Philip Wilson
ORTHOPEDIC INJURY FOLLOWING TRAUMA AND SPORTS
INJURY EVALUATION
The assessment of a patient for an injury either during a game or practice or in regard to checking the status of an old injury begins with a focused sports-oriented history and physical exam. The basic features of sports examination involve joint range of motion, muscle strength screening, palpation for discomfort, and comparison to the contralateral side. Cervical spine motion can be evaluated by asking the patient to face the examiner and look at ceiling, floor, and over shoulders, and touch ears to shoulders. Shoulder screening involves trapezius muscle strength screening by shrugging shoulders against resistance, and deltoid testing by resisted abduction of shoulders at 90°. Standing and supine shoulder external rotation at 90° of abduction can screen for motion asymmetry, or patient apprehension that may indicate shoulder instability. Evaluate elbows for tenderness or motion asymmetry with flexion and extension, and forearm rotation (symmetric palm up and palm down) with the elbows held against the torso in 90° of flexion. Resisted thumbs-up, finger spreading, and clinched fist testing can be used for peripheral nerve function screening and finger motion deficits or deformity. Lower extremity screening for gross strength and motion deficits may be accomplished by “duck walking” 4 steps away from examiner, standing from squatting position, and rising up first on heels and then toes. The examiner evaluates for symmetry in motion and muscle bulk. In a supine position, the hips are flexed and rotated to evaluate for symmetry. The quadriceps are compared in contraction, and the knees are examined for symmetric flexion and extension, ligamentous laxity (anterior/posterior drawer testing and varus/valgus testing), and the presence of an effusion (as evidenced by a mobile fluid wave at the medial and lateral patellar margins). The ankles are evaluated for symmetric flexion and extension, pain or laxity with rotation and inversion, and the presence of an effusion (as evidenced by mobile fluid at the anterior ankle joint crease).
Screening for symmetry with this basic exam allows the identification of injuries and descriptive features of findings for use in diagnosis or referral.
Many orthopedic injuries present with obvious pain and swelling. At times, decreased use of an extremity or a limp may be presenting signs. Despite communication challenges in younger children, methodical and directed palpation using this examination technique will often localize the injury. When no reasonable history of injury is present, musculoskeletal infection should also be considered with these presenting signs of pain and swelling.
FRACTURES
OCCULT FRACTURES
Radiographs should be obtained in most cases with significant signs of injury or duration of symptoms. When bony abnormalities are not readily apparent, a close examination of radiographic soft tissue swelling may help to localize injury and redirect examination.1 In older children and adolescents, RICE (rest, ice, compression, and elevation) is appropriate for most nonbony injuries. In younger children, occult fractures are common. Common occult fracture locations are the lateral malleolus, evidenced by lateral ankle swelling, and the elbow, in which fat pad signs demonstrate a joint effusion (Fig. 218-1A–C). Three weeks of splint or cast immobilization is most appropriate for suspected occult fractures.2
INCOMPLETE FRACTURES
Buckle (Torus)
Buckle fractures, also called torus fractures because of a shape similar to the base of a decorative column, are characterized by a buckling of one side of the bone while the other cortex remains intact (Fig. 218-2). The presence of an intact cortex accounts for the stable nature of these fractures. Three to 4 weeks of cast or splint treatment allows symptomatic relief while rapid healing occurs.2
Greenstick
Greenstick fractures may occur in children due to the combination of the plastic quality of immature bone and the thick periosteum present. As in breaking a “green” immature stick, the tension side of the bone fractures completely while the cortex and periosteum in compression remain intact but bend (Fig. 218-3). These fractures often require manipulative reduction of gross deformity and are more unstable than buckle fractures.
Physeal Fractures
In addition to deformity and instability that may be seen in other fracture locations, growth plate fractures may also result in alteration of normal growth.
Growth arrest generally occurs in less than 10% of all physeal fractures and may be seen most commonly at the distal femur. Treatment of the fracture displacement prior to initiation of healing, minimizing the number of manipulation attempts, and minimizing fracture displacement through the physis are all factors felt to be important for reducing the risk of growth arrest.2 The Salter–Harris classification is the most common system used to describe patterns of growth plate fractures and is useful when communicating regarding orthopedic care3 (Fig. 218-4).
COMMON FRACTURES
Distal Radius and Ulna
Fractures of the distal radius and ulna are the most common childhood fractures and usually occur from a routine fall. Buckle fractures can be treated in short arm cast or volar splint for 4 weeks of immobilization. Deformity or physeal involvement is best treated within 1 to 2 days following injury. Displaced fractures may usually be splinted and referred for orthopedic office evaluation and treatment.2,4
Elbow
Elbow fractures occur commonly from a fall on an outstretched hand. A fall on the trampoline or a fall from the monkey bars are common mechanisms of injury. Displaced fractures with significant deformity and swelling should be referred for prompt evaluation and orthopedic treatment. Even though relatively uncommon, neurovascular injury from deformity or swelling can occur. Occult fractures are common and may be diagnosed by focal pain to palpation and fat pad signs on radiographs. Nondisplaced supracondylar, radial neck, and olecranon fractures are most common and may only be seen later as they heal, or by magnetic resonance imaging (MRI). Treatment for an occult elbow fracture is 3 weeks of splinting with subsequent return to activity if pain free and full range of motion.
