Common Musculoskeletal Injuries

Fingertip avulsion/injuries (Link):

● Fingertip and nail bed injuries are the most common pediatric hand injury
● Most injuries involve crush mechanisms in doors, despite supervision, therefore
prevention education is key
○ Installing finger-shield door hinge safeguards or door stoppers
○ Encourage use of safety gloves for high risk sports
● Mismanagement of fingertip injuries can result in lasting functional and cosmetic deficits
● Common injuries:
○ Common injuries are subungual hematomas, nail bed lacerations (simple and
stellate), crush injuries, fingertip avulsions and amputations, and distal phalanx
fractures
● Primary care management:
○ Initial management of injuries is typically done in emergency room and urgent care
settings
○ Aftercare for fingertip injuries
■ Suture removal is unlikely since most lacerations of the nailbed are repaired
with absorbable sutures or skin adhesive
■ Some distal phalanx fractures (Seymore fractures) and fingertip avulsions
and amputations require surgical intervention and need to be referred to
hand surgery for close follow up
■ Splinting of the nailbed with the nail or a nail replacement is recommended
after nailbed laceration repair; the nail should be left in place for 2-3 weeks
■ Wound care for avulsion injuries:
● Small finger tip avulsions can be followed-up in primary care
○ 2-3 days after injury for wound check
○ Two weeks after injury to evaluate healing
○ Wound care guidance:
■ Keep wound clean and dry
■ Daily dressing changing
● Nail bed repairs, sutured fingertip avulsions or amputations,
complete amputations should follow up with hand surgery (Link)
○ 5-7 days after injury
○ Wound care guidance:
■ Keep bandage intact until follow-up with hand
surgery
■ Advise parents that the sutured nail will fall off
within 1-3 weeks and a new nail will grow in 3-12
months
■ Continue to splint tuft fractures for at least 14 days
Nursemaid’s elbow (Link, Link):
● Caused by subluxation of annular ligament off of radial head
● Due to longitudinal traction of arm
● Most common orthopedic injury in children under 6, peak incidence in toddler aged
children
● Clinical manifestations: pain and limited supination
○ Suspect in a child who resists moving their arm and is holding it in slight flexion
against the body
○ Pain is often not reported when the arm is not being manipulated
● Management is reduction
○ Hyperpronation: forearm rotated inwards (palm facing down)
○ Supination and flexion: forearm rotated outwards (palm facing down) followed by
flexion
○ Some evidence that pronation may be more effective as an initial reduction
technique (Link)

