MSK Flashcards
PE for MSK
- gait
- focus on pelvis, hips, knees, ankles, feet
- spine
- joint swelling/asymmetry
- palpate joints
- ROM
- neuro: strength, sensory, reflexes
- limb length
- hip dysplasia in infants
Diagnostic studies/labs for MSK
- Radiology: XR, US, Bone scan, MRI ($$)
- Lab: ESR, CBC, Blood culture
- Joint aspiration: cell count, gram stain, culture, protein count
Joint aspiration
- technique
- aseptic (don’t want skin sample)
- needle and syringe
Joint aspiration
- fluid analysis
- gross exam: appearance, color, volume, viscosity
- Microscopic exam: WBC #, smear, glucose, protein
- C&S
Joint fluid analysis
- Non-inflammatory
- Gross appearance: transparent, clear-yellow
- WBC: <2,000/mcL
- PMN: <25%
- culture: neg
ex. osteoarthritis
Joint fluid analysis
- Inflammatory
- Gross appearance: cloudy yellow
- WBC: 5,000-50,000/mcL
- PMN: 50-75%
- culture: neg
ex. JIA, SLE, RA
Joint fluid analysis
- Septic arthritis
- Gross appearance: opaque, yellow, purulent (like pus)
- WBC: >100,000/mcL
- PMN: <75-100%
- culture: pos
ex. staph, strep, gram-neg infections
Joint fluid analysis
- Hemorrhagic
- Gross appearance: red and opaque (bloody)
- WBC: <5,000/mcL
- PMN: <25%
- culture: neg
ex. trauma, bleeding disorder, neoplasia
By what age do most kids have a “normal” adult gait pattern
age 3
Toe walking
- nl 10-18 months as learn to walk
- Can be normal up to age 3
- Ddx: muscle spasticity/contractures (CP), muscular dystrophy, congenital tight heel cords
- check ankle ROM and heels
Normal pediatric gait pattern (knees)
- Genu varum normal up to age 2
- Genu valgum normal from 2-6 (toes might point in, kids trip over toes)
- reassure parents this is normal for the age range
Antalgic gait
- less time on painful limb
- knee injury, ankle sprain, etc.
- think trauma or infection
Trendelenburg gait
- abductor lurch
- pelvis/shoulder drop away from affected hip
- remember weak glue on affected side, when step on weak muscle, gives out and swings outward
- if bilateral, will waddle
Circumduction gait
- hemiplegic gait
- swing affected leg in semicircle out to the side
- think CP or neuropathy (foot drop)
Equinus gait
- foot contact with toes or front of foot first
- heel cord contracture or short limb
- look like prancing pony
Hip pain in limping child
- <4 yo ddx
- transient synovitis
- osteomyelitis/septic arthritis
- juvenile idiopathic arthritis
- non-accidental injury (abuse, spiral fracture)
- referred pain from limb
Hip pain in limping child
- 4-10 yo ddx
- transient synovitis
- Perthes disease
- osteomyelitis/septic arthritis
Hip pain in limping child
- 10-16 yo ddx
- SCFE
- avulsion fx
- osteomyelitis/septic arthritis
Growing pains
- bilateral
- non-articular, common in the shin
- intermittent
- worse at night (can wake from sleep)
- M>F
- NO limping, limited ROM
- NO signs trauma or infection
- Dx of exclusion
Growing pains
- Dx
- Tx
- Dx of exclusion
- watch out bc cancer can also present as night pain…
- TX: supportive, reassurance, rest, NSAIDS if necessary
Developmental Dysplasia of the Hip (DDH)
- dislocation or instability of the hip joint
- F > M
- bones (shallow socket) and soft tissue (stretched capsule)
- can occur any time from conception to skeletal maturity
- **screen all newborns for this
- L more common than R dt position in utero
Developmental Dysplasia of the Hip (DDH)
- risk factors
- Native American
- Fam hx of DDH
- Female
- first-born child
- breech
- oligohydramnios
- swaddled often in adduction
