4- Pediatric Musculoskeletal Flashcards
List 6 Differential Diagnosis of Torticollis 🔑🔑 Dr. Haitham
CONGINITAL
- Congenital postural torticollis: Intrauterine crowding
- Congenital vertebral anomalies: Segmentation failures or Formation failures
- Congenital ocular torticollis: Strabismus, Nystagmus
ACQUIRED
- Habitual
- Syringomyelia
- Atlanto-occipital subluxations: Down’s syndrome
- Tumor of the cervical spine
- Lymphoma
- Acquired structural torticollis
- Traumatic: Rotary subluxation, Fracture/dislocation, Muscular injury
- Infection: Cervical osteomyelitis, Tuberculosis
DeLisa 5th edition Chapter 56 Children With Disabilities pg1494 Table 56.7
DDx, Examination & Management 🔑🔑
Diffrential Diagnosis
- Fibrosis of the sternocleidomastoid muscle (SCM).
- “olive sign” nontender enlargement or fibrosis of the sternocleidomastoid caused by birth trauma and ischemia due to the intrauterine position
- Subsides within 4 to 6 months of age.
- Cervical hemivertebra
- Atlantoaxial rotary subluxation
Examination
- Ipsilateral face flattening
- Contralateral occipital flattening
- Orbital asymmetry (plagiocephaly)
- Ipsilateral hip dysplasia
- Developmental dysplasia of the hip (DDH)
- Congenital cervical scoliosis → Cervical hemivertebra
Investigation
- Xray shows rotation of C1–C2
Conservative treatment
- Stretch the contracted SCM 15 to 29 times per session, 4 to 6 times a day (at every diaper change).
- Position the child’s bed to point child’s gaze toward the ipsilateral superior direction
- Position bed mobile to be kept in Ipsilateral side
Surgical Intervention
- SCM lengthening is considered when no improvement is shown by 18 to 24 months, with best results if performed when the child is <12 years old.
Cuccurollo 4th Edition Chapter 12 Peds pg745-746
List 3 DDx for atraumatic hip pain in pediatrics
1. Transient (toxic) synovitis of the hip
Most common in children
2. Legg–Calv–Perthes disease (AVN of the proximal femur)
Rapid growth in relation to blood supply
Secondary ossification centers in the epiphysis are subject to AVN.
3. Slipped capital femoral epiphysis (SCFE)
Separation of the proximal femoral epiphysis through the growth plate (epiphysiolysis).
Most common preadolescent and adolescent children, obese boys > girls
List 3 Causes of lateral trunk bending in pediatrics. 🔑
- Legg-Calve Perthes
- SCFE
- Acute transient synovitis
- Septic arthritis
- Scoliosis
- Pelvic obliquity
- Leg length discrepancy
Ref: Pediatric rheumatology 2009, 7:10.
Most likely cause of hip pain in 🔑🔑
(a) 7 y/o child with hip pain
(b) 12 y/o obese boy with hip pain
(c) 2 y/o female, flu 2 weeks ago + normal serology
(d) 5 y/o no fever, normal serology
(a) AVN - Legg-Calve-Perthes
(b) SCFE
(c) Transient Synovitis
(d) JIA
Diagnosis, 2 Risk Factors, Associations, Examination & Management 🔑🔑
Developmental Dysplasia of the Hip → instability of the hip
- Hip subluxation
- Hip dislocation (at birth)
- Acetabular dysplasia (months later).
Risk factors
- Mother has a history of dislocated hip
- Breech presentation
- Females
Associations
- Metatarsus adductus
- Torticollis
Examine
- Galeazzi test
- Barlow test “BLOW”
- Determine if a dislocated hip can be readily dislocated
- With the leg in a flexed and adducted position, push the femur posteriorly
- If the hip dislocates posteriorly, Barlow test is positive, and dislocation is palpable.
- Dislocation is verified with the Ortolani test, which reduces the dislocation
- Ortolani test ردني مكاني
- Determine if a dislocated hip can be readily reduced
- As the hip is gently abducted, the long finger over the greater trochanter pushes anteriorly to lift the femoral head over the posterior lip of the acetabulum to reduce the hip.
