Musculoskeletal Flashcards
2 inflammatory musculoskeletal disorders seen in pediatrics
- Osgood-Schlatter disease
2. Toxic synovitis
Osgood-Schlatter disease
Inflammation of the tibial tubercle as a result of repetitive stressors (ie avulsion injury) in patients with immature skeletal development
- athlete that does repetitive stress
- during a time of rapid growth
- causes a painful lump below the kneecap
Peak age of Osgood-Schlatter disease
11-14 years
**associated with rapid growth spurt
S/S of Osgood-Schlatter disease
- Pain and tenderness at tibial tubercle (below the kneecap)
- Point tenderness
- Enlargement compared to unaffected side (lump)
Labs/diagnostics for Osgood-Schlatter disease
None: typically diagnosis is made clinically
*make the diagnosis with your thumb
Radiographs can be done to rule out more serious causes of pain
Management of Osgood-Schlatter disease
- Self-limiting disease
- Limit activity to control pain.
- Complete activity restriction is not recommended. Need to LIMIt acitivity based on pain in order to decrease pain and bump/inflammation. Once they are done growing/done with growth spurt, the pain will go away.
- Knee immobilizers may provide some relief.
* to decrease vibration of the inflamed tendon
Toxic Synovitis
Self-limiting inflammation of the hip that is most likely due to a viral or immune cause.
Often proceeded by URI or other viral illness.
Also called transient synvotitis.
*inner lining of the hip joint is inflamed
Peak age of Toxic Synovitis
Occurs most often between 2-6 years, but can occur from 1-15 years old
Males > females
S/S Toxic Synovitis
- Painful limp
- Unilateral involvement
- Insidious onset
- Internal rotation of hip causes spasm ***
- No obvious signs of infection on inspection/palpation (no hotness, warmth, or swelling)
**hurts and limping on 1 hip = unilateral
Labs/diagnostics for Toxic Synovitis
- Normal radiographs
2. Normal joint fluid aspiration
Management of Toxic Synovitis
- Analgesics/NSAIDs
- Bed rest as needed
- Typically benign and self-limiting
- Hospitalization should be considered if the patient has a high fever or septic arthritis is suspected.
2 non-inflammatory musculosketal disorders in pediatrics
- Legg-Calve-Perthes disease
2. Slipped capital femoral epiphysis
Legg-Calve-Perthes disease (LCPD)
Aspectic or avascular necrosis of the femoral head
- no good blood flow to the area
Etiology/Incidence of Legg-Calve-Perthes disease
- Unknown etiology, possibly d/t vascular disruption
- - increased risked in sickle cell and those on steroids - Slightly shorter stature or delayed bone age compared to peers
- Most common in Caucasian boys, ages 4-9
S/S Legg-Calve-Perthes disease
- Insidious onset of limp with knee pain; pain may also migrate to groin/lateral hip
* *pain starts in knee and goes up to groin - Pain less acute and severe than transient synovitis or septic arthritis
- Afebrile
Physical findings in Legg-Calve-Perthes disease
- Limited passive internal rotation and abduction of the hip joint
- May be resisted by mild spasm or guarding
- Hip flexion contracture and leg muscle atrophy occur in long-standing cases
**any movement of the joint is painful
Labs/diagnostics for Legg-Calve-Perthes disease
- Radiographic studies
2. No labs necessary
Management treatment for Legg-Calve-Perthes disease
- Goal: to restore range of motion (ROM) while maintaining femoral head within acetabulum
- Observation only
OR - Aggressive treatment/ortho referral
Observation only in Legg-Calve-Perthes disease if:
- Full ROM is preserved
- Less than 6 years of age
- Involvement of less than 1/2 of the femoral head
Aggressive treatment in Legg-Calve-Perthes disease if:
- Indicated when more than 1/2 femoral head is involved
- Children > 6 yo
- Refer to orthopedics
Slipped capital femoral epiphysis
Spontaneous dislocation of femoral head (capital epiphysis) both downward and backward relative to the femoral neck and secondary to disruption of the epiphyseal plate
Etiology/Incidence of Slipped capital femoral epiphysis
- Unknown etiology; perhaps precipitated by puberty-related hormone changes
- Generally occurs withOUT severe, sudden force or trauma
- Typically during growth spurt and prior to menarche in girls
- Rare: 1-8:100,000
- Males and African American adolescents most common
- Incidence greater among OBESE adolescents with sedentary lifestyles!!!
