Common Pediatric MSK Problems

Question 1

2 yr old

 Refuses to use arm

 Vague history

 Arm held at patient’s side with forearm pronated
 Diagnosis?

Answer 1

Pulled/nursemaids elbow, caused by a sudden pull/extension of elbow usually in pronation.

Question 2

etiology of pulled elbow

Answer 2

• loose ligmants
• shape of proximal radius can affect it
• it’s due to the subluxation of the annular ligament.

Often because the annular ligament between the radial head slips down and the annular ligament which normally attaches these two bones at the elbow joint ends up intra-articularly in a subluxed position causing the bones to slip out of place

Question 4

does a pulled elbow show anything on xray?

Answer 4

no. bones and cartilage are normal. the annular ligament is affected, maybe would show on CT or something butyou shouldn’‘t need an Xray to diagnose a nursemaids elbow. you should just reduce it.

Question 5

how to reduce a pulled elbow

Answer 5

Reduction maneuver
 Supinate and flex elbow
 Hyperpronation

Question 6

T/F you should splint a pulled elbow

Answer 6

false. occasionally needs to be splinted if still not moving it. normally, should be better within 24-73 hours .it’s really just for pain control. it doesn’t help the reduction.

Question 7

age group pof legg calve perthes disease

Answer 7

4-10

Question 8

most common joints for septic arthritis in peds

Answer 8

hip and knee most common. the infection within the joint may cause the limbing. it’s often monoarticular, but could be bilateral if wide spread sepsis.

Question 9

3 main routes of infection

Answer 9

1. hematogenous most common
   - bacteremia assocated with URTI, skin or GIT infections, invasive procedures
2. direct inoculation (child falls on nail or needles)
3. contiguous spread – osteomyelitis. adjacent spread from metaphysic beside the joint.

Question 10

contiguous spread often occurs at the ___ part of the bone. why?

Answer 10

at the metaphysis. it’s a transphyseal area with vessels. the metaphyseal circulation is sluggish, causing the baceteria to remain stagnant and causing contigous spread of osteomyelitis.

Question 11

main bacteria cause of bone infection

Answer 11

staph auereus. maybe Ngonorrhea or strep A.

Question 12

would you see anything on Xray if there was an infection of the bone?

Answer 12

no. xrays are usually normal because this is a soft tissue issue. but in severe cases you might ses soft tissue SHADO, showing swelling or edema in the joint. may also see distention in the joint or displacement because of severe bacterial swelling.

consider an ultrasound or MRI

Question 13

tests you should do if someone comes to emerge with severe pain in monoarticular joint with redness and fever

Answer 13

WBC– would be high

ESR– maybe elevated

CRP– elevated indicating inflammation

Blood cultures– positive 50% of the time.

Question 15

kocher criteria to diagnose septic arthritis.

Answer 15

Question 16

treatment of septic arthritis

Answer 16

irrigation of joint

antibiotics

continue until clincal and lab values resolve

Question 17

a person comes in with asymmetric monoarticular joint redness and pain. septic arthritis is ruled out and the kid had rhinovirus 2 weeks ago. what might it be?

Answer 17

reactive arthritis in terms of TOXIC SYNOVITIS (usualyl of the hip).

• non-infectious but inflammatory condition that may be preceded by a viral illness. usually sudden onset but ATRUAMATIC.

Question 18

T/F transient synovitis is a diagnosis of exclusion

Answer 18

true. rule out septic arthritis. a person with TS may have a mild or absent fever, ESR and CRP only mildly elevated. negative aspriate and cultures.

Question 19

treatment of transient synovitis

Answer 19

benign, self limited, improved 24-48 hours. complete resolutoin of symptoms <1 week.

