11/9- Common Pediatric Musculoskeletal Findings Flashcards
Describe the pediatric skeleton vs. adult
- What is the most metabolically active part
- Bone is more porous and pliable
- The metaphysis is the most metabolically active part of the bone
What is the weakest part of the pediatric skeleton?
- When is this visualized
The physis (epiphyseal plate or growth plate)
- Growth plates usually aren’t visualized until 12-24 mo
T/F: Remodeling and healing occurs rapidly in the pediatric skeleton
True
Describe developmental dysplasia of the hip in newborns/infants
- Prevalence
- Risk factors
Abnormal development that causes the proximal femoral head to displace from the acetabulum (but may present anytime during childhood)
- `1/1000 live births
Risk factors:
- Female > Male
- First born
- Breech
- Caucasian descent
How do you test for developmental dysplasia of the hip?
- Barlow test: adduct and push posteriorly (to displace)
- Ortolani test: abduct and push anteriorly (to replace)
What is seen here?
Asymmetric skinfolds (in developmental dysplasia of the hip)
What is seen here?
Positive Galeazzi (hip displacement)
- Lower knee is the affected knee (necrosis)
What should be done if there is newborn/infant developmental dysplasia of the hip?
- Fitting with Pavlik harness
- Outpatient Orthopedic consultation
- In high risk patients (girls, + family history, breech)
- Hip ultrasound at 6 weeks of age or frog-legged films at 4 to 6 months of age
What is Congenital Torticollis?
- Incidence
- Risk factors
- Suspected cause
- Signs/symptoms
- Incidence 1-2 %
- More often in breech presentation
- Suspected trauma to SCM and resulting fibrosis
Signs/symptoms:
- Head tilt to the side of the affected muscle by 2-4 weeks
- “tumor” or “psudotumor” noted on exam
- Can present with facial deformity
- Can result in plageocephaly
What is seen here?
The facial deformity common in congenital torticollis
What is plagiocephaly?
What is treatment/therapy for congenital torticollis?
- Stretching Exercises with OT/PT
- Surgical release if persists 12-18 months
What is Congenital Talipes Equinovarus?
- Incidence
- Uni or bilateral
- Gender prevalence
- Etiologies
Excessively plantar flexed, rotated medially, and the sole facing inward (club foot)
- Incidence is about 1 -3/1000
- Almost half are bilateral
- 2x in females
- Multiple causes
What is treatment/therapy for Congenital Talipes Equinovarus?
- Cereal casting every 1-2 weeks to hold foot in desired position.
- Surgical correction
- Combination of both
What is seen here?
Arthrogryposis
What are factors leading to arthrogryposis?
- Neurologic deficits
- Fetal crowding
- Maternal illness
- Connective tissue/skeletal defects
- Vascular compromise
- Muscle defects
All contribute to limitation of fetal joint mobility and then joint fixations (arthrogryposis)
What is Osteogenesis Imperfecta?
- Aka
- Prevalence
- Signs/symptoms
- It is often called “brittle bone disease.”
- Occurs in about 1/20,000 births
- Severely affected patients suffer multiple fractures with minimal or even no trauma
- Infants with the worst form of OI die in the perinatal period
Describe the different types of Osteogenesis Imperfecta?
- Signs/symptoms
- Severity (lethality)
Type I
- Blue sclera
Type II
- Most lethal type
Type III
- Most severe non-lethal form
What is Legg-Calve Perthes?
Avascular necrosis of the femoral head
Describe Legg-Calve Perthes
- Gender prevalence
- Risk factors
- When is it commonly seen
- Uni or bilateral
(Avascular necrosis of femoral head)
- 4x in males
- Common among first-born children
- Common during periods of rapid growth of epiphyses (peak between 5-7 years)
- Usually unilateral but up to 12 percent are bilateral
How does Legg-Calve-Perthes commonly present?
- Present with limp of insidious onset
- Pain is often referred to the antero-medial thigh or knee.
- On exam, patients may have limited internal rotation and abduction of the hip.
- Pain may lead to disuse, which may result in atrophy of the thighs and buttock
What is seen here?
Legg-Calve-Perthes disease on radiography
- Left = normal
- Right = hip with perthes
What radiographs should be taken in Legg-Calve-Perthes evaluation?
- What are the radiographic findings (early/intermediate/late)?
Should take AP and frog-leg views
Findings:
- Early: effusion of joint and wide joint space
- Intermediate: decreased bone density and collapse of the femoral head
- Late: new bone replacing necrotic bone
How to treat Legg-Calve-Perthes disease?
- Pedi ortho consulation
- Contain femoral head in acetabulum (may require abduction splint
• < 6 yrs: if no significant subluxation and at least 40-45 degrees abduction, observation is warranted.
• > 6 yrs: containment with brace/splint until re-ossification or sugery
What is Slipped Capital Femoral Epiphysis?
Displacement of the proximal femoral epiphysis from the femoral neck through the pysis, usually posteriorly and medially
Caused by:
- Most cases are idiopathic
- Weak growth plates
- Local trauma
Who gets Slipped Capital Femoral Epiphysis?