FIGURE 218-1. A: Anterior and posterior fat pad positions in a normal elbow. B: Elevation of fat pads secondary to elbow effusion as seen in occult fractures. C: Radiograph with anterior and posterior fat pad signs.
Nursemaid’s Elbow
Although not a fracture, nursemaid’s elbow may be a common presentation of elbow pain and decreased use of the arm. This injury results from traction on the extended arm in a child less than 5 years old (Fig. 218-5). At this age, the shape of the immature radial head allows subluxation of the annular ligament over the margin of this structure and into the radio-capitellar articulation. In this situation, the child presents with pain and decreased use of the affected limb. The elbow is held slightly flexed and pronated (palm down), and the child may complain of wrist or elbow pain.
FIGURE 218-2. Buckle fracture of the distal radius. Note that there is no break or deformity of the bone opposite the buckle.
Radiographs in this condition are negative and may be avoided with a classic presentation. A reduction maneuver is best performed upon suspicion of the diagnosis and does not require anesthetic or sedating medications. Flexing the elbow to 90° and rapidly and firmly rotating the forearm into full supination (palm up) will allow reduction of the annular ligament and radial head. The child should begin to use the arm within minutes, as evidenced by a positive “reaching for a lollipop” sign. Immobilization is not necessary following reduction. Parents should be counseled regarding the potential risk of recurrence in children under 5 years of age. With further growth, the proximal radial shape enlarges, preventing annular ligament subluxation.2,4
Toddler’s Fracture
A toddler’s fracture is a nondisplaced or occult spiral tibia fracture that occurs during the first 2 to 3 years of ambulation. Three to 4 weeks of long-leg, weight-bearing casting will allow symptom relief and union. Occult fractures may be diagnosed by diffuse new periosteal bone evident at 3 weeks following injury.2,4
FIGURE 218-3. Greenstick fracture. Note that there is deformity of both sides of the bone, but some bone remains intact.
Finger Fractures
Finger fractures may occur from a twisting injury or from an axial load while attempting to catch a ball. When joint swelling is present beyond 2 days, true lateral radiographs of the finger are important to evaluate for a periarticular fracture. Quality finger x-rays are obtained by using the fingernail as a visual guide for anteroposterior (AP) and lateral alignment. Angulated finger shaft and periarticular fractures require orthopedic evaluation and treatment.2,4
CHILD ABUSE
There are few actual “pathognomonic” signs of abuse, and fractures in children less than 1 year of age should be evaluated carefully for history or other indications of nonaccidental trauma. Metaphyseal corner fractures (Fig. 218-6), posterior rib fractures, and several fractures in varied stages of healing are highly correlated with abuse. Femur fractures and elbow fractures in children less than 12 months of age should also be evaluated with a high index of suspicion for abuse or neglect. A skeletal survey should be obtained when nonaccidental trauma is a consideration.2,4
FIGURE 218-4. Salter classification of fractures. I. Shearing separation of epiphysis from metaphysis. II. Small segment of metaphysis attached to epiphysis. III. Intra-articular epiphyseal, but no epiphyseal plate, injury. IV. Vertical fracture through metaphysis, epiphyseal plate and epiphysis. V. Crush injury of epiphysis.
GENERAL FRACTURE CARE
Many fractures in children can be treated with casting. Pain, swelling, and neurovascular status are important factors in initial fracture evaluation. Cast or splint management is appropriate when neurovascular examination is normal and pain and swelling are reasonably controlled. With more severe injuries, splinting, which allows for increased volume with swelling, is a safer alternative than casting. Follow-up is important to prevent cast-related complications. Poorly controlled pain or ongoing narcotic requirement, swelling unresponsive to elevation, or changes in neurovascular exam should prompt immediate treatment. Cast removal and thorough evaluation for point pressure, or swelling leading to compartment syndrome should be undertaken in this setting.2
Fractures of the metaphysis (the bony flare by the growth plate) in children most often heal in 4 to 5 weeks. Shaft fractures require 6 to 8 weeks of treatment.
In children younger than 6 years old, the cast or splint should be placed on the entire extremity to avoid slippage and decrease the risk of skin pressure complications.5
REMODELING
Remodeling is the reshaping of a bone that may occur with growth following a fracture (Fig. 218-7A–D). The determinants that increase remodeling capability are younger age, proximity of the fracture to the physis, and deformity that exists in the same plane as the primary motion of the nearest joint. Remodeling potential is significantly decreased following adolescence, and occurs very little around the elbow at any age following infancy.1,2
FIGURE 218-5. Longitudinal traction on the arm of a young child may result in Nursemaid’s elbow.