Investigations
- Ultrasound (US) infants under 6 months of age
- X-rays
Management
- Pavlik harness or hip spica cast (to maintain hip reduction in 90- to 120-degree flexion and to limit hip adduction) for 3 to 4 months usually produces good results
Cuccurollo 4th Edition Chapter 10 Peds pg743-745
When is a Pavlik harness suitable for congenital DDH (developmental dysplasia of the hip)?
DDH < 6 months of age and a hip that is reducible.
Ref: orthobullets – DDH.
Diagnosis, What to Rule out? Return to play? 🔑🔑
ACUTE TRANSIENT SYNOVITIS
- Unclear Etiology
Age onset
- 3–6 years; boys > girls
Diagnosis
- Rule out septic arthritis
- Normal or slight elevated inflammatory markers (WBC, CRP, ESR)
Symptoms
- Mild or absent fever
- Acute hip pain and limping
- Refusal to bear weight
- Muscle spasms
Xray
- Normal
Examination
- Limited internal rotation of hip
Treatment:
- Rest, NSAIDs, usually resolves in 3–5 days
- Full activity should be avoided until hip is pain free
Prognosis
- Good, <10% have second episode
Cuccurollo 4th Edition Chapter 10 Pediatrics pg747-748
Name the most common cause of painful hip in children younger than 10 years of age. 🔑🔑
Acute transient synovitis, non-specific and self limited
PMR Secrets 3rd Edition Chapter 46 Hip pg367
Diagnosis. List 4 Conditions to be investigates.
Complication, Management & Return to Play? 🔑🔑
SLIPPED CAPITAL FEMORAL EPIPHYSIS
- Separation of proximal femoral epiphysis through the growth plate due to weakness in the growth plate (physis)
Seen in
- Children aged 11 to 16 years.
- During its growth spurt secondary to increased weight
- Delayed development of secondary sex characteristics
- Obesity in 80% of children
- Acute trauma or repetitive microtrauma
- Strain on the growth plate
- Bilateral involvement: 30%–40%
Rule Out
- Panhypopituitarism
- Growth hormone deficiency
- Hyperthyroidism
- Hypothyroidism (most common)
- Multiple endocrine neoplasia (MEN syndromes)
- Down syndrome
Presentation
- Groin or hip pain but may also present as thigh or knee pain
- Loss of internal rotation— when the hip is flexed it rolls into external rotation
- Antalgic gait
- Muscle spasms and synovitis occur in the acute phase.
- True leg-length discrepancy
- Painless limp and external rotation of the affected leg in chronic phase
Complications
- Hip OA
- AVN
Imaging
- Medial and posterior displacement of the epiphysis
- AP and frog-leg lateral radiographs
- Grade I: <33%
- Grade II: 33%–50%
- Grade III: >50%
Orthopedic Emergency
- Immediate nonweight-bearing status
- Percutaneous in situ fixation (stabilizing the epiphysis with screws or pins)
Rehabilitation
- Protected weight bearing after 6 to 8 weeks
- Gradually progressive strengthening and functional exercises are advanced
- Return to advanced activities (i.e., sports) full strength and can participate without pain.
- Total hip arthroplasty (advanced arthritis 50 years after their slip)
Cuccurollo 4th Edition Chp 4 MSK pg219 & Chp 3 Rhu pg139-140 & Chp 10 Peds pg747-748
Braddom 6th Edition Chapter 36 LL Injuries pg728-729
PMR Secrets 3rd Edition Chapter 46 Hip pg336
13 y/o girl hip + knee pain, limping, obese
(a) What is diagnosis
(b) List 2 complications
DIAGNOSIS
SCFE (note: normally seen in males).
COMPLICATIONS
- AVN with collapse of head
- Early hip OA
- Chondrolysis (degradation of cartilage)
Hip AVN. Two most common causes& differentials 🔑🔑
Main rehab goal and how to achieve it.
EPIDEMIOLOGY
- 2-12 years: Legg–Calvé–Perthes disease
- < 12 years: Avascular Necrosis
- Boys, Obese, Hypothyroid
DEFFERENTIALS
- Septic arthritis
- Transient synovitis
TOP CAUSES
- Corticosteroid use
- Alcohol abuse
OTHER CAUSES
- Sickle cell disease
- Trauma
- Radiation
- Chemotherapy
- Lupus erythematosus
- Idiopathic, infection
- Amyloid
PRESENTATION
- Pain in groin and radiates anterior/medial thigh toward knee
- Short stature due to low bone age
- Pain with ROM and with weight bearing
- Antalgic gait: Short swing and stance phase on the affected side
- Loss of hip internal rotation & abduction.