- Between ages 6-10 yo
- More in males
- Obesity
- Hypothyroidism
- Growth hormone administration
What are signs/symptoms of Slipped Capital Femoral Epiphysis?
- Limping with or without pain
- Pain can radiate to groin or knee
- lost flexion and abduction
- child holds his/her leg in external rotation at rest
How is Slipped Capital Femoral Epiphysis diagnosed?
- AP and frog-leg lateral
- Bloomburg’s Sign (widening epiphysis)
- Klein’s Line
- Always get contra-lateral films
What is seen here?
Slipped Capital Femoral Epiphysis
What is shown here?
Slipped Capital Femoral Epiphysis
What is Osgood-Schlatter? Symptoms?
- Inflammation of the proximal tibial tubercle at the insertion of the patellar tendon secondary to traction
- Pain and swelling at the tibial tubercle
What populations/demographic are affected by Osgood-Schlatter?
- Uni or bilateral
- Children 9 -14 years of age who have undergone a rapid growth spurt
- 20% of adolescents who are active in sports compared with 5% of non-athletes
- Sports that involve running, cutting, and jumping
- These activities place stress on the tibial tubercle through repetitive contraction of the quadriceps muscle
• Bilateral in 25-50% of cases
What are signs/symptoms of Osgood-Schlatter?
- How is the diagnosis made
- Anterior knee pain that increases gradually over time
- Pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by rest.
- The diagnosis of Osgood-Schlatter disease is made by physical examination, radiographs are optional
What are exam findings in Osgood-Schlatter?
- Tenderness and soft tissue or bony prominence of the tibial tubercle
- Pain may be reproduced by extending the knee against resistance or squatting
- Evaluation the hip to make sure knee pain not referred pain from pathology in the hip
What is intoeing?
- What most commonly causes it
- Commonly known as “Pigeon-toed”
- More common than outtoeing
- Most commonly due to:
- Metatarsus adductus
- Tibial Torsion
- Medial femoral torsion
What are the 3 rotational deformities characterized under “intoeing”?
- Metatarsus adductus
- Tibial torsion
- Medial femoral torsion
What is Metatarsus adductus?
- What kind of defect is it
- Gender prevalence
- Correction
- Intoeing originates at the foot
- Considered a packing defect
- Girls > Boys
- Correction
- Actively correctable (spontaneously corrects)
- Passively correctable (stretching exercises)
- Uncorrectable (casting)
What is tibial torsion?
- Age group seen in
- Gender prevalence
- Treatment
Intoeing originating between knee and ankle
- Most common cause in children < 3 yo
- Male = Female
- Usually spontaneous correction over first year of ambulation
- Sometimes takes up to 8 years to completely correct!
What is Medial femoral torsion?
- Could be acquired how
- Most common in what populations
- Correction
Intoeing originates between the knee and the hip
- May be acquired from sitting in the “W” position
- Most common cause in children >3 years old
- Usually corrects spontaneously but slowly until about 8-10 years
What is outtoeing?
- More or less common than intoeing?
- Improves when
In utero packing defect
- Less common than intoeing
- Improves during the first year of walking
What are angular deformities seen in childhood?
- Genu valgum (knock-kneed)
- Genu varum (bow-legged)
What is normal alignment at birth? Progression?
Varus
- Varus condition can worsen as child begins to stand and walk
- Around 18-24 mo, alignment should be neutral
- After 24 mo, alignment should progress to valgus until reaches max at 4 yrs
- Valgus decreases toward physiologic adult alignment of slight valgus to neutral by about 7 yrs
Describe physiologic genu varum?
- Uni or bilateral
- Stature/gait
- Bilateral and relatively symmetric deformities
- Normal stature
- Normal gait
Describe pathologic genu varum?
- Causes
- Seen in what diseases/conditions
- Blount disease
- Rickets
- Skeletal dysplasia
- Asymmetric growth:
- Unilateral trauma
- Infection
Describe physiologic genu valgum
- Uni or bilateral
- Stature/gait
- Other signs/symptoms
- Bilateral and relatively symmetric deformities
- Normal stature and normal gait
- Flat feet and external tibial torsion
Describe pathologic genu valgum
- Uni or bilateral
- Causes/associated conditions
- Unilateral or unequal
Seen with:
- Fracture of metaphysis
- Fracture of physeal with growth plate arrest
- Rickets
- Skeletal dysplasia
What is teratment for angular deformities (genu varum and valgum)?
- Physiologic: don’t treat; will resolve over time
- Pathologic: optimize medical management
- If not improved, surgical intervention
Mnemonics for genu varum/valgum?
- Varum: air between the knees (or barrel of rum)
- Valgum: gum sticking kenes together
What is scoliosis?
- Gender prevalence
- Complication in severe cases
Scoliosis is defined as a 10’ curvature of the spine in the coronal plane, and typically accompanied by rotation
- More in girls
- Severe curvature may -> impairment of pulmonary function
How is scoliosis evaluated?
