Approach to common musculoskeletal injuries (pediatrics): Clinical sciences

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Introduction 0:00–0:36

Pediatric musculoskeletal injuries refer to various conditions affecting bones, joints, connective tissue, and muscles. While most childhood musculoskeletal injuries are related to low-energy trauma like falls or sports, severe injuries can result from high-energy trauma like motor vehicle accidents.
Common pediatric musculoskeletal injuries include fractures, sprains, joint separation or subluxation, and overuse injuries.
Now, if a pediatric patient presents with chief concerns suggesting a musculoskeletal injury, perform an ABCDE assessment to determine if they are unstable or stable.

Unstable 0:36–1:20

If unstable, stabilize the airway, breathing, and circulation. Next, obtain IV access and put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry.
Now, here’s a clinical pearl to keep in mind! Pelvic, hip, and proximal femur fractures can result in significant hemorrhage requiring urgent surgical intervention.
Other orthopedic emergencies include open fractures and injuries associated with nerve or vascular damage. Now, let’s take a look at stable ones.

Stable 1:20–1:51

First, perform a focused history and physical examination. Patients typically describe localized pain with a distinct mechanism of injury.
During the exam, you can often locate a point of maximum tenderness, and you may notice deformity, swelling, ecchymosis, or decreased range of motion.
With these findings, consider musculoskeletal injury, so be sure to assess the type and mechanism of the injury. Let’s first look at acute trauma.

Acute/known/witnessed trauma 1:51–2:31

If your patient reports acute trauma with a clear mechanism of injury, assess for focal bony tenderness. If present, consider the possibility of a fracture.
These patients will describe localized pain and may report a pop or snap at the time of injury. If the injury involves a lower extremity, your patient might be unable to bear weight.
The physical exam will demonstrate maximum tenderness at the injury site, often in combination with deformity, swelling, or ecchymosis.
Next, obtain an X-ray of the injured bone and adjacent joints. If radiographs demonstrate bending and a fracture on the convex side of the bone, with plastic deformation on the concave side, diagnose a Greenstick fracture.

Greenstick fracture 2:31–2:57

This type of fracture is common in children because their bones are more porous and elastic than adult bones. Greenstick fractures often involve the radius and ulna; and, in newborns, the clavicle.
Next, if the imaging reveals a compression fracture at the junction of the metaphysis and diaphysis, diagnose buckle fracture, also called a torus fracture.

Buckle fracture 2:57–3:15

These fractures often involve the distal radius and are typically caused by a fall on an outstretched hand. Now, if the X-ray reveals a fracture that spans the entire width of the bone; with a spiral, transverse, or oblique pattern; your patient has a complete fracture.

Complete fracture 3:15–3:32

These often involve the diaphysis, or shaft, of a long bone such as the femur. Finally, let’s take a look at Salter-Harris fractures which involve the physis or “growth plate”.

Salter Harris fracture 3:32–4:32

In this case, you can use X-ray findings to determine severity. Type I fracture passes straight through the physis, while type II involves the physis and part of the metaphysis above it.
Type III involves the physis and the lower epiphysis, and type IV passes through the epiphysis, physis, and metaphysis. Lastly, type V fracture describes a crush injury of the physis.
If the X-ray reveals any of these fractures, diagnose Salter-Harris fracture. The Salter-Harris classification predicts the impact of fracture on future bone growth with a higher classification corresponding to an increased risk of growth disturbance.
For example, Type I fractures are unlikely to affect growth, while Type V can cause deformity or premature growth arrest.
Now, let’s focus on individuals with no focal bony tenderness. In this case, consider a joint sprain or joint separation.

Ankle sprain 4:32–5:29

First, let’s take a look at the ankle sprain, which is associated with ankle pain after an inversion injury. Patients will also report difficulty bearing weight, and their physical exam will reveal joint swelling and tenderness, possibly with ecchymosis over the lateral malleolus.
Finally, there will be no obvious deformities of the ankle. With these findings, diagnose ankle sprain!
Now, here’s a high-yield fact! If your patient has an ankle injury, use the Ottawa Rules to determine whether they need an X-ray.
Individuals who report ankle pain with either bony tenderness at the lateral malleolus or the inability to bear weight require an X-ray, which might reveal joint dislocation or a fracture of the malleolus, tibia, or fibula.
Now, let’s move on to acromioclavicular, or AC joint separation. These patients often report a blow to the acromion and pain while lifting the arm above the shoulder line.

AC joint separation 5:29–6:15

If the exam reveals point tenderness of the acromioclavicular joint and, possibly, joint deformity or a step-off between the clavicle and acromion, consider an acromioclavicular joint separation, so be sure to obtain an X-ray of the shoulder.
X-ray findings suggestive of acromioclavicular joint separation include joint space widening or superior displacement of the clavicle, so at this point, you can confirm AC joint separation.
Now, switching gears and moving on to cases with no clear history of trauma. First, assess the consistency of the caregiver’s history with the injury’s severity, pattern, mechanism, and timing; and with the child’s development.

Trauma uncertain 6:15–6:37

If the reported history is inconsistent with any of these, consider non-accidental trauma or abuse. This is especially common in non-mobile infants younger than 4 months of age.

