Evaluation and Triage of Five Adolescent Diagnoses

UW Sports RehabUW Sports RehabAmy G. Schubert, MPTAmy G. Schubert, MPT

ObjectivesObjectives

By the end of this presentation you will be able By the end of this presentation you will be able to accurately assess for the following pediatric to accurately assess for the following pediatric diagnoses:diagnoses:

tibialtibial spine avulsion fracturesspine avulsion fracturessaltersalter--harrisharris fracturesfracturesOCD of the kneeOCD of the kneeSCFESCFEpediatric bone and soft tissue tumorspediatric bone and soft tissue tumors

TibialTibial

Spine Avulsion FracturesSpine Avulsion Fractures

involves the medial spine of the involves the medial spine of the intercondylarintercondylareminenceeminenceincompletely ossified incompletely ossified tibialtibial eminence fails prior eminence fails prior to the ACLto the ACLfxfx can also encroach into the medial can also encroach into the medial tibialtibialplateauplateau

TibialTibial

Spine Avulsion Fractures: Who Spine Avulsion Fractures: Who is at Risk??is at Risk??

most common in children aged 8most common in children aged 8--14 years14 yearsossification of the proximal tibia is not ossification of the proximal tibia is not complete, surface of spine is cartilaginouscomplete, surface of spine is cartilaginous

TibialTibial

Spine Avulsion Fractures:Spine Avulsion Fractures: When to be Suspicious??When to be Suspicious??

any MOI which you would suspect ACL injuryany MOI which you would suspect ACL injuryfall from bike on outstretched leg is most fall from bike on outstretched leg is most common common painful painful hemiarthosishemiarthosis often preventing further often preventing further accurate assessmentaccurate assessment

TibialTibial

Spine Avulsion Fractures:Spine Avulsion Fractures: TriageTriage

AP and lateral views of knee are essential; AP and lateral views of knee are essential; oblique and tunnel views may be needed oblique and tunnel views may be needed depending on location of fragmentdepending on location of fragment

TibialTibial

Spine Avulsion FractureSpine Avulsion Fracture Classification and TreatmentClassification and Treatment

Type I: Type I: nondisplacednondisplacedType II: partially displaced or hingedType II: partially displaced or hingedType III: completely displacedType III: completely displacedType IV: comminuted Type IV: comminuted fxfx----------------------------------------------------------------------------------------------------Type IType I--II typically treated with closed reductionII typically treated with closed reductionType III often treated with ORIFType III often treated with ORIF

Case Study: Case Study: ““TonyTony””11 11 y.oy.o. male. maleMOI: riding bike and lost control with back tire sliding MOI: riding bike and lost control with back tire sliding out from under himout from under himimmediate pain and swellingimmediate pain and swellingER imaging concerning for ER imaging concerning for tibialtibial spine avulsion spine avulsion fxfx; ; placed in immobilizerplaced in immobilizerappt with Dr. Noonan; placed in straight leg cast x 6 appt with Dr. Noonan; placed in straight leg cast x 6 weeksweeksPresented to PT 7 weeks Presented to PT 7 weeks s/ps/p injury in ELS locked at 15 injury in ELS locked at 15 degrees knee flexdegrees knee flexd/cd/c brace at 11 weeks and progressed per ACL rehab brace at 11 weeks and progressed per ACL rehab guidelinesguidelines

SalterSalter--Harris FracturesHarris Fractures

Injuries to growing bones at the growth Injuries to growing bones at the growth plate/plate/physesphyses

Pressure Pressure physesphyses ((EpiphysealEpiphyseal growth plates): at ends of growth plates): at ends of long bones, responsible for longitudinal growth long bones, responsible for longitudinal growth Traction Traction physesphyses ((ApophysealApophyseal growth plates): present growth plates): present where large tendons insert to bonewhere large tendons insert to bone