Overuse injuries:
● Patellofemoral pain syndrome
○ Common overuse disorder presenting with anterior knee pain (patella) with weight
bearing on a flexed knee without any other pathological cause
■ Walking up stairs, squatting
■ Seen frequently with over training and sports specialization at an early age
■ Overload with or without malalignment
○ May be unilateral or bilateral
○ Typically seen with recent increase in training load
○ Adolescent females
○ Evaluation
■ The diagnosis is purely clinical
■ The Q angle is no longer used to evaluate
■ Check for muscle weakness, knee pathology, malalignment, body habitus
(obesity) and evaluate gait
■ Patellar Grind test is no longer recommended as it is both painful and lacks
sensitivity Link
○ Treatment
■ Acute phase
● Activity modification, NSAIDs, and ice
■ Recovery phase
● Physical therapy
 ● Weight management
● Shin-splints
○ Aka: Medial tibial stress syndrome
○ Shin splints are the most common overuse injury of lower leg
○ Occur in children who participate in repetitive activities such as running and
jumping
○ Clinical manifestations: pain during exercise that is alleviated by rest, diffuse
tenderness over lower ⅓ of tibia
■ Focal tenderness concerning for tibial stress fracture
○ Diagnosis is based on history and physical exam findings
■ Radiographs and advanced imaging are not necessary but can provide
prognostic information
● X-rays may be normal for 1st few weeks
● MRI is more sensitive and can be used to rule out a tibial stress
fracture
○ Management is supportive
■ Rest from high impact activities
■ NSAIDs
■ Ice
● Osgood-Schlatter (Link, Link)
○ Caused by apophysitis of tibial tuberosity
○ Commonly occurs during the early adolescent growth spurt (12-15 in boys, 8-12 in
girls)
○ Incidence is higher in children who are active in sports that involve running and
jumping
○ Boys are more affected than girls
○ Clinical manifestations: pain localized over tibial tuberosity that is aggravated by
sports (jumping, running and kneeling), swelling, and firm prominence
○ Characteristic radiographic findings are irregularity, separation, and eventual
fragmentation of the tibial tubercle
○ Most cases and self limiting and resolve with supportive care
■ Relative rest
■ NSAIDs
■ Ice
■ Home exercises/PT to stretch and strengthen the quadriceps and
hamstring muscles
● Sever disease (Link)
○ Calcaneal apophysitis
○ Common cause of heel pain in athletically active child
○ Normal development: appears at 9 y/o, fuses at 16 y/o
 ■ Pain develops around time of appearance 9-10y/o at onset of early
adolescent’s rapid growth spurt
○ Occurs more commonly in males
○ 61% are bilateral
○ Risk factors: beginning a new sport/season, foot pronation, tight
gastrocnemius-soleus complex, growth spurt, worn out athletic shoes, running on
hard surfaces
■ Higher risk sports are those which require repetitive running and jumping
○ Clinical manifestations:
■ Heel pain that is worse during activity, pain improves with rest
■ Tenderness and swelling may be present at the Achilles tendon insertion at
heel and with medial and lateral heel compression
■ Pain often reported with passive ankle dorsiflexion and with compression
of the posterior calcaneus (known as the squeeze test) or by standing on
tiptoes (Sever sign)
○ Diagnosis is based on history and physical exam
○ X-rays are not recommended unless pain is persistent, severe, or atypical
■ Radiographic signs of Sever disease includes fragmentation, sclerosis, or
increased density of the calcaneal apophysis
○ Treatment is supportive
■ NSAIDs
■ Ice
■ Activity modification guided by pain
■ Stretching of heel cord
■ Strengthening dorsiflexors
■ Cushioning (heel cups or pads)

Ankle sprain (Link):

● Most common sports-related injury in children
● Inversion injury > eversion injury
○ Eversion injuries are often more severe
● Diagnosis is clinical, however radiographs are recommended if focal tenderness over
malleoli, is unable to bear weight, or focal tenderness of distal fibula/tibia (Ottawa ankle
rules)
○ Children with negative x-rays who are tender to palpation over the distal fibula and
growth plate are more likely to have a ligamentous/tendon injury versus a
Salter-Harris 1 fracture (Link)
 ■Repeat x-ray in 10-14 days not recommended because a Salter-Harris 1
fracture of the growth plate of the distal fibula is a stable injury with low
risk for growth arrest
● Management: RICE
○ Removable brace
○ Crutches as needed
○ Return to activity as tolerated

Concussion or Minor Traumatic Brain Injury (mTBI):

● Intro:
○ 1.6 to 3.8 million concussions in US each year
○ Due to direct blow to head, face, or neck
■ May be indirect
○ Pediatric populations are at higher risk for concussion due to weaker neck muscles
○ Most patients who enter the healthcare system for a sports-related concussion
enter through their primary care provider
○ Highest rate of concussion in football, boy’s hockey and lacrosse, and girls soccer
● Signs/symptoms: 1 or more symptoms → suspect concussion; onset may be delayed ( Link)
○ Signs and symptoms are classified into 5 categories: Somatic, vestibular,
oculomotor, cognitive, and emotional and sleep
■ Common symptoms include: headache, N/V, balance problems, visual
problems, sensitivity to light and noise, fatigue, dazed/stunned, seizure,
feeling “foggy” or slowed down, difficulty concentrations, amnesia,
confusion, slow response, repeating questions, difficulty with school, loss of
consciousness, irritability, sadness, anxiety, emotional lability, depression,
drowsiness, sleep changes
○ Most common symptoms are headache, dizziness, difficulty concentrating and
confusion
○ LOC occurs in less than 5% of patients with a concussion
● Evaluation (based on ☆ AAP Clinical Report [Link] & CDC Guidelines [Link])
○ History and exam:
■ History:
● ☆ AAP Clinical Report [Link]: History of the event, previous head
injuries, and any pre-existing conditions (eg, anxiety, depression,
learning disabilities, migraine headaches)
■ Physical exam:
● ☆ AAP Clinical Report [Link]: Physical exam may include a
neurologic exam, head and neck exam, ocular evaluation, balance
assessment, and assessment of cognitive function
 ○ Balance Tests → Balance Error Scoring System (BESS)
■ Concussion assessment tools: (Link)
● ☆ CDC Guidelines (Link):
○ “Health care providers should use an age-appropriate,
validated symptom rating scale as a component of the
diagnostic evaluation in children seen with acute mTBI.”
■ Examples:
● SCAT3, Child SCAT3
● Symptoms scales (eg, Graded Symptom
Checklist)
○ “Health care providers may use validated, age-appropriate
computerized cognitive testing in the acute period of injury
as a component of the diagnosis of mTBI”
■ Eg, Automated Neuropsychological Assessment
Metrics (ANAM), CogSport/AXON
○ “The Standardized Assessment of Concussion (SAC) should
not be exclusively used to diagnose mTBI in children 6-18
years.” (Below)

