Musculoskeletal Disorders Flashcards
Which of the following disorders is usually associated with adduction of the forefoot?
a) internal femoral torsion
b) talipes equinovarus congenita
c) genu valgum
d) internal tibial torsion
b) talipes equinovarus congenita
The most common rheumatoid disease of childhood is:
a) Systemic lupus erythematosus
b) Kawasaki disease
c) JRA
d) Legg-Calve-Perthes disease
c) JRA
Radiographic findings of disease progression and sphericity of femoral head is helpful in the diagnosis and follow-up of:
a) Transient synovitis of the hip
b) Osgood-Schlatter disease
c) Legg-Calve-Perthes disease
d) Slipped capital femoral epiphysis
c) Legg-Calve-Perthes disease
A 4 yo boy is brought in by his mother concerned about sudden onset of a painful limp in his right leg 2 days ago. Today he has a low-grade fever. Which of the following diagnoses is most likely?
a) Osgood-Schlatter
b) JRA
c) Osteomyelitis
d) Transient synovitis of the hip
d) Transient synovitis of the hip
Which of the following would be the most appropriate initial management of a newborn diagnosed with developmental dysplasia of the hip?
a) observe and reexamine at 2-week well child visit
b) triple diapering in nursery
c) pavlik harness
d) surgical reduction
c) pavlik harness
A physical finding not usually associated with talipes equinovarus congenita is:
a) contracture of the illiotibial bands
b) deep crease on medial border of foot
c) atrophy of calf muscles
d) small foot with limited dorsiflexion
a) contracture of the illiotibial bands
A characteristic feature of polyarticular JIA disease is:
a) the involvement of 5 or more inflamed joints
b) confinement to lower extremity joints, knees, and ankles
c) asymmetric involvement
d) high, daily intermittent spiking fevers
a) the involvement of 5 or more inflamed joints
ANA seropositivity for antibodies is:
a) a valuable diagnostic marker for JIA
b) is not positive in any other childhood diseases
c) more commonly found in older boys or in systemic disease
d) present in over 75% of cases
a) a valuable diagnostic marker for JIA
dislocation of the hip of a child six months or older may typically present with:
a) asymmetry of skin folds
b) atrophied hip muscles
c) positive Galeazzi sign
d) negative Trendelenburg sign
c) positive Galeazzi sign
For a newborn, the correct management of hip dislocation should include:
a) use of flexion-abduction device such as Pavlik harness to stabilize hip
b) follow and observe closely for 3-4 weeks then refer
c) surgical reduction
d) traction for 6 weeks
a) use of flexion-abduction device such as Pavlik harness to stabilize hip
Duchenne muscular dystrophy is characterized by which of the following signs and symptoms?
a) at birth, affected infants are notably hypotonic, “floppy” babies
b) earliest symptom is often refusal to bear weight
c) abnormalities of gait and posture become evident during preschool years
d) unable to keep up with peers when running by school age
c) abnormalities of gait and posture become evident during preschool years
Most children with Duchenne muscular dystrophy become wheel-chair dependent by what age?
a) 7-9
b) 10-12
c) 14-16
d) highly variable depending on response to treatment
b) 10-12
School-aged children and young adolescents involved in athletic activities may not be at increased risk for:
a) Osgood-Schlatter disease
b) Chondromalacia
c) Spondylolysis
d) Slipped capital femoral epiphysis
d) Slipped capital femoral epiphysis
Management of scoliosis depends on the severity of curve as well as the age of the child. Which of the following would require surgical intervention?
a) curves of 15 degrees in a child who is still growing
b) thoracic and/or lumbar curve greater than 25 degrees, even if growth is complete
c) thoracic curve greater than 30 degrees or lumbar curve greater than 40 degrees that has not progressed while in brace
d) thoracic curve greater than 50 degrees or lumbar curve greater than 40 degrees
d) thoracic curve greater than 50 degrees or lumbar curve greater than 40 degrees
In performing a diagnostic workup and management plan for a child with osteomyelitis, which of the following is not accurate or recommended?
a) elevated ESR confirms diagnosis
b) aspiration is usually indicated
c) antibiotic treatment for 4-6 weeks is recommended
d) surgery is recommended if abscess if present
a) elevated ESR confirms diagnosis
A 6 yo child presents with a limp and knee pain. the PNP finds limited passive internal rotation and abduction of the hip joint on PE. The most likely diagnosis is:
a) Slipped capital femoral epiphysis
b) Osgood-Schlatter disease
c) Transient synovitis of the hip
d) Legg-Calve-Perthes disease
d) Legg-Calve-Perthes disease
Which of the following statements is true about acute osteomyelitis?
a) occurs more frequently in females than males
b) peak ages are infancy (
b) peak ages are infancy (
Which of the following statements is not true of slipped capital femoral epiphysis?