- Neuromuscular disorders (CP)
Developmental Dysplasia of the Hip (DDH)
- Signs and Sx
- asx at birth, usually note when start walking
- Shortening of leg (femur is behind the socket)
- painless limp
- Trendelenburg Gait (or waddling)
- excessive lordosis of low back, hip flexion contracture
Developmental Dysplasia of the Hip (DDH)
- Exam
- Screen ALL newborns
- Provocative maneuvers:
- Barlow and Ortolani
- limited ABduction, shortened limb (Galeazzi sign), increased thigh folds
Developmental Dysplasia of the Hip (DDH)
- Barlow and Ortolani
- Barlow: adduct thigh, push posterior, trying to dislocate hip. Dislocation if positive
- Ortolani: hold contra hip still, abduct femur and pull anterior, trying to relocate if out. Will clunk into place in positive test
Developmental Dysplasia of the Hip (DDH)
- Imagine
US
- in newborns, babies <6 mo bc un-ossified bone
- Shows shape of socket and position of femoral head
XR
- not necessary if exam is positive
- Only if >6 mo
- femur will be dislocated posteriorly
Developmental Dysplasia of the Hip (DDH)
- Treatment
- Goal is containment
- Keep femur head in socket will help deepen socket as child grows
- Abduction brace or casting :(
- ortho referal!
Transient Synovitis
- Transient inflammation of hip (sterile effusion)
- MC cause limping 2-7 yo (peak 4-5)
- Limp +/- pain
- M>F
- Cause unknown, often assoc. with recent viral illness
Transient Synovitis
- Signs and Sx
- Recent URI, pharyngitis, gastroenteritis
- NO fever
- Limp worse at end of day
- Toddler may refuse to walk
- if pain, usu unilateral groin, proximal thigh, +/- knee
Transient Synovitis
- Dx
- dx of exclusion (must rule out trauma and infection)
- Pain with ROM and palpation
- Normal XR, CBC
- ESR may be elevated
- Joint fluid: clear/straw colored, neg culture
Transient Synovitis
- Tx
- Bed rest if severe pain
- +/- NSAIDs
- Expect improvement in 3-14 days
Septic Arthritis
- cause
- Hematogenous seeding
- Adjacent osteomyelitis
Septic Arthritis
- Sx
- Acute onset pain/limp
- guarding of joint
- usu hip or knee
- hx of trauma
- 90% monoarticular
Septic Arthritis
- Exam
- Peak <2 yo
- Febrile, SICK kid: malaise, anorexia, apprehension
- Tenderness, warmth, swelling
- Hip held in flexion, abduction, external rotation
- Resists ROM
Septic Arthritis
- Dx
CBC
- WBC >15,000 **
- Elevated ESR
- Pos blood culture in 40%
US guided hip aspiration
- Fluid cloudy/pus
- > 50,000 WBC
- pos culture in 50%
XR
- Normal will appear nl
- late shows bone resorption
Septic Arthritis
- two MC organisms
- Staph aureus
- GBS
Septic Arthritis
- Treatment
- Hospital admission and supportive care
- Ortho consult STAT
- Immobilize joint with splint
- IV abx X 2w + oral abx (Vanc and Cefotaxime)
- Sx if needed: joint drainage and irrigation
Septic Arthritis
- Complications
- AVN
- Degenerative joint disease
Juvenile Idiopathic Arthritis
- define
- age
- dx
- chronic arthritis >6 weeks
- <16 yo
- Dx of exclusion, must r/o: Lyme, malignancy, infection, psoriasis, IBD, Strep, bleeding dz, vasculitis
Juvenile Idiopathic Arthritis
- three types
- Oligoarticular
- Polyarticular
- Systemic
Oligoarticular Juvenile Idiopathic Arthritis
- MC
- onset <6 yo
- F>M
- ≤ 4 joints
- Knees, ankles, wrist, elbow
- NEVER hips
- Lab: possible ANA+
- Good prognosis
- Uveitis complication = screen Q3Months
Polyarticular Juvenile Idiopathic Arthritis
- ≥ 5 joints
- Large and small joints
- Symmetric
- 1-6 yo and 11-16 yo
Polyarticular Juvenile Idiopathic Arthritis
