MSK The limping child (Pitcher- CCP 4 questions)

Question 1

when does the adult gait pattern occur ?

Answer 1

by 8-10 years old

Question 2

normal gait has what 5 key maneuvers

Answer 2

cadence
stride length 
walking velocity 
single limb support time
support base width

Question 3

antalgic gait

Answer 3

usually from pain

less time in stance phase

Question 4

trendelenburg limp

Answer 4

Trendelenburg limp—stance phase body sway away from the weak hip abductor & swing phase droop of the weak side

Question 5

waddling gait

Answer 5

seen in b/l hip involvement or neurologic dz

Question 6

stiff legged gait

Answer 6

knee extension & circumduction w/ pelvic elevation on affected side

Question 7

toe walking

Answer 7

Toe walking—habitual or due to muscle contractures, spasticity or (puncture wound on heel)

Question 8

steppage gait

Answer 8

Steppage—difficulties w/ dorsiflexion of foot usu. Assoc. w/ peroneal neuropathies

Question 9

stooped gait

Answer 9

abdominal pathology

Question 10

limping DDx in a 0-4 year old

Answer 10

hip dysplasia
toddler' fx
physeal fx
puncture wound
sprain
contusion
osteomyelitis
septic arthritis
transient/toxic synovitis ***

discitis
neoplasm

Question 11

limping DDx in 4-10 year old

Answer 11

physeal fx
puncture wound
sprain
contusion
transient/toxic synovitis
septic arthritis
osteomyelitis
Legg-Calve Perthes disease
Leukemia
Juvenile idiopathic arthritis

Question 12

DDx limping in 10-18 year old

Answer 12

Slipped capital femoral epiphysis
fx
sprain
contusion
osteomyelitis
septic arthritis
lymp disease
gonococcal arthritis 
stress fx

Question 13

developmental hip dysplasia

Answer 13

age- 0-4 years
abnormal formation of hip joint
more common in females**

• femoral head unstable within acetabulum- don’t stick together
• may be loose in socket or completely dislocated
• may occur during fetal development, at delivery or after birth
• risk factors-genetic component, anything causing crowding of the fetus—large birth, oligohydraminos; female, first born, breech (esp. feet up)
• 5-9X more common in females
• left hip> right
• more common with other ortho problems (torticollis, metatarusadductus, clubfoot) or connective tissue d/o (Larsen syn)

Question 14

Barlow

Ortolani

Answer 14

Barlow- move femoral head posterior

Ortolani- move femoral head anteriorly

Question 15

what is galeazzi sign

Answer 15

flex infants knees when lying down so that feet touch the surface and the ankles touch the buttocks

if the knees are not level then the test is positive

congential hip malformation

Question 16

toddler’s fx?

Answer 16

Def: Spiral fracture of tibia under age of 5 years

Common childhood fx

Sudden twisting of tibia
Often difficult to visualize on x-ray

Sx: pain, refusal to walk, minor swelling/warmth over site, pain with palpation

Tx: long-leg cast; heal within 3-4 wks

Question 17

physeal fracture

Answer 17

Growth plate injuries are fractures

Age: 0-16 yrs girls; 0-18 yrs boys
Weakest area of growing bone
15% of all childhood fractures

Boys>girls

Salter-Harris classification

Question 18

stress fracture?

Answer 18

Small crack in bone
Often from overuse, high impact sports
Weight bearing bones
2nd/3rd metatarsal most common
Age: 10-18 years
Sx: pain that increases with weight bearing activities, reduced with rest, tenderness to touch
Tx: rest, possible surgery depending on site

NOTE:
When muscles are overtired, they are no longer able to lessen the shock of repeated impacts. When this happens, the muscles transfer the stress to the bones. This can create small cracks or fractures

Question 19

salter type I

Answer 19

Salter 1: epiphysis separate from shaft & metaphysis—-through physis—most common in newborns/young children—excellent prognosis

slip (epiphysis separated from shaft)

Question 20

salter type II

Answer 20

Salter 2: like type 1 through physis separation of physis from metaphysis but with a small metaphysis triangle—most common epiphyseal fx—excellent prognosis

Question 21

salter type III

Answer 21

Salter 3: intraarticular fx through epiphysis—uncommon—ORIF needed

Question 22

salter type IV

Answer 22

Salter 4: intraarticular fx through epipysis, physis & metaphysis—poor prognosis—needs perfect reduction

Question 23

salter V

Answer 23

Salter 5: Crush of physis—poor prognosis, early x-ray negative, rarely occurs

Question 24

osteomyelitis

Answer 24

Inflammation of bone marrow & adjacent bone (long bone). painful

Age: all
Children: hematogenous spread
Location: metaphysis of long bones

Sx: local inflammation & fever, irritability, lethargy, bone tenderness & dec. ROM

Adults: subacute/chronic forms, secondary to open wounds

Tx: IV antibiotics (4-6 wks min.)

