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Pediatrics 2 > MSK > Flashcards

MSK Flashcards

1
Q

PE for MSK

A
  • 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
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2
Q

Diagnostic studies/labs for MSK

A
  • Radiology: XR, US, Bone scan, MRI ($$)
  • Lab: ESR, CBC, Blood culture
  • Joint aspiration: cell count, gram stain, culture, protein count
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3
Q

Joint aspiration

- technique

A
  • aseptic (don’t want skin sample)

- needle and syringe

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4
Q

Joint aspiration

- fluid analysis

A
  • gross exam: appearance, color, volume, viscosity
  • Microscopic exam: WBC #, smear, glucose, protein
  • C&S
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5
Q

Joint fluid analysis

- Non-inflammatory

A
  • Gross appearance: transparent, clear-yellow
  • WBC: <2,000/mcL
  • PMN: <25%
  • culture: neg
    ex. osteoarthritis
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6
Q

Joint fluid analysis

- Inflammatory

A
  • Gross appearance: cloudy yellow
  • WBC: 5,000-50,000/mcL
  • PMN: 50-75%
  • culture: neg
    ex. JIA, SLE, RA
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7
Q

Joint fluid analysis

- Septic arthritis

A
  • Gross appearance: opaque, yellow, purulent (like pus)
  • WBC: >100,000/mcL
  • PMN: <75-100%
  • culture: pos
    ex. staph, strep, gram-neg infections
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8
Q

Joint fluid analysis

- Hemorrhagic

A
  • Gross appearance: red and opaque (bloody)
  • WBC: <5,000/mcL
  • PMN: <25%
  • culture: neg
    ex. trauma, bleeding disorder, neoplasia
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9
Q

By what age do most kids have a “normal” adult gait pattern

A

age 3

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10
Q

Toe walking

A
  • 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
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11
Q

Normal pediatric gait pattern (knees)

A
  • 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
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12
Q

Antalgic gait

A
  • less time on painful limb
  • knee injury, ankle sprain, etc.
  • think trauma or infection
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13
Q

Trendelenburg gait

A
  • 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
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14
Q

Circumduction gait

A
  • hemiplegic gait
  • swing affected leg in semicircle out to the side
  • think CP or neuropathy (foot drop)
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15
Q

Equinus gait

A
  • foot contact with toes or front of foot first
  • heel cord contracture or short limb
  • look like prancing pony
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16
Q

Hip pain in limping child

- <4 yo ddx

A
  • transient synovitis
  • osteomyelitis/septic arthritis
  • juvenile idiopathic arthritis
  • non-accidental injury (abuse, spiral fracture)
  • referred pain from limb
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17
Q

Hip pain in limping child

- 4-10 yo ddx

A
  • transient synovitis
  • Perthes disease
  • osteomyelitis/septic arthritis
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18
Q

Hip pain in limping child

- 10-16 yo ddx

A
  • SCFE
  • avulsion fx
  • osteomyelitis/septic arthritis
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19
Q

Growing pains

A
  • 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
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20
Q

Growing pains

  • Dx
  • Tx
A
  • Dx of exclusion
    • watch out bc cancer can also present as night pain…
  • TX: supportive, reassurance, rest, NSAIDS if necessary
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21
Q

Developmental Dysplasia of the Hip (DDH)

A
  • 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
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22
Q

Developmental Dysplasia of the Hip (DDH)

- risk factors

A
  • Native American
  • Fam hx of DDH
  • Female
  • first-born child
  • breech
  • oligohydramnios
  • swaddled often in adduction
  • Neuromuscular disorders (CP)
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23
Q

Developmental Dysplasia of the Hip (DDH)

- Signs and Sx

A
  • 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
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24
Q

Developmental Dysplasia of the Hip (DDH)

- Exam

A
  • Screen ALL newborns
  • Provocative maneuvers:
  • Barlow and Ortolani
  • limited ABduction, shortened limb (Galeazzi sign), increased thigh folds
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25
Q

Developmental Dysplasia of the Hip (DDH)

- Barlow and Ortolani

A
  • 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
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26
Q

Developmental Dysplasia of the Hip (DDH)

- Imagine

A

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
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27
Q

Developmental Dysplasia of the Hip (DDH)

- Treatment

A
  • Goal is containment
  • Keep femur head in socket will help deepen socket as child grows
  • Abduction brace or casting :(
  • ortho referal!
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28
Q

