Approach to common musculoskeletal injuries (pediatrics): Clinical sciences

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.

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. 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. 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. 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. 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. 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”. 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.

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.

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. 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. 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!