Module 16: Advanced Extremities Flashcards
Sprain Vs Fracture:
IAt preschool age- ligament is stronger than bone so if you see evidence of ligament injury look for a fracture.
Good to know
Heel pain differential Diagnosis
There are numerous causes of heel pain
Most are due to:
-minor trauma
-repetative stress
-abnormal biomechanics
-subluxation
Important to rule out infection:
-consider osteomyelitis
-consider septic arthritis, nail puncture wound and ingrown toenail in this category.
-antalgic limp and pain, local tenderness and soft tissue swelling
-the calcaneus is the most common site
-there may be a history of puncture wound
-Xray may reveal bone changes, however bone destruction is not seen until 10-21 days
-
What is sever disease?
How do we treat it?
Sever’s disease is a painful condition of the heel that occurs in growing children. It happens when the tendon that attaches to the back of the heel (the Achilles tendon) pulls on the growth plate (the apophysis) of the bone of the heel (the calcaneus).
Treat it with?
Chiro management?
Find subluxation and correct it
Medical management:
RICE, NSAIDS, activity modification
-Achillies stretching
-Strengthening of the ankle dorsiflexors
-massage, ultrasound
-insertion od heel lift or heel cup- padding
-plantafascitis stretching.
Discuss a calcaneus stress fracture
Can occur after frequent running of strenuous activity
-generalised heel pain, diffuse tenderness and a limp
- a bone scan will be positive
-Xray showing a healing fracture
-medical management is with a below knee walking cast for 3-4 weeks.
What subluxation is in- toeing typically associated with as well as out- toeing?
In toeing is typically associated with an Anterior medial internal rotation tibia subluxation
Out toeing is typically associated with an Anterior lateral external rotation tibia subluxation
Fibula (proximal)
Can subluxate?
What other signs may you see?
Anterior Posterior Inferior
* Often asymptomatic
* May cause local pain
* Assessed similar to distal fibula
* May affect ankle, knee and hip joint
* WeakTFL
List some generalised Swollen painful knee differential diagnosis?
List some localised swollen knee differential diagnosis?
Generalised:
1. Arthritis
2. Infection
3. RSD
4. Other rare conditions:
-Reactive synovitis due to femoral condyle lesion
-TB arthritis
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Localised:
1. Patella tendonitis
2. Osgood Schlager disease
4. Ligament sprain
5. Stress fractures of the patella
6. Bursitis
7. Direct Injury causing fracture can cause localised swelling
8. Tumours (benign and malignant)
Patellofemoral pain syndrome
What is it?
What are risk factors that may cause it?
What are common presenting symptoms?
What are differential diagnosis?
Whats your examination
Whats you Chiropractic management?
A condition in which the cartilage under the kneecap is damaged due to injury or overuse.
Patellofemoral Pain Syndrome (PFPS) is an umbrella term used for pain arising from the patellofemoral joint itself, or adjacent soft tissues. It is a chronic condition that tends to worsen with activities such as squatting, sitting, climbing stairs, and running.[1
Risk factors:
-Onset timing of vast muscles
-structural abnormalities
-muscle strength
-kinematic variables
-quadriceps angle
Common symptoms:
Pain + stiffness behind, underneath or around the patella. Achy but sharp at times.
-Usually gradual onset, but can be cause by trauma
-Stiffness or pain after prolonged sitting with knees flexed
-Swelling not usual
-popping or catching sensation may be described
DDX:
1. Intra-articular pathology
2. Plica syndrome
3. OSgood Schlager disease
4. Bursitis or tendinitis
5. neuroma
6. Other rare pathologies
Examination:
BLA
Chiro management:
-Identify vertebral subluxation -Especially pelvis and mid Lumbars
-Strengthen VMO
-Strengthen Core
-Increase stretches (eg lateral leg and hamstring)
-Modify activities:
-Avoid squatting
-change volume of activity
-change activity type (runners can swim or cycle)
Orthotics if excessive pronation
Patellofemoral (PF) pain is a common ailment of the lower extremity.
* A theorized cause for pain is patellar maltracking due to vasti muscle activation imbalance, represented as large vastus lateralis:vastus medialis (VL:VM) activation ratios.
Jake, aged 10, presents with right medial knee pain and limp.
* There is no fever or other illness.
* There has been no trauma.
* He is not a very active child–he is not involved in any jumping or running sports, and there has been no increase in recent physical exercise.
* Your knee examination is unremarkable.
* There is bilateral pronation. You adjust his talus, and his pelvis
and expect him to improve.