Transient Synovitis

A
  • 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
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29
Q

Transient Synovitis

- Signs and Sx

A
  • 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
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30
Q

Transient Synovitis

- Dx

A
  • 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
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31
Q

Transient Synovitis

- Tx

A
  • Bed rest if severe pain
  • +/- NSAIDs
  • Expect improvement in 3-14 days
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32
Q

Septic Arthritis

- cause

A
  • Hematogenous seeding

- Adjacent osteomyelitis

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33
Q

Septic Arthritis

- Sx

A
  • Acute onset pain/limp
  • guarding of joint
  • usu hip or knee
  • hx of trauma
  • 90% monoarticular
34
Q

Septic Arthritis

- Exam

A
  • Peak <2 yo
  • Febrile, SICK kid: malaise, anorexia, apprehension
  • Tenderness, warmth, swelling
  • Hip held in flexion, abduction, external rotation
  • Resists ROM
35
Q

Septic Arthritis

- Dx

A

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
36
Q

Septic Arthritis

- two MC organisms

A
  • Staph aureus

- GBS

37
Q

Septic Arthritis

- Treatment

A
  • 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
38
Q

Septic Arthritis

- Complications

A
  • AVN

- Degenerative joint disease

39
Q

Juvenile Idiopathic Arthritis

  • define
  • age
  • dx
A
  • chronic arthritis >6 weeks
  • <16 yo
  • Dx of exclusion, must r/o: Lyme, malignancy, infection, psoriasis, IBD, Strep, bleeding dz, vasculitis
40
Q

Juvenile Idiopathic Arthritis

- three types

A
  • Oligoarticular
  • Polyarticular
  • Systemic
41
Q

Oligoarticular Juvenile Idiopathic Arthritis

A
  • MC
  • onset <6 yo
  • F>M
  • ≤ 4 joints
  • Knees, ankles, wrist, elbow
  • NEVER hips
  • Lab: possible ANA+
  • Good prognosis
  • Uveitis complication = screen Q3Months
42
Q

Polyarticular Juvenile Idiopathic Arthritis

A
  • ≥ 5 joints
  • Large and small joints
  • Symmetric
  • 1-6 yo and 11-16 yo
43
Q

Polyarticular Juvenile Idiopathic Arthritis

- two subtypes

A
  • RF Negative: younger, gradual onset, multiple joints, ANA+ most
  • RF Positive: older, abrupt onset, aggressive, +/- RA nodules, poorer prognosis, persists into adulthood, F>M
44
Q

Systemic Juvenile Idiopathic Arthritis

A
  • 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
45
Q

Systemic Juvenile Idiopathic Arthritis Complications

A
  • Macrophage activation syndrome: coagulopathy, pancytopenia, liver failure, encephalopathy
  • pericarditis
46
Q

Juvenile Idiopathic Arthritis

- Treatment

A
  • NSAIDs: 1st line
  • Intraarticular steroids if only 1-2 joints
  • DMARDS (methotrexate and biologics)
47
Q

Legg-Calve-Perthes Disease

A
  • idiopathic AVN of proximal femur
  • Flattening and collapse of femoral head
  • 4-8 yo
  • M>F
  • 90% unilateral
48
Q

Legg-Calve-Perthes Disease

- pathogenesis

A
  • Ligamentum teres not developed yet = poor blood supply

- From 4-7 yo, femoral head depends entirely on lateral epiphyseal vessels

49
Q

Legg-Calve-Perthes Disease

- Stages of development

A

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

50
Q

Legg-Calve-Perthes Disease

- Signs and Sx

A
  • Painless limp ≥ 3 weeks
  • insidious onset
  • sx worse at end of day
  • activity worsens limp
  • if pain: aching groin, proximal thigh, +/- knee
51
Q

Legg-Calve-Perthes Disease

- Exam

A
  • 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
52
Q

Legg-Calve-Perthes Disease

  • XR
  • lab
A
  • 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
53
Q

Legg-Calve-Perthes Disease

- Treatment

A
  • Ortho referral!
  • <50% femoral head: observation
  • > 50% femoral head: brace or cast to contain femoral head, sx for severe deformities
54
Q

Legg-Calve-Perthes Disease

- Prognosis

A
  • Younger = better

- >10, very high risk of osteoarthritis

55
Q

Slipped Capital Femoral Epiphysis (SCFE)

A
  • 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
56
Q

Slipped Capital Femoral Epiphysis (SCFE)