SalterSalter--Harris FracturesHarris Fractures

Pressure Pressure physesphyses injuries may disturb growth of injuries may disturb growth of long bones thereby resulting in limb length or long bones thereby resulting in limb length or deformitydeformity““Salter HarrisSalter Harris”” is best known is best known fxfx classification classification system to rate probability that system to rate probability that fxfx will cause will cause growth disturbancegrowth disturbanceType I Type I fxfx has low likelihood of causing growth has low likelihood of causing growth disturbance, Type V disturbance, Type V fxfx has very high likelihood has very high likelihood of growth disturbanceof growth disturbance

SALTER Mnemonic for SALTER Mnemonic for ClassificationClassification

II--SS==SameSame. Fracture of cartilage of the . Fracture of cartilage of the physisphysisIIII--AA==AboveAbove. . FxFx lies above lies above physisphysis (in (in metaphysismetaphysis))IIIIII--LL==LowerLower. . FxFx is below the is below the physisphysis (in (in epiphysis)epiphysis)IVIV--TT==ThroughThrough. . FxFx is through is through metaphysismetaphysis, , physisphysis, and , and epipysisepipysis..VV--ERER==ErasedErased (crushed). (crushed). PhysisPhysis has been has been crushed.crushed.

Salter Harris Classification SystemSalter Harris Classification System

Adolescent FracturesAdolescent Fractures

Fractures constitute 5Fractures constitute 5--6% of all musculoskeletal sports6% of all musculoskeletal sports--related injuriesrelated injuriesMost adolescent Most adolescent fxfx’’ss occur in the extremitiesoccur in the extremities1515--20% of pediatric 20% of pediatric fxfx involve the involve the epiphysealepiphyseal region, region, therefore up to 1/5 has potential for interrupted therefore up to 1/5 has potential for interrupted growth if undetectedgrowth if undetected

Salter Harris Fractures:Salter Harris Fractures: Who is at Risk??Who is at Risk??

AdolescentsAdolescentsmay be due to biomechanical and structural weakness of may be due to biomechanical and structural weakness of physealphyseal cartilage cartilage during rapid musculoskeletal growthduring rapid musculoskeletal growthlonglong--bone growth surges, inflexibility increases in muscle mass and bone growth surges, inflexibility increases in muscle mass and torquetorque--generating capacity of muscle may also contributegenerating capacity of muscle may also contribute

Males incur more Males incur more physealphyseal injuries than female counterpartsinjuries than female counterpartsgreater propensity for impact sportsgreater propensity for impact sportshigher overall rate of traumatic injuryhigher overall rate of traumatic injurygreater % of increase in muscle massgreater % of increase in muscle massgrowth plates remain open longer than do femalesgrowth plates remain open longer than do females

Salter Harris Fractures:Salter Harris Fractures: Where??Where??

Salter Harris Fractures:Salter Harris Fractures: Why Suspicious??Why Suspicious??

Likely Likely hxhx of traumaof traumaConcomitant soft tissue injury (pain, tenderness, Concomitant soft tissue injury (pain, tenderness, deformity, edema, deformity, edema, ecchymosisecchymosis))Loss of mobility and functionLoss of mobility and function

Salter Harris Fractures:Salter Harris Fractures: TriageTriage

Refer for appropriate imagingRefer for appropriate imaging

OsteochondritisOsteochondritis

DissecansDissecans of the Kneeof the Knee

condition in which condition in which subchondralsubchondral bone becomes bone becomes avascularavascularif healing doesnif healing doesn’’t occur, bonet occur, bone--cartilage complex cartilage complex can become loosecan become loosecan cause pain, loss of motion, can cause pain, loss of motion, articulararticular cartilage cartilage destruction, and mechanical destruction, and mechanical sxsx

OCD of the Knee:OCD of the Knee: Who is at Risk??Who is at Risk??

prevalence rate of 15prevalence rate of 15--20 cases per 100,000 (0.02%)20 cases per 100,000 (0.02%)primarily occurs between 10primarily occurs between 10--20 20 y.oy.o..if if physisphysis is open, the term juvenile OCD (JOCD) is is open, the term juvenile OCD (JOCD) is usedusedmale:femalemale:female ratio is 2:1ratio is 2:1frequently, cause is idiopathicfrequently, cause is idiopathicEtiologic factors may include: trauma, Etiologic factors may include: trauma, endrocrineendrocrine--related pathology, vascular insult or insufficiency, related pathology, vascular insult or insufficiency, genetic factors??genetic factors??

