Musculoskeletal Conditions Children

Question 1

Bony structure children

Answer 1

Physis - growth plate, causes longitudinal bone growth
Epiphysis - cartilagenous, then develops into secondary ossification centres
Apophysis - grows where large tendon attaches to the bone, contributes to overall shape of the bone
increased blood vessel concentration = reduced density
- means more elastic, highly vascular speeds up healing

Question 2

Apophysitis - pathophysiology

Answer 2

traction of the msucle tendon unit on the apophysis distraction
causes very localised pain and swelling
can occur at any apophysis in the body

Question 3

Apophysitis - assessment

Answer 3

onset related to increased activity or growth spurt
very localised pain
pain with contraction of relevant muscles
pain with palpation of local site
very localised swelling

Question 4

Apophysitis - management

Answer 4

self limiting - will eventually resolve once the growth plate closes and ossifies
need to manage their pain 
load reduction and modification 
stretching of involved muscle 
strengthening of involved muscles 
address biomechanics

Question 5

Osteochrondroses - pathophysiology

Answer 5

disorder of the subchondral bone
may follow trauma/microtrauma
avauscular necrosis can cause it
family genetic defect

Question 6

Osteochondritis Dissecans

Answer 6

can develop from osteochondroses - when bony damage causes loose bony fragment
has pain and may develop severe mechanical symptoms

Question 7

Osteochondroses - management

Answer 7

Type 1 and 2 - activity modifcation, immobilisation

Type 3 and 4 - surgical intervention

Question 8

Diaphysis/Metaphysis Fracture

Answer 8

Greenstick - partial fracture, doesn’t completely break the bone
Plastic Bowing - bone bent with pressure and doesn’t return to normal position
Buckle - crush fracture, tend to occur at metaphysis

Question 9

Physis Fractures

Answer 9

Salter-Harris Classification of fractures 
Type 1 - straight across the physis 
Type 2 - above the physis 
Type 3 - lower than the physis 
Type 4 - two or through the physis 
Type 5 - erasure of teh physis

Question 10

Avulsion Fracture

Answer 10

occur at the attachment of large tendons or ligaments to bone
Manage through load management, rest, gradually reloading

Question 11

Red Flags Fractures

Answer 11

complete diaphysis fracture - not normal for childrne

Question 12

Paediatric Limp - Red Flags

Answer 12

refusal to walk
pain
out toeing - when acute and with pain

Question 13

Potential Diagnosis Limp 0-3yo

Answer 13

septic arthritis
DDH
fracture
soft tissue injury

Question 14

Potential Diagnosis 3-10yo

Answer 14

irritable hip
septic arthritis
Perthes disease

Question 15

Potential Diagnosis 10-15yo

Answer 15

SUFE 
septic arthritis 
Perthes disease
fracture 
soft tissue injury

Question 16

Acetabular Dysplasia

Answer 16

develops from DDH

Question 17

Transient Synovitis/Irritable Hip

Answer 17

most common cause of hip pain in 2-10 yo 
diagnosis of exclusion - need to rule out other possibilities first 
Present with 
- limp 
- all movement is limited by discomfort 
- anterior thigh, groin or knee pain 
- normal x-ray 
Should begin to resolve within 3 days 
Be fully resolved by 2 weeks

Question 18

Perthes Disease - pathophysiology

Answer 18

avascular necrosis of the femoral head

Question 19

Perthes Disease - presentation

Answer 19

Presentation

• typically young male <13 yo
• usually small, thin and extremely active
• limp which is exacerbated by activity
• mild pain in groin, thigh or knee
• reduced ROM into Abduction, IR and maybe hip flexion
• gluteal atrophy

Question 20

Perthes Disease - management

Answer 20

want to maintain the height of the femoral head
reduced weight bearing
use orthotic devices if needed
if >8 yo = require surgery

Question 21

Leg Length Discrepancy - pathophysiology

Answer 21

Potential Causes

• congenital
• neurological conditions
• trauma
• infection
• tumours
• juvenile arthritis
• DDH
• perthes
• SUFE

Question 22

Leg Length Discrepancy - assessment

Answer 22

Observation - gait, in standing, scoliosis, look at spine in sitting 
Galeazzi sign 
Measure anatomical landmarks 
x-ray 
CT scan

Question 23

Leg Length Discrepancy - management

Answer 23

<1.5-2cm = monitor 
1.5-2.5cm = shoe raise 
>2.5 cm - refer to ortho for surgical opinion 
- shorten longer limb 
- if >5cm lengthen shorter limb

Question 24

Slipped Upper Femoral Epiphysis - Pathophysiology

Answer 24

femoral head slips from its normal allignment with the femoral neck at the physis
most common hip condition in adolescents
caused by weakness of and excessive stress through the growth plate
hormonal imbalances

Question 25

Slipped Upper Femoral Epiphysis - patient demographic

Answer 25

adolescent 11-13 yo mainly male recent growth spurt may be obese

Question 26

Slipped Upper Femoral Epiphysis - Presentation

Answer 26

``` antalgic limp LL held in ER - out toeing Hip ROM restricted in IR and Abd passive ER when passively flex the hip leg shortened on the affected side ACUTE - sudden onset of severe pain - unable to WB on LL - pain with all movements CHRONIC - dull vague pain in the groin, thigh, and knee - able to WB on LL ```

Question 27

Slipped Upper Femoral Epiphysis - Management

Answer 27

REFER TO ED - need to be non weight bearing - wheelchair Surgery - growth plate stabilisation and pinning of femoral head Rehab - NWB 2-6wks post op - maintain ROM and strength - hydro - gait training

Question 28

Osgood Schlatter Disease - pathophysiology and presentation

Answer 28