- Leg-length discrepancy
- Hip flexion contracture
- Disuse atrophy
COMPLICATIONS
- Permanent femoral head deformity
- Premature osteoarthritis (OA)
- Avascular Necrosis
INVESTIGATIONS
- Normal WBC and ESR
RADIOLOGY
💡 Literature shows an 80% risk of bilateral involvement. One side may be entirely asymptomatic.
- Xray AP and frog-lateral projections
- Smaller ossified femoral head
- Sclerotic femoral head
- Widening of hip joint space
- MRI of both hips is indicated (more sensetive and specific)
ER - POLICE - MIS
- Risk Factor & Education
- Maintain the femoral head within the acetabulum while healing and remodeling occurs.
- Protection & Orthosis
- Protected weight bearing
- Limited physical activity
- Permit weight bearing of the femoral head to assist healing and remodeling
- Abduction bracing (poor evidence)
- Optimal Loading
- Physical therapy for ROM
- ICE & Modalities
- Medications
- NSAIDs
- Surgery
- Pediatric: Femoral head core decompression
- Adult: Total hip arthroplasty (THA)
Cuccurollo 4th Edition Chp 4 MSK pg219 & Chp 3 Rhu pg139-140 & Chp 10 Peds pg747-748
Braddom 6th Edition Chapter 36 LL Injuries pg728
PMR Secrets 3rd Edition Chapter 46 Hip pg367
What Are the Four Stages of LCPD/Perthes Disease? 🔑🔑
Describe the 4 pathologic stages of Legg-Calve-Perthes disease.
Four Stage (Waldenström)
- Necrosis: Initial period of ischemia/loss of blood supply to femoral head
- Fragmentation: Re-absorption of bone with femoral head collapse
- Re-ossification: New bone re-grows to reshape the femoral head
- Remodeling: Femoral head reshapes itself into normal spherical shape
https://www.orthobullets.com/pediatrics/4119/legg-calve-perthes-disease
Five Stage
- Growth arrest—avascular stage
- Subchondral fracture—“crescent sign”
- Resorption
- Reossificatio
- Healed
Cuccurollo 4th Edition Chapter 3 Rheumatology pg139
Two y/o girl, holding parents hands while walking, jumps down off ledge, father pulls up by hands. Complains of severe elbow pain, unwilling to move elbow.
- Diagnosis 2. Treatment
Subluxation of the Radial Head (Nursemaid’s Elbow)
- Radial head and neck are displaced distal to the annular ligament
Reduction
- Pronation of hand and full extension of elbow
- Supination of hand and flexion of elbow
Cuccurollo 4th Edition Chapter 10 Pediatrics pg746
https://www.orthobullets.com/pediatrics/4012/nursemaids-elbow
Spot diagnosis and management?
Medial Epicondylar Apophysitis (Little Leaguer’s Elbow)
- Repetitive traction stress on the apophysis of the medial epicondylar ossification center of the humerus
- Repetitive valgus stress on the elbow from activities such as throwing a baseball (especially pitching)
Treatment
- Rest
- Instruction on proper body mechanics
Cuccurollo 4th Edition Chapter 10 Pediatrics pg746
List 3 DDx & Management. 🔑🔑 Dr. Maryam
1. NORMAL
- Normal in infants
- By 12 to 18 months of age, the legs have straightened and progresse to genu valgus
- Then gradually assume their ultimate configuration by 6 to 7 years of age.
2. BLOUNT’S DISEASE (TIBIA VARA)
- Obese children who walk at 9 to 10 months.
- History of genu varum worsening with gait before the age of 2 years.
- Abnormal compression of the medial aspect of the proximal tibial physes, causing retardation of growth in that area or increased growth laterally of the proximal tibia or fibula
- Bowing of the proximal tibia due to abnormal growth medial portion of the proximal tibial growth plate
- Treated by osteotomy of the proximal tibia and fibula, which may have to be repeated.
3. RICKETS
- Vitamin D deficiency and results in softening of the bones’ growth plates.
- Legs will appear bowed and the ankles thickened
- In pediatrics, Bisphosphonates should be used with caution, as there is a risk of developing rickets.