S/S Slipped capital femoral epiphysis
- Pain in the groin and often referred to thigh/and or knee
2. When acute onset, pain will be severe with the inability to ambulate or move hip
Physical findings in Slipped capital femoral epiphysis
Unable to properly flex hip as femur abducts/rotates externally
May observe limb shortening, resulting from proximal displacement of metaphysis
Labs/diagnostics for Slipped capital femoral epiphysis
Accurate history combined with knowledge of etiological factors
Radiographs
Typically no labs
Management/Treatment for Slipped capital femoral epiphysis
- IMMEDIATE referral to orthopedist
- No ambulation permitted
- Monitor other hip for same problem
3 structural musculoskeletal disorders seen in pediatrics
Genu varum
Genu valgum
Scoliosis
Genu varum
Bowleg
Lateral bowing of the tibia, often due to joint laxity
Considered a normal variant until age 2 years; most common in toddlers
S/S Genu varum
- It is acceptable for bowing that does not increase after walking
- Retains FROM
Labs/diagnostics for Genu varum
None
Management of Genu varum
- None necessary under age 2 years if appear as normal variant
Refer Genu varum to orthopedics if:
- Continues after age 2 years
- Unilateral
- Gets worse with walking
- Becomes progressively worse after first year
Genu Valgum
Knock-Knee
Knees are abnormally close and ankle space is increased
Typically evolves to normal alignment by 7 years of age
Preschool most common age
S/S of Genu Valgum
- Knees close together
- Distance b/w medial malleoli (ankles) in > 3 inches
- No pain
- FROM
- Walk or run may be awkward
Labs/diagnostics for Genu Valgum
- None necessary
2. Radiographs if over age 7 years of if unilateral involvement is present
Management of Genu Valgum
- None necessary
2. Refer if lasting after age 7 or if unilateral involvement
Scoliosis
Lateral curvature of the spine that is idiopathic and most common in adolescence.
Other types are congenital (ie infancy) or neuromuscular (a/w conditions).
Females > males 8:1
70% of cases are familial
S/S of Scoliosis
- May occur at any age
- Rarely painful
- Asymmetry of shoulder, ribs, hips, and waistline (Adam’s Forward Bend Test)
* *if asymmetry seen in any of the places = scoliosis
Labs/diagnostics for Scoliosis
Radiographs for further evaluation
**put on x-ray order: “quantification of scoliosis” in order to see the degree of curvature
Management of Scoliosis
- Further evaluation in any degree if pain occurs
- - possible PT to increase muscle tone and decrease pain - Observe if no pain exists and if less than 25 degree curvature
- REFER if painful or greater than 25 degree curvature
Muscular Dystrophy (Duchenne)
Chronic progressive disorder
Progressive genetic disorder beginning in the lower extremities and progressing to the upper extremities and torso
*The most common inherited neuromuscular disease in children.