OCD of the KneeOCD of the Knee Where??Where??

although most common in the knee, also can although most common in the knee, also can affect elbow (affect elbow (capitellumcapitellum), shoulder, ankle (), shoulder, ankle (talartalardome) and hipdome) and hiptypically unilateral, but can be bilateral (15typically unilateral, but can be bilateral (15--30% 30% of cases)of cases)In the knee, most commonly affected sites:In the knee, most commonly affected sites:

#1 lateral aspect of medial femoral #1 lateral aspect of medial femoral condylecondyle#2 lateral femoral #2 lateral femoral condylecondyle#3 patella#3 patella

OCD of the KneeOCD of the Knee When to be Suspicious??When to be Suspicious??

Clinical presentation may varyClinical presentation may varyInitially may report vague, poorly localized pain around Initially may report vague, poorly localized pain around affected affected condylecondyle or ant knee?or ant knee?SxSx may become mechanical if a stable lesion becomes may become mechanical if a stable lesion becomes unstableunstableEffusion may be present depending on severity and Effusion may be present depending on severity and stability of lesion (may be intermittent and based on stability of lesion (may be intermittent and based on activity)activity)ER of affected extremity during gait to unload lesionER of affected extremity during gait to unload lesionQuad atrophy secondary to relative disuseQuad atrophy secondary to relative disuse

OCD of the Knee:OCD of the Knee: Clinical Exam TechniqueClinical Exam Technique

Wilson testWilson test: (evaluation of medial lesions) : (evaluation of medial lesions) performed with examiner holding ptperformed with examiner holding pt’’s foot in IR s foot in IR with knee flexed to 90with knee flexed to 90pt extends leg against resistancept extends leg against resistancetest is considered (+) when pt feels pain at 30 test is considered (+) when pt feels pain at 30 degrees of flexion (from impingement of degrees of flexion (from impingement of tibialtibial spine spine against the lesion)against the lesion)pain relieved when leg comes out of IRpain relieved when leg comes out of IR

OCD of the Knee:OCD of the Knee: TriageTriage

WB AWB A--P, PP, P--A tunnel views (at 45 knee flex), A tunnel views (at 45 knee flex), lateral and Merchant viewslateral and Merchant viewstunnel view permits best visualization of femoral tunnel view permits best visualization of femoral condylescondylesComparison views in skeletally immature Comparison views in skeletally immature individual may be usefulindividual may be useful

Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis (SCFE)(SCFE)

Progressive displacement of femoral head Progressive displacement of femoral head relative to neck through open growth platerelative to neck through open growth plate

SCFESCFE Who is at Risk??Who is at Risk??

Pre growthPre growth--plate closureplate closureMore common in males (males 13More common in males (males 13--16 16 y.oy.o. are 2. are 2--5x more likely affected than females 115x more likely affected than females 11--14 14 y.oy.o.).)OverweightOverweight2525--33% bilateral (in boys <12 33% bilateral (in boys <12 y.oy.o.).)More common in African AmericansMore common in African Americans

SCFESCFE Why Suspicious??Why Suspicious??