Non-accidental trauma 6:37–7:39

Exam findings might include bruising on the Torso, Ear, or Neck; but also injuries to Frenulum, Angle of the jaw, Cheeks, and Ears.
Additionally, you might notice Subconjunctival hemorrhage. Be sure to look for skin lesions with distinct patterns, including squeeze and slap marks.
Moreover, you can use the mnemonic TEN-4-FACESp to remember the most important red flags suggesting abuse! Next, the exam might reveal bony point tenderness, swelling, or deformity.
Then obtain X-rays. For children over 2 years of age, focus on the affected bones and joints, and for children under 2, perform a skeletal survey.
Multiple fractures at different stages of healing and fractures in unusual locations are suggestive of non-accidental trauma or abuse.
On the other hand, if the reported history is consistent with the injury’s severity, pattern, mechanism, and timing; and with child’s development, consider unrecognized or unwitnessed accidental trauma, such as Toddler fracture and radial head subluxation.

Unrecognized/unwitnessed accidental trauma 7:39–7:58

First, let’s take a look at the toddler fracture! These patients are typically between one and 4 years of age and present after an unwitnessed or minor twist or fall.

Toddler fracture 7:58–8:30

The patient will refuse to bear weight on the leg, and the exam typically demonstrates point tenderness over the tibia and fibula.
In this case, consider a toddler fracture. Your next step is to obtain an X-ray of the bone and possibly the adjacent joints.
If the X-ray reveals a non-displaced spiral fracture, diagnose a toddler fracture. Next up is radial head subluxation, also known as nursemaid elbow.

Radial head subluxation 8:30–9:50

Patients are typically under the age of 5 and present with elbow pain and refusal to move the affected arm. The history often reveals that the child fell and was caught by an extended hand, or the child might have been pulled or swung by the hand.
On the exam, the child will hold the affected arm close to their side with the elbow slightly bent, and you will notice minimal swelling.
These findings suggest radial head subluxation. This occurs when the radial head slips under the annular ligament.
Next, attempt reduction, which can be both diagnostic and therapeutic. You can use one of two maneuvers.
To reduce with hyperpronation, grasp and stabilize the elbow on the affected side, then hold the child's wrist, extend the elbow, and hyperpronate the forearm.
To reduce with supination, stabilize and extend the elbow, then supinate the forearm and flex the elbow so the hand approaches the ipsilateral shoulder.
After either maneuver, you should feel a "click" or "clunk", which indicates that the radial head is back in place. If reduction restores mobility, you've confirmed radial head subluxation.
Finally, let’s discuss repetitive or overuse injuries. First, assess the location of the pain.

Repetitive/overuse trauma 9:50–9:58

Let’s begin with elbow pain. These patients often participate in sports that require a repetitive throwing motion, such as baseball, football or tennis.

Little League elbow 9:58–10:28

Pain involves the medial elbow and occurs during a throwing motion. The exam demonstrates elbow edema, and bony tenderness.
In some cases, you might notice a flexion contracture of the elbow or instability of the medial collateral ligament. These findings confirm Little League elbow, or medial epicondyle apophysitis.
Now, let’s discuss shin pain. Your patient might report pain along the medial tibia while running or at the end of exercise.

Shin splints 10:28–11:02

If the exam reveals diffuse tenderness over the mid- to lower medial tibia without point tenderness, diagnose shin splints.
Here’s another clinical pearl! Stress fractures are overuse injuries that commonly involve the tibia or bones in the foot.
These fractures cause severe pain throughout an entire workout and are associated with point tenderness. Let’s move on to knee pain that’s located over the tibial tubercle.

Osgood Schlatter 11:02–11:41

Patients are typically between the ages of 10 and 15 and report knee pain that increases with sports and persists during rest.
The exam reveals point tenderness over the tibial tubercle and distal patellar tendon, with swelling and prominence of the tibial tubercle.
These clinical findings confirm Osgood-Schlatter disease. Now, here’s a clinical pearl!
If you obtain an X-ray in individuals with Osgood-Schlatter disease, you will see fragmentation of the tibial tubercle. Next up is anterior knee pain.

Patellofemoral pain syndrome 11:41–12:07

Patients typically describe pain that increases with bent knee activity or vigorous exercise. Some patients also report pain during prolonged sitting with a flexed knee, which is called the Theater sign.
If the exam reveals medial or lateral patellar tenderness without edema, diagnose patellofemoral pain syndrome, also known as runner’s knee.
Finally, let’s take a look at heel pain. These patients are usually between 8 and 15 years of age and participate in running or jumping sports.

Sever disease 12:07–12:39

Patients report posterior heel pain that is often bilateral, so they might limp or walk on the toes to avoid pressure on the heels.
If the physical exam demonstrates tenderness of the lateral and medial calcaneus or a positive squeeze test, diagnose Sever disease, or calcaneal apophysitis.
Alright, as a quick recap… Diagnosis of a musculoskeletal injury is based on the mechanism of injury and history, exam, and radiographic findings.

Review 12:39–13:21

Common injuries associated with known trauma include greenstick fracture, buckle fracture, complete fracture, and Salter-Harris fractures; as well as ankle sprains or acromioclavicular joint separation.
When trauma history is unclear, consider non-accidental trauma, toddler fractures, and radial head subluxation. Finally, overuse injuries include Little League elbow, shin splints, Osgood-Schlatter disease, patellofemoral pain syndrome,
Approach to common musculoskeletal injuries (pediatrics) | Osmosis