* 10dayslaterhereturnswiththesamesymptoms.Thepainhas increased in severity, and is now waking him from sleep. Pain medications are required throughout the day and night.
What do you suspect and why? What is your management?
Osteosacrcoma
Osteosarcoma is a type of bone cancer that begins in the cells that form bones. Osteosarcoma is most often found in the long bones — more often the legs, but sometimes the arms — but it can start in any bone.
-Often dismissed as growing pains
-becomes more constant and sever*
-Limp may develop
-Can be confused with injury or sprain
-May or may not be palpable mass, limited ROM, tenderness and warmth
-Most patients aren’t sick
-We must exercise some suspicion
Highest risk when Adolescent growth spurt (10-25 yrs)
Ewings Sarcoma
A cancer that most often occurs in and around the bones.
Ewing’s sarcoma typically occurs in children and young adults. It often begins in the legs, bones of the pelvis and arms.
Bone pain, localised swelling and tenderness are symptoms. In rare cases bone fractures may also be found.
Occurs ages 10-20
How does it present clinically?
Similar to Osteosacrcoma
- similar to osteosarcoma.
- Pain, swelling, limitation of motion, and tenderness, mild erythema. may mimic a playground trauma.
mild trauma may lead to ultimate diagnosis
10-15% have pathologic fracture.
many have limp - 61% have a tumour mass (one study)
- 50% have pain for more than 6 months before diagnosis (another study)
- With chest wall primaries, patients may present with respiratory distress.
- With paraspinal or vertebral primary tumors may present cord compression.
- not sick until late in disease.
- if in the pelvis, symptoms and signs will be delayed.
- typically present with gait abnormalities from root compression, bowel or bladder dysfunction, or back pain
Maggie presents with John, age 4.
John is moving his right leg “differently” to the left He seems to be favoring the left leg.
He has been grumpier than usual.
The onset was today.
What are your first questions?
- What is the type of limp?
- What is the Diff. Dx?
- What is the Dx?
- What are the key points to take away?
- Has there been any trauma?
- Has there been an infection (URTI, digestive, other), or raised temperature/fever?
Maggie says that John is very active, and he is often climbing, falling, and bumping his body, but there has been no obvious fall. He has a cold last week, but there was no raise in temperature that she noticed?
Examination:
Gait: obvious decreased use of right leg.
Ankle/knee normal.
Hip – decreased internal rotation, normal otherwise
Temperature: 36.6, ear exam – normal, tongue – healthy colour, throat observation – normal, CSLN’s – normal.
Palpation of abdomen – no tenderness, no fecal impaction. Subluxation patterns – right pelvis subluxation, left C1/2 subluxation
Transient Synovitis
A non-specific, benign inflammation of the synovial lining (Do, 2000)
- most common age 3-6, causing an pain, stiffness and antalgic limp.
- It is a diagnosis of exclusion.
- Causes: often unknown, may include virus’s and trauma (Do, 2000)
History:
- acute onset of pain in anterior groin, anterior thigh, or knee. (non-traumatic anterior thigh or knee pain may be referred from the hip) - a history of URTI may be present, but systemic signs are absent.
Examination
- decrease in internal rotation of the hip may be seen.
- Use log roll test to help determine decrease in internal rotation (Leet 2000)
-occasional low grade fever (under 38)
Xray - NAD (except for the possibility of mild joint effusion indicated by medial joint space widening)
Prognosis and treatment: (Do, 2000)
- self limiting and lasts 3 to 10 days,
- treatment is usually given to alleviate symptoms.
- rest, avoidance of weight bearing, anti- inflammatory therapy
Med MX:
Chiro Mx:
Rest and NSAIDS
Monitor for vascular necrosis Adjusting as indicated.
Nutrition to improve immune function and to regulate inflammation
- A 2 year old male presents with fever and limp for two days.
- He complains of pain and points to his right lower extremity.
- The pain has become increasingly worse, and he is unable to sleep at night. His appetite is decreased. There is a recent history of an upper respiratory tract infection about two weeks ago, but no recent trauma. The pain is not known to migrate.
- There is no history of cough, headache, abdominal pain, vomiting, diarrhea, hematuria, or known tick exposure. Family history is negative for sickle cell disease and arthritis.
- Exam: VS T 39.5, P 120, R 18, BP 100/50.
- He is thin appearing and refuses to walk.
- HEENT exam is normal. His neck has good range of motion without pain.
