis

• Fractures

• Sprains

– 1st Metatarsal Midfoot Sprains

– Turf toe

• Plantar Fasciitis

• Tendonitis

• Punctures and Lacerations

Foot Injuries

• Fifth Metatarsal Base Fracture

• Toe and Metatarsal Fractures

• Calcaneal fractures

Fractures

metatarsal fractures 90%phalangeal fractures 18%navicular fractures 5%talar fractures 3%calcaneal fractures 3%cuboid fractures 2%

15

• Most common cause of “foot” pain

• Ankle extensors

• Achilles Tendon

• Peroneals

• Treat with rest, ice, boot if needed

– WBAT

Tendonitis

• Midfoot

• Intermetatarsal ligaments

• Treat with boot or cast

• Crutches

Sprains of the Foot

Midfoot Sprain

• Ligaments of the midfoot maintain the longitudinal arch of the foot

• Important Lisfranc ligament spans medial cuneiform and 2nd metatarsal

Spinal Cord Injury

• Spinal Cord Injuries are extremely serious

• More children playing sports now than ever before

– 41 million kids engage in some form of youth sports

• 17.5 million play soccer (2 million more since 1987)

• 220,000 play Pop Warner football (doubled in last 20 yrs

• 2.2 million play Little League Baseball

• Lacrosse increased from 82,000 in 2001 to 220,000 in 2005

• 69% of girls and 75% of boys will participate in an organized sport

Kids on the Go

• The amount of time we dedicate to sports is also changing

– Kids play more sports

– Kids play on more teams– Rec league

– School team

– Travel team

– Summer team

Youth Sports

16

• We are seeing more sports related injuries– 3.5 million sports-related injuries per year in children less than 15

years old

– Children under 10 more likely to be injured in unorganized setting

• We are seeing more overuse injuries than ever before– Kids playing on multiple teams

– No rest between seasons

– The growing skeleton was not intended for this much stress

• Strength to Weight Ratio constantly changing

– Most children achieved balanced running and jumping by 6-7years

– During pubertal growth spurt, increase in weight and lengthening of bone levers outstrips the growth of muscle

– Children will intermittently master and then struggle with certain skills

Differences in Children