Diffuse/vague groin, buttock, thigh or knee Diffuse/vague groin, buttock, thigh or knee pain/stiffness (frequently begins as pain surrounding pain/stiffness (frequently begins as pain surrounding knee)knee)Insidious onsetInsidious onsetAntalgicAntalgic gaitgaitHxHx recent growth spurt or traumarecent growth spurt or traumaGroin aching exacerbated with WBGroin aching exacerbated with WBInvolved LE held in ER (and sometimes flex and Involved LE held in ER (and sometimes flex and abdabd))hip IR and ABD ROM limitationship IR and ABD ROM limitations

SCFESCFE TriageTriage

AP and lateral views helpful; AP and lateral views helpful; frogviewfrogview is is definitivedefinitiveIf this is significant concern, should be NWBIf this is significant concern, should be NWBMD consultMD consult

PediatricPediatric

Cancer: Cancer: Who is at Risk?Who is at Risk?

Incidence of Childhood Cancer Incidence of Childhood Cancer 1515--19 19 y.oy.o..

under 5 under 5 y.oy.o..1010--14 14 y.oy.o..55--9 9 y.oy.o..

HighestHighest

LowestLowest

PediatricPediatric

Cancer: Cancer: WhereWhere

7 Top Adolescent Cancers7 Top Adolescent CancersHodgkinHodgkin’’s diseases disease: cancer of lymphoid tissue: cancer of lymphoid tissueGerm cell, Germ cell, trophoblastictrophoblastic, and , and gonadalgonadal tumorstumorsCentral Nervous System TumorsCentral Nervous System TumorsRhabdomyosarcomaRhabdomyosarcoma: soft tissue carcinoma: soft tissue carcinomaNonNon--HodgkinHodgkin’’s lymphomass lymphomas: solid tumors arising from : solid tumors arising from cells of lymphatic systemcells of lymphatic systemCarcinomas and other malignant epithelial Carcinomas and other malignant epithelial neoplasmsneoplasms: : cancer of thyroid, melanomas, cancer of thyroid, melanomas, adenocarcinomasadenocarcinomas, , nasopharyngeal carcinomas, other skin carcinomasnasopharyngeal carcinomas, other skin carcinomasLeukemiaLeukemia: cancer of blood forming cells: cancer of blood forming cells

Pediatric Bone and Soft Tissue Tumors: Pediatric Bone and Soft Tissue Tumors: RhabdomyosarcomaRhabdomyosarcoma

Most common soft tissue sarcoma in childrenMost common soft tissue sarcoma in childrenDerived from Derived from unsegmentedunsegmented mesodermmesoderm2 peaks: 2 peaks: 22ndnd during adolescenceduring adolescenceCan occur at any site where striated muscle Can occur at any site where striated muscle existsexistsCommon primary sites: head/neck > Common primary sites: head/neck > genitourinary tract > extremity > trunk > genitourinary tract > extremity > trunk > retroperitoneumretroperitoneum

Pediatric Bone andPediatric Bone and

Soft Soft Tissue Tissue TumorsTumors

#8= #8= OsteosarcomaOsteosarcomaprimitive boneprimitive bone--forming forming mesenchymalmesenchymal cellscellsfirst peak of incidence in 10first peak of incidence in 10--14 14 y.oy.o.; coincides with pubertal growth .; coincides with pubertal growth spurtspurtmales > femalesmales > femaleslong bones of extremities near long bones of extremities near metaphysealmetaphyseal growth plates most growth plates most common (femur>tibia>common (femur>tibia>humerushumerus>skull/jaw and pelvis)>skull/jaw and pelvis)

#9= Ewing sarcoma#9= Ewing sarcomaCharacterized by morphologically similar roundCharacterized by morphologically similar round--cell neoplasm and cell neoplasm and presence of common chromosomal translocationpresence of common chromosomal translocationAffects young children and adolescents (5Affects young children and adolescents (5--20 20 y.oy.o.).)Males > femalesMales > femalesAxial skeleton, Axial skeleton, diaphysisdiaphysis or or metaphysismetaphysis of long boneof long bone