NOTE:Staphlococcus aureus implicated in most pts with hematogenous spread

Question 25

septic arthritis

Answer 25

Infection with the joint space hot, red, swollen join Age: all Causes: injury? Bacterial, viral, (fungi or parasite) Intense synovitis is the result of the inflammatory response Sx: monoarticular, erythema, swelling, pain, dec. ROM Knee most common*** can stick a needle in and aspirate- culture Tx: IV/PO antibiotics (4-6 wks)

Question 26

what is transient toxic synovitis

Answer 26

Sx: “irritable hip syndrome” acute hip pain*** , dec. ROM Hip in flexion/abduction & ext. rotation Age 0-10 yrs Dx of exclusion Cause: ? Infectious ---> preceding URI Tx: self limited*** (5-7 days), NSAIDS

Question 27

what is legg-calve-perthes disease

Answer 27

aka Perthes disease or idiopathic osteonecrosis of the femoral head Age 4-10 years Lack of blood flow to femoral head=necrosis Bone collapses—flattens Blood supply returns after several months New bone replaces old Boy>girls--4:1 *** Typically thin, active boys Sx: slight limp, pain in knee, thigh or groin, limited ROM, leg length discrepancy Tx: meds/reduce activity to dec. pain (children under 6); splinting or surgery to keep hip stable

Question 28

slipped capital femoral epiphysis (SCFE)

Answer 28

Noninflammatory condition; femoral head displaced from femoral neck (femoral neck is moving not head) Initially bilateral 20-40%, if unilateral, the other side slips in 30-60% Age: 10-14 years Typically overweight boys: shear stress Association with endocrine disorders - 1° hypothyroid - HGH deficiency (growth hormone) Sx: insidious, complaint of pain in hip and limp Tx: surgical stabilization

Question 29

Juvenile Idiopathic Arthritis (JIA)

Answer 29

Chronic joint pain for min. of 6 wks & age onset <16 yrs Sx: joint effusion, pain, limited ROM, warmth over the joint Morning stiffness; hip involvement unusual Prevalence: 16-150 per 100,000 Cause: unknown (?immune/environment) 7 subtypes elevated CRP and sed rate

Question 30

Lyme arthritis

Answer 30

2nd most frequent presenting sx (rash #1; erythema migrans) May occur months or years after infection Sx: Episodic initially 2/3 monoarthritis of knee Age: 10-18 yrs. Cause: Borrelia burgdorferi transmitted by tick Prevalence: US--northeast, midwest, south & west costal areas Boys=girls Tx: IV/PO antibiotics, NSAIDs

Question 31

Gonococcal arthritis

Answer 31

only going to be found unless they are sexually active Septic arthritis of the joint caused by gonococcus Age: 10-18 yrs (sexually active) Sx: same as septic arthritis Dx/Tx: aspiration of joint fluid IV/PO antibiotics (at least 1 week)

Question 32

growing pains

Answer 32

Intermittent non-articular pains in childhood Diagnosis of exclusion Sx: Typically pain at night & limited to calf, thigh or shin - -pain is short-lived and resolved with heat, massage, or mild analgesics - --Pain free during the day Cause: unknown Tx: reassurance to parents/child

Question 33

what is the most common organism involved in septic arthritis/osteomyelitis

Answer 33

staph aureus THEN nongroup A beta-hemolytic streptococci

Question 34

most common organism causing septic arthritis in neonates

Answer 34

Group B Streptococcus, Staphlococcus aureus, gram-negative bacilli

Question 35

most common organism causing septic arthritis infant (1-3 months)

Answer 35

strep staph haemophilus influenza

Question 36

most common organism causing septic arthritis in child

Answer 36

s. aureus strep pneumoniae group A strep

Question 37

most common organism causing septic arthritis in adolescent

Answer 37

S. aureus, S. pneumoniae, group A Streptococcus | plus neisseria gonorrhea

Question 38

most common organism causing septic arthritis in sickle cell disease

Answer 38

salmonella staph aureus, strep pneumonia, group A strep

Question 39

puncture wound cause of septic arthritis

Answer 39

pseudomonas

Question 40

if a pt has septic arthritis of the hip, what else are they at risk for

Answer 40

Septic arthritis of hip associated with highest risk of avascular necrosis Due to increased joint pressure on blood vessels supplying cartilage & femoral head

Question 41

how is the diagnosis of septic arthritis made

Answer 41

Definitive diagnosis by aspiration and culture of synovial fluid Radiology not diagnostic but supportive-may not be apparent until 10 days into illness

Question 42

treatment of septic arthritis

Answer 42

Treatment Most important prognostic factor for good outcome is early antibiotic treatment Cefotaxime IV (Claforan) Due to the high incidence of MRSA in the United States (62% of all skin infections), ID should be consulted for most appropriate regional antibiotic (guided by local resistance pattern) With clinical improvement, change to PO abx Total treatment 4-6 wks Low dose steroids have been shown to reduce residual joint sx with hematogenous spread

Question 43

what is the treatment for SCFE

Answer 43

Non-weight bearing until assessed by ortho Tx: surgical fixation with central screw or bone graft epiphysiodesis Most patient have good prognosis Risk for acute chondrolysis or avascular necrosis

Question 44

what are the risk factors for development of hip dysplasia

Answer 44

female breech first born (nulliparous) oligohydramnios

Question 45

presentation of acute lymphocytic leukemia in kid

Answer 45

CBC reveals elevated WBC and low HgB and plts If infectious cause (septic arthritis/toxic synovitis) would see elevated WBC but not low Hgb and plts This is picture of WBC crowding out the other cell lines Likely to see blasts on differential Patient: 2 weeks of low grade fevers, malaise & hip pain. Her temp. is 38.4 C. She refuses to bear weight on her right leg. no joint inflammation. spleen tip palpable