(From: Link)
○ Diagnostic imaging:
■ CT
 ● ☆ CDC Guidelines (Link): “Health care providers should not
routinely obtain head CT for diagnostic purposes in children with
mTBI”
● Follow validated decision tools such as PECARN to help identify
patients as higher risk for intracranial injury
● Consider head CT to rule out intracranial injury (ICI)
○ ICI occurs in only 7.5% of children presenting with a
concussion
■ Intracranial bleed
■ Cerebral edema
■ Skull fracture
■ MRI
● ☆ CDC Guidelines (Link): “Health care providers should not
routinely use MRI in the acute evaluation of suspected or diagnosed
mTBI.”
● MRI if symptoms persisting over 3 weeks to rule out underlying
issues, not recommended in acute evaluation
■ Skull x-rays
● ☆ CDC Guidelines (Link):
○ “Skull X-rays should not be used in the diagnosis of pediatric
mTBI.”
○ “Skull X-rays should not be used in the screening for ICI.”
● Management (based on ☆ AAP Clinical Report [Link] & CDC Guidelines [Link])
○ Management is collaborative between the patient, medical team, family, and school
○ Parental/patient education:
■ ☆ CDC Guidelines (Link): “In providing education and reassurance to the
family, the health care provider should include the following information:
● Warning signs of more serious injury
● Description of injury and expected course of symptoms and
recovery
● Instructions on how to monitor postconcussive symptoms
● Prevention of further injury
● Management of cognitive and physical activity/rest
● Instructions regarding return to play/recreation and school
● Clear clinician follow-up instructions
○ Cognitive and physical rest:
■ “When in doubt, sit them out!”
■ ☆ CDC Guidelines (Link):
● “Health care providers should counsel patients to observe more
restrictive physical and cognitive activity during the first several
days following mTBI in children”
○ ☆ AAP Clinical Report [Link]: “A reasonable approach to
physical rest includes immediate removal from play and,
while the athlete is having consistent symptoms, limiting
physical exertion to brisk walking but avoiding complete
inactivity. Allowing some light cardiovascular activity, such
as brisk walking, although not allowing a return to full sports
participation, seems prudent and is supported by recent
research”
○ ☆ AAP Clinical Report [Link] “Because many young athletes
are highly socially connected through their electronics and
social media, blanket recommendations to have athletes
with SRCs completely avoid the use of electronics,
computers, television, video games, and texting is
discouraged... Individuals with light sensitivity or
oculomotor dysfunction may find their symptoms worsen
while using electronics and may need to limit their overall
screen time, adjust brightness levels, or increase font sizes
to reduce episodes of symptom worsening.”
● “Following these first several days, health care providers should
counsel patients and families to resume a gradual schedule of
activity that does not exacerbate symptoms, with close monitoring
of symptom expression (number, severity).”
● “ To assist children returning to school following mTBI, medical and
school-based teams should counsel the student and family
regarding the process of gradually increasing the duration and
intensity of academic activities as tolerated, with the goal of
increasing participation without significantly exacerbating
symptoms.”
○ These children may need special accommodations at school
● “For students who demonstrate prolonged symptoms and academic
difficulties despite an active treatment approach, health care
providers should refer the child for a formal evaluation by a
specialist in pediatric mTBI.”
● “ Following the successful resumption of a gradual schedule of
activity... health care providers should offer an active rehabilitation
program of progressive reintroduction of noncontact aerobic
 activity that does not exacerbate symptoms, with close monitoring
of symptom expression (number, severity)”
● “Health care providers should counsel patients to return to full
activity when they return to premorbid performance if they have
remained symptom free at rest and with increasing levels of
physical exertion.”
● Return to play criteria:
○ Asymptomatic at rest
○ Asymptomatic with activity
○ Balance testing returned to baseline
○ Neurocognitive testing returned to baseline
○ Symptom management:
■ Headache:
● ☆ CDC Guidelines (Link): “Health care professionals and caregivers
should offer nonopioid analgesia (ie, ibuprofen or acetaminophen) to
children with painful headache after acute mTBI but also provide
counseling to the family regarding the risks of analgesic overuse,
including rebound headache”
○ Recovery:
■ ☆ CDC Guidelines (Link):
● “Health care providers should counsel patients and families that most
majority (70-80%) of children with mTBI do not show significant
difficulties that last more than 1-3 months after injury.”
● “Health care providers should counsel patients and families that,
although some factors predict an increased or decreased risk for
prolonged symptoms, each child’s recovery from mTBI is unique and
will follow its own trajectory.”
■ Recovery may be delayed with
● History of previous concussion
● Lower cognitive ability
● Neurologic or psychiatric disorder
● Learning difficulties
● Postconcussive symptoms
● Family and social stressors
■ Recovery can be assessed with validated symptom tools
● Symptom scales, balance testing, cognitive testing
○ Referral:
■ ☆ CDC Guidelines (Link): “ For children with mTBI whose symptoms do not
resolve as expected with standard care (i.e., within 4-6 weeks), health care
providers should provide or refer for appropriate assessments and/or
interventions”
 ● Chronic headache after concussion needs to be referred for evaluation
and treatment
● Persistent vestibule-oculomotor symptoms should be referred for
vestibular rehabilitation