- Feet hip-width apart
- Hands joined at midline
- Stand directly behind patient
- Bend forward 90’
What are the 3 classifications of Scoliosis?
- Ideopathic
- Neurogenic
- Congenital
What are signs of scoliosis?
- Uneven shoulders
- Curve in spine
- Uneven hips
Describe ideopathic scoliosis
- Etiology
- Age ranges/classes
No definite etiology; it is therefore a diagnosis of exclusion
Types:
- Infantile: 0-3 yrs
- Juvenile: 4-9 yrs
- Adolescent: 10+ yrs
Describe neurogenic scoliosis
- Seen with what conditions
- Due to what
- Do most have rotational component?
Conditions such as:
- Cerebral Palsy
- Myelomeningocele
- Muscular Dystrophy
- Neurofibromatosis
Due to muscle imbalance and lack of trunk control
Most have no rotational component
Describe congenital scoliosis
- Causes
- Manifestation (time)
Asymmetry in the vertebrae secondary to congenital anomalies
- Hemivertebrae
- Failure of segmentation
Congenital scoliosis usually manifests before adolescence
What is the management for scoliosis with a curve < 20’?
PT and exercises to strengthen back muscles
What is the management for scoliosis with a curve 20-40’?
(Immature skeleton): back brace to prevent further curve progression
What is the management for scoliosis with a curve > 40’?
Spinal fusion to correct deformity
What is the concern in management for scoliosis with a curve > 60’?
Associated with poor pulmonary function
Describe periosteum in pediatrics vs. adults
- Osteogenic potential
- More metabolically active than adult
- Active periosteum may result in:
- Callus formation
- Union of fractures
- Remodeling
- Periosteum is thicker and stronger:
- Limits fracture displacement
- Reduces likelihood of open fractures
- Maintains fracture stability
What is a buckle (torus) fracture?
- Commonly occur where
- Management
- Often occur at the junction between the porous metaphysis and the denser diaphysis
- Commonly in distal radius after fall on an outstretched hand (also seen in the distal tibia, fibula, and femur)
- Stable fracture that can be managed with splinting and a single orthopedic follow-up visit
What is seen here?
Buckle (torus) fracture
What is a plastic deformation fracture?
- What cuases it
- Commonly seen where
- Management
- Longitudinal force exceeds the bone’s ability to recoil
- Microscopic fractures dissipate the impact energy
- Commonly seen in the ulna, the radius, and sometimes in the fibula
- If < 20’ or if the deformity occurs < 4 yo, the angulation often corrects itself
What is seen here?
Plastic deformation fracture
What is a greenstick fracture?
- Management
Fracture line does not extend completely through the width of the bone
• May be the most significant risk factor for repeat fracture
- occurring in as many as 84 – 100% of forearm re-fractures
• Closed reduction and casting
What is seen here?
Greenstick fracture
What is a physeal (growth plate) fracture?
- What causes it?
- Growth plates are susceptible to fracture and represent a weak point in pediatric bone
- Tensile strength of pediatric bone is less than that of the ligaments
- Physis will separate or fracture before disruption or “spraining” of an strong and flexible ligament
What is seen here?
Physeal (growth plate) fracture
What is the Salter-Harris classification for pediatric trauma?
I- Separation through the physis; usually through areas of hypertrophic and degernating cartilage cell columns
II- Fracture through a portion fo the physis that extends through the metaphyses
III- Fracture through aprotion of hte physis that extends throught he epihpysis and into the joint
IV- Fracture across the metaphysis, physis and epiphysis
V- Crush injury to the physis
What is the Salter-Harris classification for physeal fractures?
S- straight across (type I)
A- above (type II)
L- lower or beLow (type III)
T- two or through (type IV)
ER- erasure of growth plate or cRush (type V)
Case 1
- You are called to the delivery of a term female with decreased amniotic fluid.
- Baby will be delivered via c/s for breech presentation.
Which of the following will be an important part of her newborn exam secondary to her risk factors?
A. Finding a Klein Line
B. Babinski Sign
C. Ortolani Maneuver
D. Moro Reflex
A. Finding a Klein Line
B. Babinski Sign
C. Ortolani Maneuver
D. Moro Reflex
Case 2
- A 9 year old boy is brought by his mother to your office because she noticed he has been limping for the last 2 weeks.
- He reports unilateral knee pain after he began an exercise program prescribed to him by you after you calculated his BMI in the 90th percentile.
- On exam he holds his leg in external rotation and has pain with flexion of the hip. Knee exam is normal.
What is the most-likely diagnosis?
A. Osgood Schlatter
B. Slipped Capital Femoral Epiphysis (SCFE)
C. Subluxation of the patella
D. Legg-Calve-Perthes
A. Osgood Schlatter
B. Slipped Capital Femoral Epiphysis (SCFE)
C. Subluxation of the patella
D. Legg-Calve-Perthes
Case 3
What type of Salter Harris Fracture is shown?
A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V
A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V