Braddom 6th Edition Chapter 2 Examination of the Pediatric pg47
Spot diagnosis and management.
Osgood–Schlatter Disease (OSD)
- Traction apophysitis of the anterior tibial turbercle typically seen in active adolescent children, boys > girls (3:1).
- 50% of patients have bilateral involvement.
- Pain results from inflammation/repeated microfractures in the apophyseal cartilage between the tibial tubercle and the secondary ossification center of the tibial tuberosity where the patella tendon attaches
- Inflammation results, followed by pain, tenderness, and calcification in the area of cartilage involved
Examination
- Tenderness to palpation directly over the tibial tubercle and distal portion of the patellar tendon.
- The anterior tibial tubercle becomes prominent over time as a result of osseous healing of the tubercle
Imaging
- Xray
- Soft tissue swelling anterior to the tibial tubercle
- Bony fragment over the anterior tibial tubercle
- Loss of the inferior angle of the infrapatellar fat pad
- Bony sclerosis.
- US may be useful for confirmation of the diagnosis
- MRI is a more sensitive and specific imaging modality
- Avulsion/bony fragmentation of the ossification center
- Patellar tendon thickening
Treatment
- Strenuous activity restriction (4–8 weeks)
- Limiting activities requiring flexed knee position (low bike seat, jumping).
Cuccurollo 4th Edition Chapter 10 Pediatrics pg746-747
Figure 1. List 4 Causes of in-toeing 🔑🔑
List 2 Other joint examination
List 2 Associated conditions
Causes
- Metatarsus Adductus
- Skew foot
- Club foot
- Internal Tibial Torsion
- Increased Femoral Antervesion → from W sitting
Metatarsus Varus
- Forefoot adduction with normal heel position or slightly valgus
- Medial angulation of forefoot relative to hindfoot.
- 85% correct by age 3 to 4 years
Types
- Flexible deformities are secondary to intrauterine posture
- Passive stretching
- Rigid deformities
- Splinting
Classification
- Heel bisector line, check for foot progression angle
Other Joint Examination
- Tibial torsion
- Thigh-foot angle > 10° = intoeing
- Transmalleolar angle (TMA): Abnormal > 15 degrees internal
- Femoral anteversion
- Craig test, Greater than 65° of IR = femoral anteversion.
Associated Conditions
- Torticollis
- Developmental hip dysplasia (DDH).
Cuccurollo 4th Edition Chapter 10 Pediatrics pg742
https://posna.org/Physician-Education/Study-Guide/Metatarsus-Adductus
https://www.uptodate.com/contents/image?imageKey=PEDS%2F68100
Diagnosis, Components, What would like to examine? Management. 🔑🔑
Club Foot or Congenital Talipes Equinovarus (CTEV) = CAVE
- Midfoot Cavus
- Forefoot Adductus
- Hindfoot Varus
- Hindfoot Equinus
Examination
- Spine deformity
- Leg length discrepancy
- Calf atrophy
Management
- Dennis brown orthosis
- Serial casting (Ponseti method)
Cuccurollo 4th Edition Chapter 10 Peds pg742
Figure 2. Diagnosis & Management
Talipes Calcaneovalgus
- Excessive dorsiflexion at the ankle and eversion of the foot
- Secondary to intrauterine position
Management
- Stretching and rarely splinting
Cuccurollo 4th Edition Chapter 10 Pediatrics pg
What is your DDx? List 2 Complications and 2 Shoe modifications 🔑🔑
Cavus Foot / Pes Cavus
- Unusually high longitudinal arch
DDx
- Cerebral Palsy (Central)
- Spina Bifida (SCI)
- Syringomyelia
- Poliomyelitis (AHC, MND)
- Friedreich’s ataxia (Dorsal Column, Spinocerebellar, Corticospinal)
- Charcot–Marie–Tooth (CMT) disease (Polyneuropathy)
- Duchenne Muscular Dystrophy (Myopathy)
Complications
- Contracture of toe extensors (claw toes)
- Metatarsophalangeal joints are hyperextended and interphalangeal joints flexe
- Metatarsalgia
Modifcations
- Rocker bar
- Metatarsal pad
- Wide toe box
Cuccurollo 4th Edition Chapter 10 Pediatrics pg742