Common Non-Operative Pediatric Fractures

● Clavicle fracture (Link, Link)
○ The most commonly fractured bone, 10-15% of all pediatric fractures
○ Neonatal -- due to shoulder dystocia/birth trauma
○ Mechanism of action is a fall onto shoulder, direct trauma, or fall on outstretched
hand
■ Most common is forceful fall to one side during contact sports
■ Consider non-accidental trauma, rickets, or malignancy in children with no
history of trauma
○ Diagnosis made by history and physical, confirmed by x-ray
■ Assess for injuries to surrounding structures
● Brachial plexus
● Trachea and vessels if posterior injury
● Sternoclavicular joint
○ Simple fractures: Middle third (most common), minimally displaced, greenstick,
angulated
■ Management is conservative and can be management by primary care
● Sling or figure of eight brace
■ Counsel parents on the possibility of a prominent callus
○ Open fractures, tenting of skin, or any neurovascular compromise needs surgical
management
● Buckle/torus fracture
○ Buckling of the cortex of the radius, ulna, and the distal ulna styloid, bone appears
“wrinkled” on x-ray
○ Mechanism is compression from fall on outstretched hand
○ Diagnosis made on x-ray
■ Have a low threshold to image children with wrist trauma
■ Look for a greenstick fracture
● Buckling of cortex on one side with a complete break on the other,
no fracture going through the entire bone
○ Less stable, can become angulated
○ Management is splinting or casting for four weeks
○ Management
■ Splinting is supported over casting in current literature (Link)
● Splint up to four weeks
 ○ Follow-up imaging
■ ☆ Choosing Wisely Recommendation (Link): “Do not order follow-up
X-rays for buckle (or torus) fractures if they are no longer tender or painful.”
● Toddler fracture (Link, Link)
○ Common spiral fracture of the distal tibia
○ Occurs in ambulatory children between 9 months and 3 years
○ Mechanism: harmless twist/fall
○ Typically present as a child who refuses to bear weight or is limping
■ Localized tenderness may be present
○ X-rays may be negative; keep a high index of suspicion if refuse to bear weight
○ Management is a 3-4 week course of immobilization
■ Boot allows faster return to weight-bearing, but short-leg cast can also be
used
■ Radiographic follow up is not necessary and does not affect treatment
decisions

References:

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