- two subtypes
- RF Negative: younger, gradual onset, multiple joints, ANA+ most
- RF Positive: older, abrupt onset, aggressive, +/- RA nodules, poorer prognosis, persists into adulthood, F>M
Systemic Juvenile Idiopathic Arthritis
- Daily spikes of high fever
- Recurring evanescent erythematous rash (w/ the fever)
- +/- hepatosplenomegaly and lymphadenopathy
- M=F
- Very ill, leukocytosis, anemia, high ferritin, elev CRP/ESR
- Specialist STAT
Systemic Juvenile Idiopathic Arthritis Complications
- Macrophage activation syndrome: coagulopathy, pancytopenia, liver failure, encephalopathy
- pericarditis
Juvenile Idiopathic Arthritis
- Treatment
- NSAIDs: 1st line
- Intraarticular steroids if only 1-2 joints
- DMARDS (methotrexate and biologics)
Legg-Calve-Perthes Disease
- idiopathic AVN of proximal femur
- Flattening and collapse of femoral head
- 4-8 yo
- M>F
- 90% unilateral
Legg-Calve-Perthes Disease
- pathogenesis
- Ligamentum teres not developed yet = poor blood supply
- From 4-7 yo, femoral head depends entirely on lateral epiphyseal vessels
Legg-Calve-Perthes Disease
- Stages of development
1: bone death d/t interrupted blood supply
2: revascularization and repair, new bone laid atop dead bone
3: distortion and remodeling. Epiphysis collapses and femoral head flattens
Legg-Calve-Perthes Disease
- Signs and Sx
- Painless limp ≥ 3 weeks
- insidious onset
- sx worse at end of day
- activity worsens limp
- if pain: aching groin, proximal thigh, +/- knee
Legg-Calve-Perthes Disease
- Exam
- Limited hip ROM with guarding
- shortened limb
- Trendelenburg gait
- Provocative maneuver: roll tests (positive if guarding or spasm)
- Test: lay on belly, see if legs fall apart equally
Legg-Calve-Perthes Disease
- XR
- lab
- XR with frog leg view **
- Must compare to contralateral hip
- looking for small epiphysis and wide articular surface
- Early AVN: crescent sign (changes of a subcentral fracture)
- if inconclusive, CT or MRI
- ESR slightly elevated
Legg-Calve-Perthes Disease
- Treatment
- Ortho referral!
- <50% femoral head: observation
- > 50% femoral head: brace or cast to contain femoral head, sx for severe deformities
Legg-Calve-Perthes Disease
- Prognosis
- Younger = better
- >10, very high risk of osteoarthritis
Slipped Capital Femoral Epiphysis (SCFE)
- instability of proximal femoral growth plate = displaced femoral head from femoral neck
- Unilateral 70%
- L>R
- M>F (2-3X)
- AA ethnicity
- Obesity increases risk
Slipped Capital Femoral Epiphysis (SCFE)
- signs and sx
- Hip, medial thigh, knee pain **
- Painful limp
- Antalgic gait with foot out
- Limb shortening
- Decreased ROM: internal rotation, abduction. Obligate external rotation with flexion
Slipped Capital Femoral Epiphysis (SCFE)
- XR
- AP, Lateral, Frog-leg view ** Always bilateral
- Displacement of femoral head, medial displacement on AP view
- “ice cream scoop falling off cone”
- Widening epiphyseal line
Slipped Capital Femoral Epiphysis (SCFE)
- Complications
- Treatment
- AVN, DJD
- NWB and traction
- Surgical stabilization, internal fixation
Osgood-Schlatter Disease
- Anterior knee pain in kids
- Overuse injury
- 11-13 year old, active
- M>F
- Pain worse with jumping, kneeling, running
Osgood-Schlatter Disease
- Pathophys
- Repetitive quadriceps contractions
- patellar tendon pulls on growth plate of tibial tubercle
- tibial tubercle is immature, susceptible to injury
Osgood-Schlatter Disease
- Dx
- Exam: sufficient for dx
