Musculoskeletal Disorders

Question 1

Osgood Schlatter Disease

Answer 1

inflammation of the tibial tubercle as a result of repetitive stress mostly commonly at age 11-14, associated with rapid growth spurt

Question 2

Toxic synovitis

Answer 2

self-limiting inflammation of the hip, most likely due to viral or immune cause; most commonly between ages 2-6 and affects males more than females

Question 3

S/sx of toxic synovitis

Answer 3

painful lymph
unilateral involvement 
insidious onset (been there for a while)
internal rotation causes hip spasm
no obvious signs of infection on inspection/palpation (no pain with palpation)

Question 4

Management of toxic synovitis

Answer 4

analgesics
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

Question 5

Legg-calve-perthes disease (LCPD)

Answer 5

aseptic or avascular necrosis of the femoral head

Question 6

Etiology of LCPD

Answer 6

unknown–but maybe d/t vascular disruption
high dose steroids
slightly shorter stature or delayed bone age compared to peers
most common in Caucasian boys, ages 4-9
Sometimes seen in kids with sickle cell disease

Question 7

S/sx of LCPD

Answer 7

insidious onset of limp with knee pain, which may also migrate to groin/lateral hip
pain less acute and severe than transient synovitis or septic arthritis
afebrile

Question 8

Physical findings of LCPD

Answer 8

limited passive internal rotation and abduction o hip joint–starts outside of knee and moves to hip
may be resisted by mild spasm or guarding
hip flexion contracture and leg muscle atrophy occur in long-standing cases

Question 9

Management of LCPD

Answer 9

goal is to restore ROM while keeping femoral head within acetabulum

Observe if:
F-ROM

Question 10

Diagnosis of LCPD

Answer 10

radiograph studies

Question 11

Slipped capital femoral epiphysis (SCFE)

Answer 11

spontaneous dislocation of femoral head (slipped ice cream cone)

Question 12

Etiology of SCFE

Answer 12

unknown–may be due to puberty-related hormone changes
generally occurs WITHOUT severe, sudden force or trauma
typical during growth spurt and prior to menarche
RARE
more common in males and African American adolescents
greater among obese and those with sedentary lifestyles

Question 13

S/sx of SCFE

Answer 13

pain in the groin and often referred to thigh and/or knee
when acute onset, pain will be severe with the inability to ambulate or move hip
Physical findings: unable to properly flex hip as femur abducts/rotates externally; may observe limb shortening, resulting from proximal displacement of metaphysis

Question 14

Treatment of SCFE

Answer 14

immediate referral to orthopedist; no ambulation permitted

monitor other hip for same problem

Question 15

Genu Varum

Answer 15

Bowleg–“too much rum, walk bowlegged”

Question 16

Genu varum is considered normal until what age?

Answer 16

2 years old

Question 17

When should you refer genu varum to ortho?

Answer 17

when it continues after age 2
if it is unilateral
or if it becomes progressively worse after the first year

Question 18

Genu Valgum

Answer 18

knock-knee–stuck together with gum
Knees are really close, ankle space is increased
typical in preschool children–most resolves by age 7

Question 19

The distance between the ankles in menu valgum is how much?

Answer 19

3 inches

Question 20

Scoliosis

Answer 20

lateral curvature of the spine–most common in adolescents

occurs more often in females with an 8:1 ratio, familial in 70% of cases

Question 21

Adam’s Forward Bend Test

Answer 21

to check for scoliosis–bend forward and look for curvature

asymmetry of shoulder, ribs, hips, and waistline

Question 22

When to refer for scoliosis

Answer 22

if painful or if greater than 25 degree curvature

Question 23

Nursemaid Elbow

Answer 23

common in injury in young children resulting from swinging or pulling child’s arm–radial head subluxation

Question 24

Signs and symptoms of nursemaid elbow

Answer 24

inability/refusal to use affected arm
pain with supination
holds arm across body with thumb up
**significant swelling/bruising justifies X-ray

Question 25

Elbow fracture

Answer 25

associated with injuries resulting from straight, outstretched arm falls

Question 26

S/sx of elbow fracture

Answer 26

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 a radiograph, that fat-pad sign suggests the presence of an occult fracture

Question 27

Ankle sprain

Answer 27

stretching and/or treating 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)

Question 28

S/sx of a grade 1 sprain:

Answer 28

stretching, but not tearing

local tenderness
stretching
CAN bear weight and full ROM

Question 29

S/sx of a grade 2 sprain:

Answer 29

partial (incomplete) tearing of a ligament, some joint instability but definite end-point laxity

pain with weight bearing
limited ROM
edema/ecchymosis

possibly an X-ray is warranted

Question 30

S/sx of a grade 3 sprain:

Answer 30

complete ligamentous tearing, joint unstable with no definite endpoint to ligamentous stressing

significant bruising/swelling
no ROM
no weight bearing

possibly an x-ray warranted

Question 31

Radiograph is indicated in an ankle sprain according to the Ottawa ankle rule, which says:

Answer 31

there is pain near the malleoli and
bone tenderness is present at the posterior edge of the distal six cm or the tip of either malleolus or the patient is unable to bear weight for at least 4 steps at the time of injury evaluation

Question 32

Management of an ankle sprain

Answer 32

RICE (all grades typically respond)
rest:
ice: 30 min on, 30 min off, repeat
compression: immediate to reduce edema and support instability
elevation: 

NSAIDS

Question 33

Developmental Dysplasia of the Hip

Answer 33

abnormal dislocation of the hip in which the femoral head is partially or completely displaced from the acetabulum

Question 34

Galeazzi’s sign

Answer 34

compare knee height with infant supine, hips and knees flexed
asymmetry suggests DDH
not helpful if bilateral

Question 35

What age can you use the barlow and ortolanis test until?

Answer 35

barlow- until 6 months

ortolani’s- until one year old

Question 36

Muscular dystrophy

Answer 36

progressive genetic disorder beginning in the lower extremities and progressing to the upper extremities and torso

most common inherited neuromuscular disease in children
affects 1:3500 males
typically diagnosed at age 3-5 years

Question 37

Signs and symptoms of muscular dystrophy

Answer 37

lose strength in large muscles and core first

abnormalities of gait and posture
developmental clumsiness
cannot keep up with developing peers
gower's maneuver
firm, large, woody calves (healthy muscle replaced by degenerative tissue)
decreased proximal muscle strength
wheelchair dependent by age 12
eventual death from cardiopulmonary failure

Question 38

Gower’s maneuver

Answer 38

gets up like a crab

child walks hands up legs to attain standing position when getting up–suggests pelvic girdle weakness

Question 39

Laboratory and diagnostics with muscular dystrophy

Answer 39

elevated CK (15,000 to 35,000)
myopathy
decreased ejection fraction
necrotic degenerating fibers