Question 20

A disorder of abnormal fetal development
resulting in dysplasia and possible subluxation or
dislocation of the hip, secondary to capsular laxity
and mechanical factors

Answer 20

developmental dysplasia of the hip (DDH)

Question 21

most common orthopedic disorder in newborns

Answer 21

DDH

 Dysplasia 1:100  Dislocation 1:1000

Question 22

risk factors of DDH

Answer 22

Risk Factors:
— Firstborn

— Female (6:1 over male)

— Family History

— Breech

— Oligohydramnios

Question 23

factors of DDH predisposition

Answer 23

Question 24

3 associated conditions when a baby has DDH

Answer 24

1. congential knee recurvatum
2. metatarsus adductus
3. congenital muscualr torticollis

Question 26

DDH spectrum of hip malformation

Answer 26

1 .dislocated hip. femoral head does not articulate with any portion of hte true acetabulum and may or may not be reducivle.

2. unstable hip. femoral head is reduced in the true acetabulum but can be dislocated
3. dysplasia. shallow or underdeveloped acetabulum, with a normal or dysplastic femoral head.

Question 27

physical exam findings with a baby with DDH

Answer 27

1. limited abduction
2. different leg length
3. asymmetric buttock folds.
4. reduced range of motion
5. trendelenburg gait/duck waddle
6. pelvic obliquity
7. lumbar lordosis
8. toe walking

Question 28

physical exam maneuvers for DDH

Answer 28

1. ortolani (reduces an already dislocated hip)
2. barlow (test for dislocate ability)
3. galleazi (looks for leg length discrepancy.

Question 29

main imaging modality for DDH

Answer 29

Question 30

treatment for DDH

Answer 30

• Pavlik harnus. if older they might need a femoral or acetabular surgery.

if done early enough and worn for 23 hrs/day the success rate is 90% for kids with the pavlik harnus. you should not do it to kids with spina bifida

Question 31

what is slipped capital femoral epiphysis (SCFE)

Answer 31

condition of proximal femoral physis that results in shearing and displacement.

seen in adolescents.

associated with elevated BMIa nd endorcrine conditions.

Question 32

what otehr conditions are teenagers predisposed to SCFE

Answer 32

associated with elevated BMIa nd endorcrine conditions.

Question 33

_____ disease is an idiopathic AVN of the proximal femoral epiphysis. occurs in kids 4-10ish. may or may not require surgery.

Answer 33

Legg-Calbe perthes disease. add this into youn child ddx for limbing.

Question 34

normal angle of toe displaemnet from midlinenormal angle is 10 degrees outward. there’s a spectrumof normal in toeing.

Question 35

what issue might this kid have with their legs

Answer 35

in toeing. they are sitting in the classic w position,

Question 36

3 main causes of in toeirng

Answer 36

1 .femoral anteversion

2. internal tivial torsion
3. metatarsus adductus (in infants)– also associated with DDH

Question 37

T/F braces for in toeing are suggested in children

Answer 37

false. just monitor them. a lot of the times they resolve naturally. it’s a red flag if the condiiton is not bilateral though.

Question 38

at what point would you surgically treat in toeing

Answer 38

you would do an OSTEOTOMY if over 8 yeard old if they are disabled by their gait

Question 39

what is going on here

Answer 39

this is metatarsus adductus which may cause in toeing in the future

Question 40

Answer 40

genu varum

Question 41

average resolution of genu varum

Answer 41

average growth pattern is varus at walking, neutral by age 2

Question 43

things to rule out if kid has genu varum

Answer 43

rickets, blounts disease. make sure you note if is abnoramlly unilateral or not from a metabolic nutritional issue.

Question 44

what is talipes equinovarus and how do you treat it?

Answer 44

its a congenital clubfoot deformity of the foot. treated with serial manipuklation and casting (ponsetti technique)

Question 45

flexible vs rigid flat feet

Answer 45

Flexible Flat feet
 Most common
 Foot is only flat when
weightbearing Archreconstitues when
seated or toe-walking
 No need for intervention  Soft arch support if arch
pain (fatigue)

Rigid
 No sub-talar motion
 X-rays, CT, CBC, ESR
 R/o tarsal coalition, RA,
infection, tumor  Treat underlying
condition/inflammation. This is typically a surgical problem. Tarsal coalition; abnormal bony attachment between smaller bones in the foot. Can also be caused by tumor. Make sure you treat the underlying conditions, but if it’s an idiopathic rigid flat foot, you just need surgical correction.