Musculoskeletal Disorders

Question 1

Assessment of Orthopedic System - History

Answer 1

1. Onset of symptoms
2. Pain
3. Deformity
4. Altered function
5. Altered gait
6. Family history
7. Medical history
8. Review of systems

Question 2

Assessment of Orthopedic System - Inspection and palpation

Answer 2

1. skin color, swelling, etc.
2. posture while sitting, standing, walking
3. evaluation of symmetry, ROM, muscle size, strength, tone
4. reflexes, spinal nerves

Question 3

Assessment of Orthopedic System - ROM exam

Answer 3

• range, flexion, extension, rotation of joint
• hypermobility

Question 4

Assessment of Orthopedic System - Gait examination

Answer 4

1. Developmental stages
2. Observe walking with and without shoes
3. Compare stance and swing phases, ROM of each joint
4. Should be smooth, rhythmic, efficient, symmetrical
5. Limping is a disturbance in gait
6. Disturbances may be more apparent with fatigue

Question 5

Assessment of Orthopedic System - Posture

Answer 5

1. Pelvis and hips should be level
2. legs should be symmetric in shape/size
3. Feet should point straight ahead
4. Spine should be straight; back should be symmetric
5. Shoulder/scapula heights/waist angles equal

Question 6

Hip Examinations

Answer 6

1. Galeazzi maneuver
2. Barlow maneuver
3. Ortolani maneuver
4. Klisic test
5. Trendelenburg sign
6. Medial and lateral rotations

Question 7

Galeazzi Maneuver

Answer 7

• For hip examinations
• can signal leg length discrepancies
  1. Child is in the supine position with soles of feet on the table and knees up at a 45 degree angle
  2. Check that knee height is equal

Question 8

Barlow Maneuver

Answer 8

• for hip examinations
  -assesses the potential for dislocation of a non-displaced hip in an infant during the first month of life, looking for laxity and instability
  1. Infant is supine with knees flexed
  2. Hip flexed and thigh adducted with downward pressure
  3. With hip instability, femoral head slips from acetabulum with palpable dislocation

Question 9

Ortolani Maneuver

Answer 9

• for hip examinations
• only performed in the first months of life
• it reduces a posteriorly dislocated hip and is performed gently to reduce a recently dislocated hip
  1. Infant is supine with knees flexed
  2. Provider’s thumb is near the lesser trochanter; second finger on bony prominences of greater trochanter
  3. A positive sign is a palpable click as femoral head is reduced

Question 10

Klisic Test

Answer 10

• for hip examinations
• provides an observational sign of hip placement
  1. The PCP places the tip of the 3rd finger of one hand over the greater trochanter and the index finger of the same hand on the anterosuperior iliac spine
  2. An imaginary line is drawn between the index and 3rd fingers (normally the line points towards the umbilicus)
  3. If it doesn’t point towards the umbilicus, then the hip is displaced

Question 11

Trendelenburg Sign

Answer 11

• for hip examinations
• can be used to identify conditions that cause weakness in the hip abductors
  1. Have the child stand and raise one leg off the ground
  2. If the iliac crest drops on raised leg side, then the test is positive
  3. Normally the muscles around a stable hip are strong enough to maintain a level pelvis if one leg is raised

Question 12

Medial and Lateral Rotations

Answer 12

• for hip examinations
  1. Child is placed prone with knees flexed 90 degrees
  2. Asymmetric rotation is abnormal

Question 13

Adams Forward Bend Position

Answer 13

• to check for asymmetry of posterior chest wall
• can evaluate structural scoliosis
• scoliometer measures greater than 5-7 degrees will beed further evaluation

Question 14

Laboratory Studies for Orthopedic Conditions

Answer 14

1. ESR
2. CRP
3. CBC
4. Blood cultures
5. RF
6. ANA
7. carnitine, lactic acid, leptin, pyruvates (for muscle metabolism)
8. bone and muscle biopsies

Question 15

Splints

Answer 15

• used when swelling is anticipated
• used in an acute injury for initial stabilization

Question 16

Casts

Answer 16

• circumferential
• less forgiving and higher rate of complications
• teach parents circulatory assessment and nerve function assessment

Question 17

Costochondritis and Sternochondritis

Answer 17

• common cause of chest pain in children and adolescents
• the condition is characterized as an inflammatory process of one or more of the costocondral cartilages that causes localized tenderness and pain in the anterior chest wall

Question 18

Causes of Costochondritis and Sternochondritis

Answer 18

• trauma
• heavy lifting
• coughing

Question 19

Characteristics of Costochondritis and Sternochondritis Pain

Answer 19

1. Pain localized to costosternal/costochondral junction
2. Acute or gradual onset
3. Sharp, darting, dull
4. Radiation for chest to upper abdomen/back
5. Occasional reports of tightness - muscle spasm
6. Coughing/sneezing/deep inspiration/movement may exacerbate

Question 20

Physical Examination of Costochondritis and Sternochondritis

Answer 20

1. Tenderness over costochondral junction
2. Tietze syndrome - pain, swelling, redness, tenderness
3. Ecchymosis if trauma is the cause

Question 21

Diagnostic Studies for Costochondritis and Sternochondritis

Answer 21

None needed

Question 22

Management of Costochondritis and Sternochondritis

Answer 22

1. mild analgesia (NSAIDs)
2. cough suppressants

Question 23

Back pain that warrants immediate attention

Answer 23

• children younger than 4 years
• persistent symptoms
• limited activity
• increasing discomfort
• nighttime pain
• systemic/neurologic symptoms
• history of TB or cancer warrants immediate attention

Question 24

Diagnostic Studies for Back Pain

Answer 24

1. CBC, ESR, CRP - infection
2. RF, ANA - rheumatologic
3. AP and lateral x-rays
4. MRI or CT - neurologic symptoms or bone involvement

Question 25

Scoliosis

Answer 25

• three dimensional deformity
• lateral curvature of spin in frontal plane
• two types: nonstructural and structural

Question 26

Nonstructural Scoliosis

Answer 26

functional; curve without rotation of vertebrae; reversible
- caused by posture, pain, leg length discrepancy

Question 27

Structural Scoliosis

Answer 27

rotational element of spine

Question 28

Diagnosis of Scoliosis

Answer 28

• curvature greater than 10 degrees using Cobb method
• Idiopathic: most common type
• Congenital: structural anomaly at birth
• Neuromuscular: in non-ambulatory patients

Question 29

Physical Examination of Scoliosis

Answer 29

• evaluate in standing position from front/side to look for asymmetry
  1. Shoulder height
  2. Scapula prominence/height
  3. Waist angles
  4. Rib prominence/chest
  5. Elbow to flank distance
  6. Rib heights in forward bending position
  7. Leg length
  8. Also look for hairy patches, nevi, cafe au lait, and dimples

Question 30

Management of Scoliosis

Answer 30

• Stop curvature progression and improve pulmonary function
• Observation, bracing, surgery
• Referral is essential

Question 31

Leg Aches of Childhood

Answer 31

• “growing pains”
• nonarticular: in shins, calves, thighs, popliteal fossa
• almost always bilateral
• late in the day or is nocturnal, lasting minutes to hours with no pain in the morning
• must differentiate between these and more serious causes

Question 32

Physical Examination of Leg Aches in Childhood

Answer 32

• have child stand on tiptoes and heels
• measure leg lengths
• evaluation of range of motion, limp
• assess for swelling, erythema, tenderness

Question 33

Diagnostic Studies for Leg Aches in Childhood

Answer 33

None

Question 34

Management of Leg Aches in Childhood

Answer 34

• reassurance
• refer if pain localized in one region