``` apophysitis of the tibial tuberosity mainly in 11-15yo pain with knee extension TOP of tibial tuberosity localised swelling ```

Question 29

Osgood Schlatter Disease - assessment and management

Answer 29

``` don't require imaging load management stretching strengthening address biomechanics ```

Question 30

Sinding Larsen Johanssen Disease

Answer 30

apophysitis of the inferior pole of the patella TOP inferior pole of patella less common

Question 31

Sever's Disease - pathophysiology and presentation

Answer 31

calcaneal apophysitis heel pain 10-12 yo affects boys more than girls

Question 32

Sever's Disease - assessment and management

Answer 32

+ve squeeze test - pain with mediolateral compression of teh calcaneal growth plate reduced DF ROM ``` recommend use of heel raise - temporarily de-load the area load management stretching strengthening address biomechanics ```

Question 33

Pes Cavus - pathophysiology and presentation

Answer 33

may be a sign of Charcot Marie Tooth Disease - need to assess for neuropathy may have pain high arch with clawed toes

Question 34

Pes Cavus - assessment and management

Answer 34

Neurological assessment | foot structure

Question 35

Scoliosis - non structural vs structural

Answer 35

Non-Structural - non progressive, fixed | Structural - progressive, fixed

Question 36

Scoliosis - Structural types

Answer 36

Neuromuscular - result of spasticity, weakness, abnormal strength - pulled into position - develop contracture and lengthening, results in scoliosis Congenital - failure of formation - may have partial or complete hemivertebrae - failure of natural segmentation Idiopathic

Question 37

Scoliosis - Management

Answer 37

monitor as they grow manage pain Surgery - if arc is greater than 40 degrees - aims to reduce magnitude of deformity and prevent cardiopulmonary function regression

Question 38

Shouder Pain Syndromes

Answer 38

mainly affect children who participate in lots of shoulder activity - overhead sports manual wheelchair may have other pre existing conditions - fracture

Question 39

Shoulder Stress Fracture

Answer 39

occur at the growth plate involved in sports with lots of throwing have pain with throwing

Question 40

Shoulder Stress Fracture - assessment and management

Answer 40

pain on palpation x-ray shows widening of teh epiphyseal line rest load management progressive throwing program

Question 41

Rheumatology - red flags

Answer 41

``` atypical injury for age and situation prolonged loss of function night pain fever visual deficits weight loss ```

Question 41

Rheumatology - red flags

Answer 41

``` atypical injury for age and situation prolonged loss of function night pain fever visual deficits weight loss ```

Question 42

Rheumatology Non-Inflammatory conditions

Answer 42

haemophilia osteogenesis imperfects arthrogyposis hypermobility

Question 43

Rheumatology Inflammatory

Answer 43

JIA Osteomyelitis Septic arthritis

Question 44

Haemophilia

Answer 44

x-linked blood clotting disorder severe spontaneous bleeding in muscles and joints persistent joint effusion and chronic synovitis effects multiple joints

Question 45

Pulled Elbow

Answer 45

``` subluxed radial head mainly in very young children history of tension on pronated forearm pain pseudopalsy - refuse to use the arm refer to GP ```

Question 46

Elbow Apophysitis

Answer 46

chronic apophysitis of the medial elbow may also have avulsion fracture and lateral structure compression - can cause osteochondritis dissecans history of overuse pain with valgus force movements

Question 47

Osteogenesis Imperfecta

Answer 47

Brittle bone disease abnormal type 1 collagen bones more susceptible to fracture and may not form properly

Question 48

Arthrogryposis

Answer 48

disorders characterised by multiple joint contractures affecting two or more body areas prior to birth physical symptoms, not diagnosis

Question 49

Acute Osteomyelitis/Septic Arthritis

Answer 49

Osteomyelitis - bacterial infection of bone, affects the metaphysis of long bones local inflammation can lead to necrosis and bone absorption Septic Arthritis - bacterial infection of the joint rapid onset of pain all movement of the joint are painful Manage - antibiotics, surgery physio to address any complications

Question 50

Goal of Physio Rheumatology

Answer 50

``` minimise pain protect joints maintain FROM prevent contractures preserve joint allignment maintain muscle strength address motor control, balance and proprioception Exercise - to maintain build strength and endurance, advice on sport participation ```

Question 51

Resistance Training Children

Answer 51

6-12yo - body weight only 13-17yo - load lifted for at least 6 reps, no maximal lifts 18yo - weight lifting allowed To calculate weight - assess 8-15reps, see when they fatigue/lose form

Question 52

Juvenile Idiopathic Arthritis - pathophysiology

Answer 52

cause is unknown, autoimmune disease age onset <16yo most children will grow out of their condition

Question 53

Juvenile Idiopathic Arthritis - presentation

Answer 53

``` active inflammation >6 weeks swelling hot pain stiffness, worse in morning rash/fever fatigue muscle weakness ```

Question 54

Juvenile Idiopathic Arthritis - impact on muscle system

Answer 54

swelling swelling reduces = ligament laxity inflammation of adjacent muscles and tendons pain and fatigue results in reduced activity = reduced AROM and eventually PROM reduced strength poor nutrition to cartilage results in cartilage damage and erosion, narrows the joint space causes joint remodelling and deformity

Question 55

Juvenile Idiopathic Arthritis - Management

Answer 55

medication - to control the disease process Physio - activity modification - hyro - splinting - avoid vicious cycle of damage and inactivity