Exam 2 Musculoskeletal Flashcards
Wolff’s law
healthy person or animal bone will adapt to the loads placed on it.
How does Wolff’s law relate to musculoskeletal injuries?
If you don’t bear weight on it, the bone will adapt to the lighter load. Therefore, weight bearing as tolerated in many injuries.
Hueter-Volkmann principle
Compression forces inhibit bone growth while tensile forces stimulate it
compartment syndrome
increased pressure within a closed fascial space, causing decreased flow through capillary bed. Ischemia > anaerobic metabolism > lactic acid > immune response > muscle damage & necrosis
Early signs of compartment syndrome
#Pain disproportionate to injury #Refusal to move the area #Pain with passive stretch #Maybe skin swelling & tautness
Late signs of compartment syndrome, or the 5 P’s
1) Paralysis
2) Pallor
3) Parasthesia
4) Pain
5) Pulselessness
The 3 A’s of compartment syndrome, and why they’re important
1) Anxiety (increasing)
2) Agitation
3) Analgesic requirement (increasing)
They precede the 5 P’s by several hours, giving us time to get ahead of compartment syndrome
If compartment syndrome suspected, how does treatment progress?
#Immediate management: removing binding such as casts & underlying padding, keep extremity at heart level, give oxygen & analgesia #Consult specialist
What’s the definitive treatment for compartment syndrome?
Incisional fasciotomy
Hip dysplasia
DDH: developmental dysplasia of the hip. Subluxation or dislocation of the femoral head within the hip joint
Presentation of hip dysplasia
#Dislocatable/dislocated hip during newborn exam #Clunk on Barlow & Ortoloni maneuvers up to 12 weeks of age
Barlow maneuver
Supine with hip flexed 90 degrees, neutral rotation. Adduct hip while applying posterior force on knee to cause head of femur to dislocate posteriorly from the acetabulum, causing a palpable clunk
Ortolani maneuver
To ID a dislocated hip which can be reduced, infant remains supine with hip flexed to 90 degrees. From adducted position, hip is gently abducted while lifting or pushing femoral trochanter anteriorly. Palpable clunk as the hip reduces.
Asymmetric skin folds?
Sometimes but not always present with hip dysplasia
What’s diskitis?
Inflammation, often infectious, of the intervertebral space
What’s most common etiology of diskitis?
Seeding from a systemic infection localizing in lumbar spine. Most common organism is s. aureus
Diskitis presentation
#Back pain, fever, fatigue #Limp #Refusal to walk or sit #Holds self in rigid, straight position #Pain with spine flexion
Diagnostics for diskitis
#CBC with diff #CRP, ESR #Blood cultures
Treatment for diskitis
#Activity restriction #Pain control #Spine immobilization #IV ANTIBIOTICS
Legg-Calvé-Perthes Disease
Disorder resulting from temporary loss of blood flow to proximal femoral epiphysis
Stages of LCP disease
1) Initial: ischemic event, ossification stops & bone becomes sclerotic
2) Fragmentation: bone becomes deformed or fractured
3) Healing/reossification: Old bone reabsorbed & new bone formed
4) Remodeling: residual deformity may be observed
LCPD presentation
#Persistent pain on affected side #May start in the hip & radiate to the thigh or knee, not usually severe #Antalgic gait
LCPD plan of care
#Imaging tracking progression #Keep the femoral head in the acetabulum #Promote good ROM #Mild cases get normal activity with observation #Severe ones get activity restriction, physical therapy, bracing
What is slipped capital femoral epiphysis?
SCFE involves separation of growth plate in proximal femoral head. Epiphysis slips posteriorly & can progress to complete dissociation, avascular necrosis
Typical child with SCFE
#AA or Hispanic, male, between 12-15, obese #Possibly r/t rapid growth
SCFE classifications
Acute: sudden within last 3 weeks
Chronic: gradual over 3 weeks
Acute on chronic: symptoms for a month or more with exacerbation by injury
SCFE diagnosis
x-rays may show “ice cream slipping off cone”
SCFE plan of care
#Imaging #Percutaneous pinning or screw fixation of femoral head through growth plate #Maybe prophylactic pinning of the other side, depending on younger than 10 yrs, metabolic abnormality, extreme obesity, or bad follow up
SCFE disposition
#Pinning = same day surgery #Crutches: 2-3 weeks for stable SCFE, 6-8 weeks for unstable #NO SPORTSBALL until that growth plate is closed
What’s toxic synovitis?