Affects 1:3,500 MALES
Average age of diagnosis is 3-5 years
S/S of Muscular Dystrophy
- Abnormailities of gait and posture
* always leaning on something - Developmental clumsiness
- Cannot keep up with developing peers
- Gower’s sign
- Firm, large, woody calves (healthy muscle replaced by degenerative tissue)
- Decreased proximal muscle strength
* loose core muscles first and then loose peripheral - Wheelchair dependent by age 12 years
- Eventual death from cardiopulmonary failure
**intellect NOT affected
Gower’s sign a/w Muscular Dystrophy
Child “walks” hands up to legs to attain standing position when getting up
Suggest pelvic girdle weakness
Labs/diagnostics for Muscular Dystrophy
Creatine kinase: Markedly elevated in affected males (15,000-35,000 IU/L) – measures muscle death/damage
***only 1 you need to do in primary care – then refer to palliative care b/c it is a progressive disease
Electromyography (EMG): Myopathy
EKG: Abnormal
Muscle biopsy: Necrotic degenerating fibers
DNA analysis of gene: to diagnosis
Management of Muscular Dystrophy
- Symptomatic care to delay progression and maintain strength and mobility
- Genetic testing
Ankle Sprain
Stretching or tearing of the ligaments around the ankle, typically involving the lateral ligament complex
- most common sports injury
- most common musculoskeletal injury
- usually a forced inversion (lateral ankle) or eversion (medial ankle)
S/S of Grade I ankle sprain
= stretching but no tearing of ligament; no joint instability
- local tenderness
- minimal edema
- ecchymoses typically insignificant or absent
- FROM remains although it may be uncomfortable
- patient retains weight bearing ability
S/S of Grade II ankle sprain
= partial (incomplete) tearing of ligament; some joint instability but definite end-point laxity
- pain immediately upon injury
- localized edema and ecchymosis
- significant pain with weight bearing
- ROM is limited and painfull
S/S of Grade III ankle sprain
= complete ligamentous tearing; joint instability with no definite endpoint to ligamentous stressing
- severe pain immediately upon injruy
- significant edema along foot and ankle
- profound ecchymosis d/t hemorrhage; worsens over several days
- patient cannot bear weight
- No ROM to ankle
**usually go to UC or ER right after injury
Labs/diagnostics for ankle sprain
Radiograph is indicated according to Ottawa Ankle Rules if:
a. There is pain near the malleoli AND
b. Bone tenderness is present at the posterior edge of the distal 6 cm or the tip of either malleolus OR
c. The patient is unable to bear weight for at least 4 steps at the time of injury and evalution
Management for ankle sprain
- RICE: All grades including III (unless severe grade) respond well
Rest: Avoid weight bearing for first several days
Ice: Should be applied on top of the compression dressing as quickly as possible following the injury: 30 minutes on and off alternately
Compression: Immediate secure compression (will minimize edema and support stability of the ankle)
Elevation: For several days following injury (reduces pain and swelling and promotes recovery)
- NSAIDs for pharmacologic relief for pain and support`
Salter-Harris fracture
Uniqure to pediatric patients of varying ages, Salter-Harris fractures occur in the growth plate of long bones during development
Boys are twice as likely as girls to sustain a Salter-Harris fracture
S/S of Salter-Harris fracture
- Traumatic injury ***
- Localized joint pain with warmth, swelling, and tenderness
- Limited ROM and weight-bearing capability
- Bone displacement
Labs/diagnostics for Salter-Harris fracture
- Diagnosis based on clinical findings as radiographs may appear normal
- X-ray
- CT scan
- US (in infants)
Salter I
Slipped - fracture line extends through physis (growth plate)
Salter II
Above - most common fracture; extends through both the physis and metaphysis
Salter III
Lower - intra-articular fracture extending from the physis and epiphysis
Salter IV
Through/transverse - intra-articular passing through epiphysis, physis, and metaphysis
Salter V
Rammed/ruined - rare, with severe crushing or compression injury that extends through epiphysis and physis
Management of Salter-Harris fracture
- Prescription pain medicine
- Rest, elevation, ice
- Closed reduction and casting or splinting for Salter I and II
- Open reduction internal fixation for Salter III and IV
Elbow fracture
Often a/w injuries resulting from straight, outstretched arm falls
S/S of Elbow fracture
Fat pad sign
- no fracture is visible on x-ray
- the lateral view demonstrates elevation of the anterior and posterior fat pads
- even if fracture cannot be visualized on radiograph, the fat-pad sign suggest the presence of an occult fracture
Labs/diagnostics for Elbow fracture
Follow-up radiographs with an oblique view
Management of Elbow fracture
Refer to orthopedics to be treated as a fracture
Nursemaid elbow
Common injury in young children resulting from shining or pulling child’s arm
= radial head subluxation
S/S of Nursemaid elbow
- Inability/refusal to use affected arm
- Pain with supination ***
- Holds arm across body with thumb up
- Significant swelling and bruising justifies X-ray
Labs/diagnostics for Nursemaid elbow
X-ray will read as normal and is usually not done
Management of Nursemaid elbow
Pop it back in place
Supportive care at home with NSAIDs