Pediatric Bone and Soft Tissue Pediatric Bone and Soft Tissue Tumors:Tumors:

Subjective InfoSubjective Info

General Health ChecklistGeneral Health Checklistweight loss/gainweight loss/gainnausea/vomitingnausea/vomitingfatiguefatigueunusual weaknessunusual weaknessfever/chills/sweatsfever/chills/sweatsnumbness or tinglingnumbness or tingling

Pediatric Bone and Soft Tissue Tumors: Pediatric Bone and Soft Tissue Tumors: TriageTriage

Presenting features usually nonPresenting features usually non--specific and mimic specific and mimic common pediatric illness (fever, common pediatric illness (fever, painpain, HA, , HA, vomiting)vomiting)Palpable tenderness and mass (EwingPalpable tenderness and mass (Ewing’’s)s)Pain and swelling (Pain and swelling (rhabdomyosarcomarhabdomyosarcoma))

Lag time for Lag time for dxdx is longer as number of consulted is longer as number of consulted doctors/healthcare providers increasesdoctors/healthcare providers increasesGreatest lag time in brain tumors, epithelial tumors, Greatest lag time in brain tumors, epithelial tumors, and and bone tumorsbone tumors

Case Study: Case Study: ““BryanBryan””15 15 y.oy.o. male, sophomore at MG HS. male, sophomore at MG HSLandryLandry’’s clinic Dec 2009s clinic Dec 200922--year year h/oh/o R post/lat R post/lat proxprox calf pain, worsened calf pain, worsened in past couple months (also occasional in past couple months (also occasional weakness)weakness)No specific MOI but recalls someone stepping No specific MOI but recalls someone stepping on his calf with cleat while playing QB in on his calf with cleat while playing QB in football seasonfootball seasonSxSx 11--2/10 at rest, worsen by end of day. Can 2/10 at rest, worsen by end of day. Can wake him at night, 7wake him at night, 7--8/10 at worst.8/10 at worst.

Case Study: Case Study: ““BryanBryan””

SxSx not worsened with any specific activitynot worsened with any specific activitySxSx improved with ibuprofenimproved with ibuprofenOriginally Originally txtx with crutches, boot for sleeping, with crutches, boot for sleeping, PT at DeanPT at DeanPlain film imaging of tibia, fibula, ankle and Plain film imaging of tibia, fibula, ankle and calcaneouscalcaneous ((--))((--) GHC, N&T, LBP) GHC, N&T, LBPPMH: migraines, ear tubes (child)PMH: migraines, ear tubes (child)

Case Study: Case Study: ““BryanBryan””

PE: no redness/swelling, tenderness in PE: no redness/swelling, tenderness in proxproxfibula just fibula just infinf to fib head, intact sensation, to fib head, intact sensation, normal ROM at knee/ankle, full normal ROM at knee/ankle, full painfreepainfreestrength, (strength, (--) ) liglig testing at knee/ankle, (testing at knee/ankle, (--) ) meniscal testing, unremarkable gait and squatmeniscal testing, unremarkable gait and squatRadiographs reviewed and (Radiographs reviewed and (--))MRI indicated MRI indicated ““0.4x0.5x1.2cm 0.4x0.5x1.2cm osteoidosteoid osteomaosteomawithin post cortex of mid within post cortex of mid tibialtibial diaphysisdiaphysis with with associated cortical thickeningassociated cortical thickening””

Case Study: Case Study: ““BryanBryan””

Admitted to UWHC 2/11/10, underwent Admitted to UWHC 2/11/10, underwent cryoablationcryoablation by MS radiology teamby MS radiology team

Another Resource for Tumors

http://www.radiology.wisc.edu/people/schreibman/files/Schreibman_BoneTumors.pps

Summary

More atypical presentation = lower tolerance for tx without further work up Consider if pt is skeletally mature… if not, what dx need to be considered?What precautions, limitations, or restrictions are appropriate?

THANK YOU!!!!

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