- TTP, swelling over anterior knee at tibial tuberosity
- Often bilateral
- XR can be dx but is not needed
Osgood-Schlatter Disease
- tx
- Time, reassurance
- Conservative: ice after play, NSAIDs PRN
- Avoid sports for 2-3 mo to heal
- activity mods upon return
- occasional knee immobilization
Nursemaid’s elbow
- MC elbow injury <5 yo
- Subluxation of radial head dt laxity of annular ligaments**
- MOA: jerk on child’s arm with elbow extended, child forcefully lifted up by hand, elbow extended and forearm pronated
Nursemaids Elbow
- Signs and Sx
- HPI: child cries immediately after injury and then appears comfortalbe
- Reluctant to use affected arm
- Extremity held by side, palm down, elbow slightly flexed, forearm pronated
- TTP only with palpation of radial head
Nursemaids Elbow
- Tx
- Thumb over radial head, supinate the forearm
- If no “snap” of reduction, flex the elbow
- should feel snap when reduced
- child should use arm within a few minutes
Scoliosis
- 2-3% prevalence
- multifactorial etiology
- Lateral curve >10 deg
- R thoracic curve MC
- F>M
- 10-13 yo
- rotation of vertebrae, sometimes kyphosis/lordosis
Scoliosis
- Exam
- asymmetry of shoulders and iliac height
- Scalpular prominence
- Normal gait and neuro
- Screen with adams test (bend forward)
- follow with scoliometer
Scoliosis
- XR
- AP and lateral
- Use Cobb angle to measure curve magnitude
- MRI only if neuro sx
Scoliosis
- Tx
- Observation while child is growing
- 20-40 deg: brace with progressive curves
- > 40: sx fusion of vertebrae (at near skeletal maturity)
- Emotional support
Osteogenesis Imperfecta
- “brittle bone” dz
- Genetic defect Type 1 collagen** = osteoporosis
- AD inheritance, rare
- Classic triad: Fragile bone w/ pathologic fx, early deafness, blue sclera
Osteogenesis Imperfecta
- dx
- management
- genetic testing to confirm
- bisphosphates
- physical rehab, bracing
- fracture management
Osteosarcoma
- MC primary bone tumor
- “immature” bone produced by malignant mesenchymal stem cells
- Long bones MC
- Sites of rapid bone growth: distal femur, proximal tibia, proximal humerus **
- 10-20 yo
- M=F
Osteosarcoma
- Clinical findings
- Localized pain and swelling
- limp
- often noticed after minor injury
- Dec ROM, TTP, skin warmth, +/- palpable mass
- Pathological fx
- Lung mets (usually =death)
Osteosarcoma
- DX
- XR: sunburst pattern**
- Bx: required to confirm dx
- Lab: elev. alk phos
Osteosarcoma
- Tx
- Pre op chemo
- limb sparing sx or amputation
- post op chemo
Ewings Sarcoma
- malignant tumor of neural crest cell origin*
- 10-25 yo
- EEE: Extremities, Extensive, Entire shaft
Ewing Sarcoma
- Signs and sx
- femur and pelvis MC
- localized pain and swelling
- soft tissue mass surrounds bone
- fever, weight loss, fatigue
- metastatic dz common
Ewing Sarcoma
- Dx
- XR: lytic destruction, unclear borders, layered “onion skin” appearance **
- bone scan
- CT/MRI
- Bx: req for dx
Ewing Sarcoma
- Tx
- sx
- chemo
- radiation
Fx of growth plate
- Very common
- can lead to premature growth arrest, unequal bone length, limb length discrepancy
- Premature arrest of part of physics = angular deformity
- MC: distal tibia and distal femur
Salter Harris Classification
I: separation through physis. Good prognosis
II: fx through metaphysics (above). Good prognosis
III: fx through epiphysis and into joint (lower). Worse dt joint involvement
IV: Fx across metaphysics, physis, epiphysis (through). Worse prognosis than III
V: crush injury to physis. rare and bad…