- Heart, lungs, abdomen, and genital exams are normal
- He is lying with his right lower extremity externally rotated, abducted, and motionless.
- He has severe discomfort with minimal internal and external rotation of the right hip despite attempts to distract him. His other joints and neurological exam are normal. There are no notable skin lesions.
- What is your management plan?
You referred this patient- straight to E.D. – well done!
- Laboratory studies revealed increased WBC’s.
- Hip radiographs show widening of the acetabular
space on the right. - An orthopedic surgeon was consulted.
- An arthrocentesis of the right hip is performed which shows increased white blood cells.
- Treatment with vancomycin and ceftriaxone is initiated after cultures are obtained.
- Within three days of treatment onset, his fever declines and he slowly begins to ambulate.
- He is discharged with home care.
- His parents bring him back for you to continue his Chiropractic Management
Please fill in the gaps:
1. What is the type of limp?
2. What is the Diff. Dx?
Septic arthritis (Septic arthritis is an infection in the joint (synovial) fluid and joint tissues. Different types of bacteria, viruses, and fungi can infect a joint. )
Osteomyelitis (Osteomyelitis is inflammation or swelling that occurs in the bone. It can result from an infection somewhere else in the body that has spread to the bone, or it can start in the bone — often as a result of an injury.)
- What is the Dx?
- What are the key points to take away?
Septic Arthritis – overview
- an infection within the joint space.
- most often in the hip, knee, then ankle in the 0-3 age group.
In young child – difficult, signs vague, need suspicion
In older child – sickness, pain and fever
- posture: external rotation (10 degrees) and flexion (30-60), degrees
- decreased ROM
- point tenderness (anterior of the joint in septic arthritis)
recognition as a likely diagnosis and referral.
Lab tests (white cell count, ESR and CRP) - may be negative in an infant Bone scans - may show increased uptake
Ultrasound and radiography - may show joint effusion.
Confirmed with aspiration of the joint.
Drainage of the joint and antibiotics.
Osteomyelitis- overview
- an infection within the bone itself
- most often long bones, affecting the femur most commonly.
- not common, occur more often in late childhood (2009, Houghton)
Exam:
- local pain, swelling, warmth, erythema and tenderness
- systemic manifestations such as fever or malaise.
- Be aware that systemic response may be absent in an infant and toddler. - be aware hip ROM may be normal if hip joint itself is not affected
(2009, Houghton) MX: Referral for medical tests.
As for septic arthritis
MRI may be needed to permit the diagnosis of osteomyelitis
Joan presents with Matt, aged 8.
Matt has a shortened stance on the right, and some pain at the front of the groin. The pain radiates slightly down towards the knee.
This has been present for months, but seems to be getting worse.
It is worse in the evenings after a lot of exercise.
* The examination is unremarkable except for some mild loss of internal rotation and abduction.
Please fill in the gaps:
1. What is the type of limp?
2. What is the Diff. Dx?
3. What is the Dx?
4. What are the key points to take away?
5. What is your management?
Mx: You referred for an xray – Well Done!
Legg-Calve-Perthes Disease
Overview
- Idiopathic avascular necrosis of the femoral head.
- Cause is unknown - however vascular supply of the femoral head is often tenuous, and always vulnerable due to its passage intracapsular along the femoral neck.
- Most common age 2-18, Most common 4-8 years, mean at 6. (Tach).
- More common in boys.
Clinical: Presenting complaint:
Antalgic limp, with mild pain on the anteromedial aspect of the thigh and knee. Insidious onset over several weeks, agg exercise, rel rest.
Sometimes begins after trauma.
Exam: Screening exam normal, except for involved leg.
* Most prominent sign is stiffness ie loss of internal rotation and abduction
Limp is antalgic
Trendelenburg Sign may be present Mild atrophy may be present.
DDX:
leg calve- Perthes
Synovitis
12 year old boy, Jacob presents with pain at the front of the left knee. He mother has noticed him walking “funny” over the past three months. His pain was intermittent, but it is now constant.
Examination:
Observation: Jacob appears overweight. ROM: - decreased internal rotation of the hip
- on flexion of the hip, the thigh rotates externally. Temperature, EENT, CSLN’s - all normal
Spinal: Subluxation patterns at the pelvis, T6, and Occiput. Extremity: Left ankle subluxation.
What is your management?
- What is the type of limp?
- What is the Diff. Dx?
- What is the Dx?
- What are the key points to take away?
- Displacement of upper femoral epiphysis on metaphysis
- The most common adolescent hip disorder.