#Inflammatory condition affecting primarily larger joint spaces, usually hip. #Probably reaction to acute/previous viral infection, trauma, or allergic reaction
Toxic synovitis presentation
#Pain in the area of joint #Antalgic gait #Refusal of weight bearing #Mild limitation of hip in abduction & internal rotation on exam #Normal to low grade fever, slightly elevated inflammatory markers
What’s osteomyelitis?
infection of bone
Most common type of osteomyelitis in pediatrics?
Hematogenous, where blood infection seeds bone
Most common pathogen causing osteomyelitis?
Staph aureus
Osteomyelitis presentation
#Localized pain in affected bone, constant and increasing severity #Discrete tenderness @ site #Edema, erythema, hot to palpation #Antalgic gait/refusal to use
Osteomyelitis plan of care
#CBC with diff (elevated wbc) #ESR, CRP #blood cultures #x-ray #surgery for large subperiosteal, soft tissue or bone abscess, septic arthritis, necrosis, or invasion of growth plate #IV abx (2-4 days) then oral abx (at least 3 weeks)
Consults you’ll need with osteomyelitis
#Orthopedics #Infectious disease #Occupational & physical therapy #Critical care if hemodynamically unstable #Nutrition, child life, social/spiritual support
What’s rhabdomyolysis?
Rapid breakdown of skeletal muscle from injury, infection, or failed perfusion
Rhabdomyolysis: more common in kids or adults?
Adults
Common cause of rhabdomyolysis in teens?
Muscle trauma! Be suspicious of those student athletes
Rhabdomyolysis presentation
#Muscle pain/weakness #Dark or tea colored urine #Recent viral illness or prolonged/vigorous exercise #Tender, swollen muscles
Rhabdomyolysis plan of care
#IV fluids until no more myoglobinuria #Monitor electrolytes on CMP, BUN/creatinine #Avoid NSAIDS, other nephrotoxins #EKG especially for hyperkalemia
What’s septic arthritis?
Infection in the synovial joint space #hematogenous seeding #Spread from adjacent bone #traumatic or surgical contamination
Joints most often affected by septic arthritis
Knee 37%
Hip 32%
Ankle 12%
Elbow 10%
Pathogen most common in septic arthritis
S. aureus
Septic arthritis presentation
#Exquisite pain in affected joint #joint painful to palp, erythema, heat to palp #ROM painful, limited #Kid lookin' kinda septic
Septic arthritis OR osteomyelitis?
They are not mutually exclusive and can & do occur at the same time
Septic arthritis diagnosis
#CBC with diff #ESR, CRP #Cultures #Joint aspiration #X-rays & MRI, bone scan
Consults you’ll want in septic arthritis
#ortho #infectious disease #physical therapy
3 decision points on abx in septic arthritis
1) The initial IV treatment
2) Narrowing down IV treatment based on cultures
3) Transition from IV to oral
How long abx treatment in uncomplicated septic arthritis?
3-5 days of IV
2-3 weeks of oral
Success in septic arthritis treatment hinges on:
STRICT adherence to the long oral abx therapy after initial IV treatment
Septic arthritis complications in how many kids?
10-25% (if treatment delayed > 4 days, age younger than 6 months, and hip involvement with concurrent osteomyelitis of femur or septic dislocation @ hip)
Salter Harris I
Through growth plate
Salter Harris II
Through growth plate and metaphysis
Salter Harris III
Through growth plate and epiphysis
Salter Harris IV
Through growth plate, metaphysis, and epiphysis
Salter Harris V
Crush of the growth plate
What is it about pediatric bones that make fracture patterns different from adult ones?
Kid bones are more flexible, less brittle
Most frequently fractured bone in children?
Clavicle!
What arm fracture ALWAYS requires consult with orthopedic surgery?
Elbow! Gotta have near 100% perfect alignment or you risk diminished function later.
Comparment syndrome most often seen in:
lower leg or forearm
How to differentiate between septic arthritis and transient synovitis:
1) Fever
2) Inability to ambulate
3) WBC > 12k
4) ESR ≥ 40
If all 4 criteria are met, 99% chance septic arthritis. 3/4: 93%. 2/4: 40%. 1/4: < 5%
Salter-Harris is a grading scale. The higher the number, the more likelihood of what outcome?
Growth arrest