FIGURE 218-6. Corner fracture of the distal femur is highly specific for child abuse in children < 1 year old.
SPORTS AND OVERUSE INJURIES
In addition to fractures and dislocations, children active in sports may incur ligament injury, cartilage injury, epiphysitis, or stress fractures. Most commonly a result of rotational or bending forces around a joint, the term “sprain” is used to describe some degree of injury to ligament fibers. Sprains result in pain and soft tissue swelling along joint margins. A sprain is often a common diagnosis of exclusion when the exam reveals soft tissue tenderness to a greater degree than bony tenderness, and radiographs are normal. If soft tissue swelling and tenderness are concentrated at the bony physis, a clinical diagnosis of a nondisplaced physeal fracture should be made, and immobilization is appropriate. With a history of a twisting injury, and exam findings of soft tissue swelling and pain along the ligament, a diagnosis of a sprain may be appropriate. By convention, sprains are classified into three clinical grades. Type I sprains involve pain along a ligament, but no laxity in comparison to the contralateral corresponding joint. Type II sprains involve some detectible degree of asymmetry in laxity testing. Grade III sprains describe injuries to a ligament that result in greater than 10 mm of laxity in comparison to the contralateral joint. Most sprains are grade I or grade II injuries with minimal fiber injury and are appropriately treated by the RICE protocol. In addition to the RICE protocol during the initial 72 hours, low-grade sprains benefit from early range of motion and weight bearing as tolerated. Slow return to activity is allowed as pain and swelling resolve over 3 to 4 weeks. Suspected grade III sprains and lower-grade sprains that fail to improve following the initial 3 weeks should be referred to a musculoskeletal specialist for further evaluation.
FIGURE 218-7. A, B: Distal radius and ulna fracture with early union in a displaced position with deformity present. C, D: Remodeling of the fracture with growth from the physis.
The ankle is often injured in sporting activities with inversion and rotational mechanisms resulting in bone and soft tissue injuries. Any bony tenderness or significant soft tissue swelling around the malleoli or joint should prompt radiographic examination centered on the ankle joint. Obvious fractures or widening of the soft tissue shadow overlying the bony physes are indications for immobilization and orthopedic referral. Comparison radiographs of the uninjured side may be useful for identifying more subtle findings. The anterior lateral ankle is a common site of sprains, as described above. A sprain of the anterior talofibular ligament may occur following an inversion of the foot and hyper plantar flexion, or rotation through the ankle. A patient with an anterior lateral ankle sprain presents with pain and swelling anterior to the lateral malleolus, and limited ankle range of motion. As described above, the RICE protocol with slow return to activity is appropriate when this clinical diagnosis is made in the setting of normal radiographs. Persistent symptoms beyond 3 weeks and ongoing joint line swelling consistent with an ankle effusion should prompt further imaging or musculoskeletal evaluation.
FIGURE 218-8. An x-ray without visible fracture demonstrating a posttraumatic knee effusion.
Contusions and fractures are common around the knee, a posttraumatic knee effusion (Fig. 218-8) should also prompt evaluation for ligament or cartilage injury. Tibial spine fractures (Fig. 218-9), patellar dislocations, anterior cruciate ligament tears, and meniscal tears are possible causes of a knee effusion in children regardless of skeletal maturity. In addition to routine examination and radiographs, history of the knee giving way or shifting may assist with diagnosis of patellar dislocation, or anterior cruciate tear. Patient apprehension with a lateral patellar translation maneuver is seen following patellar dislocation, and asymmetry with Lachman or anterior drawer testing is seen with anterior cruciate injury. A persistent effusion should prompt further examination and imaging when the diagnosis remains uncertain.
A high volume of repetitive activity can result in stress in tissues which overcomes the mechanisms of inflammation and repair. In children, this can occur in the growth plate as well as in bone and soft tissues. Epiphysitis is bone edema and physeal widening that occurs at the growth plate as a result of repetitive stress. This can be seen most commonly at the proximal humerus (Fig. 218-10A,B) or medial epicondyle of the elbow, secondary to pitching in baseball. Forced rest and little league pitch count limits are important for treatment and prevention of injury. Stress fractures can occur at the distal femur or proximal tibia following rapid increases or high volumes of running activity. Diagnosis is made by history of a high level of activity and activity-related pain, corresponding with characteristic radiographic changes of nondisplaced linear fracture or increased radio-density. Bone scan or MRI may assist with early diagnosis. As with all overuse injuries, treatment is forced rest, with immobilization when indicated, and activity modification.2
FIGURE 218-9. Lateral knee x-ray demonstrating a displaced tibial spine fracture—the bony insertion point of the anterior cruciate ligament.
FIGURE 218-10. A: Epiphysitis of the proximal humerus with radiographic widening of the proximal humeral physis (arrow). B: Comparison radiograph of a normal-appearing proximal humeral physis.