- Common in obese boys, Peak age 13 (boys) and 11 (girls) - Bilateral in 25% of cases, most slips are gradual
- Risks:
1. Increased weight
2. Delayed skeletal maturation
3. Constitutional disorders (esp endocrine/metabolic)
4. Recent growth spurt
5. Retroversion
6. Trauma
Clinical: - Pain is often referred to the knee, causing antalgic limp,
occurs in 25% (Hawaii case based paeds) - Pain referred to knee is a risk factor for delay in diagnosis (Kocher 1999)
- Acute slips: occur suddenly with no ability to walk due to pain
- Longer standing slips may cause:
1. out-toeing gait
2. abductor lurch
3. limb atrophy
Examination:
* Loss of internal hip rotation, may notice with gait.
* Test flexion of hip – look for obligate external rotation of the hip, a sign of SFCE (Leet, 2000)
* Often overweight
Imaging:
Frog leg view of hip.
Loss of normal r/ship between epiphysis and neck.
Klein’s line (line drawn along neck of femur, should intersect epiphysis)(Houghton 2009)
Antalgic gait Differential Diagnosis
When pain is present there is usually a shortened stance, hip is most common site - search for tenderness, guarding, decreased motion
If diagnosis not certain, xray, then bone scan
Most common causes: trauma, infections and inflammations, neoplasia.
- Trauma:
Sprains, strains, contusions, Fractures (Occult Toddler’s fracture, stress fractures, Subluxation, overuse syndromes - Infections and inflammations
Septic arthritis, Osteomyelitis, Diskitis, Transient synovitis
Others: Cellulitis, Post infectious reactive arthritis.
Other rheum: Juvenile rheumatoid arthritis, Systemic lupus erythematosus - Neoplasia Benign - Unicameral bone cyst, Osteoid osteoma, Osteoblastoma.
Malignant - Osteosarcoma, Ewing’s sarcoma, Leukemia/lymphoma, Spinal cord tumors - Acquired: – LCPD, - SCFE - Osteochondritis dissecans (knee, talus)
- Osteochondritis - Kohler’s, Frieberg Disease, Severs disease - Congenital - Developmental dysplasia of the hip, Sickle cell, Congenitally short femur, Clubfoot
- Neurologic - Cerebral palsy, especially mild hemiparesis, hereditary sensory motor neuropathies
Antalgic Limp Differential Diagnosis
Based on age
Age 1-4:
* Infectious causes much more likely : 1. Septic arthritis 2. Osteomyelitis
* Non-infectious causes-
Age 1-4:
* Infectious causes much more likely : 1. Septic arthritis 2. Osteomyelitis
* Non-infectious causes-
3. Transient synovitis
4. Trauma (including Subluxation)
5. DDH (Perthes may present early, by age 3-4)
Age 4-10
1. Trauma is more likely in this age group
2. Perthes
3. Infection and
4. Transient synovitis
Age 11-16
-Trauma common
2. Slipped capitol femoral epiphesis
3. Neoplasia
All ages: cerebral palsy
Radiographic evaluation
What degrees is considered normal for a acetabular index – angle
The maximal normal measurement for the acetabular index is 30 degrees
up to age 4 months and 25 degrees up to age 2 years.
Know this!
Radiographic findings of DDH
Radiographic findings of DDH include an
1. upward slanting sourcil (roof of the acetabulum)
2. small capital femoral epiphysis
3. superolateral subluxation of the femoral head
An 8-month-old girl demonstrates bilateral DDH, with the left hip worse than the right hip.
1. Note upward slanting sourcil bilaterally.
2. The right femoral head is concentrically located within its dysplastic
acetabula.
3. The left femoral head is superolaterally dislocated.
An anteroposterior radiograph in a 1-year-old girl demonstrates
Radiographic findings of DDH include an
1. upward slanting sourcil (roof of the acetabulum)
2. small capital femoral epiphysis
3. superolateral subluxation of the femoral head
- left-sided developmental dysplasia of the hip
- upward slanting sourcil
- superolaterally subluxed femoral head
- delayed ossification of the left capital femoral epiphysis
Supracondylar fracture
- Distal humeral metaphyseal region proximal to the elbow)
- Most common elbow fracture
- Commonly ages 3-10
FOOSH injury
arm held in pronation and resists flexion
neurovascular injury common in severe displacement. flow through brachial artery may be affected
– treat as a medical emergency.
Compartment syndrome can develop in 24 hours
Medical emergency