- signs and sx

A
  • Hip, medial thigh, knee pain **
  • Painful limp
  • Antalgic gait with foot out
  • Limb shortening
  • Decreased ROM: internal rotation, abduction. Obligate external rotation with flexion
57
Q

Slipped Capital Femoral Epiphysis (SCFE)

- XR

A
  • 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
58
Q

Slipped Capital Femoral Epiphysis (SCFE)

  • Complications
  • Treatment
A
  • AVN, DJD
  • NWB and traction
  • Surgical stabilization, internal fixation
59
Q

Osgood-Schlatter Disease

A
  • Anterior knee pain in kids
  • Overuse injury
  • 11-13 year old, active
  • M>F
  • Pain worse with jumping, kneeling, running
60
Q

Osgood-Schlatter Disease

- Pathophys

A
  • Repetitive quadriceps contractions
  • patellar tendon pulls on growth plate of tibial tubercle
  • tibial tubercle is immature, susceptible to injury
61
Q

Osgood-Schlatter Disease

- Dx

A
  • Exam: sufficient for dx
  • TTP, swelling over anterior knee at tibial tuberosity
  • Often bilateral
  • XR can be dx but is not needed
62
Q

Osgood-Schlatter Disease

- tx

A
  • Time, reassurance
  • Conservative: ice after play, NSAIDs PRN
  • Avoid sports for 2-3 mo to heal
  • activity mods upon return
  • occasional knee immobilization
63
Q

Nursemaid’s elbow

A
  • 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
64
Q

Nursemaids Elbow

- Signs and Sx

A
  • 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
65
Q

Nursemaids Elbow

- Tx

A
  • 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
66
Q

Scoliosis

A
  • 2-3% prevalence
  • multifactorial etiology
  • Lateral curve >10 deg
  • R thoracic curve MC
  • F>M
  • 10-13 yo
  • rotation of vertebrae, sometimes kyphosis/lordosis
67
Q

Scoliosis

- Exam

A
  • asymmetry of shoulders and iliac height
  • Scalpular prominence
  • Normal gait and neuro
  • Screen with adams test (bend forward)
  • follow with scoliometer
68
Q

Scoliosis

- XR

A
  • AP and lateral
  • Use Cobb angle to measure curve magnitude
  • MRI only if neuro sx
69
Q

Scoliosis

- Tx

A
  • Observation while child is growing
  • 20-40 deg: brace with progressive curves
  • > 40: sx fusion of vertebrae (at near skeletal maturity)
  • Emotional support
70
Q

Osteogenesis Imperfecta

A
  • “brittle bone” dz
  • Genetic defect Type 1 collagen** = osteoporosis
  • AD inheritance, rare
  • Classic triad: Fragile bone w/ pathologic fx, early deafness, blue sclera
71
Q

Osteogenesis Imperfecta

  • dx
  • management
A
  • genetic testing to confirm
  • bisphosphates
  • physical rehab, bracing
  • fracture management
72
Q

Osteosarcoma

A
  • 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
73
Q

Osteosarcoma

- Clinical findings

A
  • Localized pain and swelling
  • limp
  • often noticed after minor injury
  • Dec ROM, TTP, skin warmth, +/- palpable mass
  • Pathological fx
  • Lung mets (usually =death)
74
Q

Osteosarcoma

- DX

A
  • XR: sunburst pattern**
  • Bx: required to confirm dx
  • Lab: elev. alk phos
75
Q

Osteosarcoma

- Tx

A
  • Pre op chemo
  • limb sparing sx or amputation
  • post op chemo
76
Q

Ewings Sarcoma

A
  • malignant tumor of neural crest cell origin*
  • 10-25 yo
  • EEE: Extremities, Extensive, Entire shaft
77
Q

Ewing Sarcoma

- Signs and sx

A
  • femur and pelvis MC
  • localized pain and swelling
  • soft tissue mass surrounds bone
  • fever, weight loss, fatigue
  • metastatic dz common
78
Q

Ewing Sarcoma

- Dx

A
  • XR: lytic destruction, unclear borders, layered “onion skin” appearance **
  • bone scan
  • CT/MRI
  • Bx: req for dx
79
Q

Ewing Sarcoma

- Tx

A
  • sx
  • chemo
  • radiation
80
Q

Fx of growth plate

A
  • 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
81
Q

Salter Harris Classification

A

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…

Pediatrics 2 (7 decks)

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