a) thought to be precipitated by hormone changes during puberty
b) unilateral involvement is more common than bilateral
c) more common among males and African-Americans
d) thought to be caused by repetitive stresses in young athletes prior to growth spurt
d) thought to be caused by repetitive stresses in young athletes prior to growth spurt
Genu varum is considered an abnormal condition when:
a) extreme knock-knees continues after 7 years of age
b) extreme bowing continues after 2 years of age
c) parents are concerned about their child’s appearance
d) evident before 2 years of age
b) extreme bowing continues after 2 years of age
Tibial torsion is commonly associated with:
a) pain
b) restricted ROM
c) internal rotation of lower extremities
d) occurance in adolescents 13-16 years of age
c) internal rotation of lower extremities
Which of the following diagnoses is associated with contracture of one of the sternocleidomastoid muscles?
a) lordosis
b) torticollis
c) scoliosis
d) kyphosis
b) torticollis
Sports injuries are commonly associated with:
a) improper training
b) higher frequency in females
c) scoliosis
d) low socioeconomic status
a) improper training
Initial treatment of a sprain includes which of the following?
a) Rest, ice, compression, elevation, & NSAIDs
b) Heat, ROM exercise, compression, elevation & NSAIDs
c) Rest, heat, compression, elevation, & NSAIDs
d) Rest, ice, ibuprofen, compression, & NSAIDs
a) Rest, ice, compression, elevation, & NSAIDs
The most definitive feature(s) for a diagnosis of “growing pains” includes:
a) exclusion of other causes of lower extremity pain
b) pain, swelling, erythema
c) loss of ambulation
d) decreased ROM
a) exclusion of other causes of lower extremity pain
Systemic-onset JIA is most commonly associated with:
a) high, daily intermittent spiking fevers and rash
b) single joint involvement
c) positive RF factor
d) painless joint involvement
a) high, daily intermittent spiking fevers and rash
Signs and symptoms associated with Duchenne muscular dystrophy are:
a) history of delayed developmental milestones
b) visual-motor disturbance, calf hypertrophy
c) delayed motor development, positive ortolani maneuver
d) history of clumsiness, visual-motor disturbance
a) history of delayed developmental milestones
Complications of SLE commonly include which of the following?
a) pericarditis, arthritis, nephritis
b) encephalitis, nephritis, pericarditis
c) nephritis, arthritis, rheumatic fever
d) nephritis, hemolytic anemia, contact dermatitis
a) pericarditis, arthritis, nephritis
Which of the following children need an orthopedic referral?
a) a 6 yo with mild bowing of the lower legs
b) a 6 mo with internal tibial torsion
c) a 3 wo with equinovarus of feet
d) a newborn with a positive pavlik sign
c) a 3 wo with equinovarus of feet
The PNP is seeing a newborn and notes on PE that both his feet turn in. When attempting ROM, the PNP finds that both feet move relatively freely in all directions. This pt has:
a) clubfoot
b) syndactyly
c) metatarsus adductus
d) fracture in his feet
c) metatarsus adductus
Which of the following is an appropriate goal for a child being treated for osteomyelitis?
a) prohibiting activities
b) complete course of antibiotic therapy
c) encouraging a low fat diet
d) restricting visitors
b) complete course of antibiotic therapy
In a newborn, a diagnosis of hip dislocation is suspected when:
a) positive galeazzi, barlow, and ortolani
b) wide hip abduction that is symmetric
c) flaccidity of the left leg following extension of both legs with return to flexion
d) tonic neck reflex in which the left leg is flexed
a) positive galeazzi, barlow, and ortolani
Which of the following statements is true regarding slipped capital femoral epiphysis?
a) more common in females
b) generally occurs during severe sudden trauma
c) incidence more common in athletes
d) the goal of treatment is to stabilize or improve the position of the femoral head
d) the goal of treatment is to stabilize or improve the position of the femoral head
In Legg-Calve-Perthes disease, which of the following signs and symptoms are seen?
a) insidious onset of limp with knee and groin pain
b) sudden onset of limp and pain in lateral hip
c) fever and insidious onset of limp
d) afebrile and sudden onset of limp
a) insidious onset of limp with knee and groin pain
Which of the following is true for idiopathic scoliosis, which occurs primarily in adolescents?
a) mild curves occur equally between the sexes
b) generally there is no family history
c) back pain is usually associated with curves of 35 degrees or greater
d) bracing is indicated for thoracic curves of 10-25 degrees
a) mild curves occur equally between the sexes
An injury at which of the following sites will most likely result in a bone length discrepancy?
a) diaphysis
b) epiphysis
c) medullary cavity
d) metaphysis
b) epiphysis
Bone length occurs at the epiphyseal plates which is also where blood supply enters. If the blood supply is compromised growth may be jeopardized.
Growth in muscle length is related to growth in length of:
a) underlying bone
b) underlying ligament
c) underlying tendon
d) opposing muscle group
a) underlying bone
Growth in muscles is due to the range of motion the muscle is asked to perform as the underlying bone lengthens.
Varus between the tibia and femur of up to 15 degrees followed by a progression to a neutral angle, which then progresses to valgus between 7 and 9 degrees is associated with which of the following?
a) Blount disease
b) internal tibial torsion
c) normal developmental growth pattern
d) abnormal tibiofemoral growth patten
c) normal developmental growth pattern
The normal growth pattern is one of slight varus (bowleg), which progresses to a neutral angle and then slight valgus (knock-knee). Persistence of any phase beyond what is expected warrants further investigation.
A 9 yo complains that she does not like to wear shorts because her knees look funny. Upon PE you note a genu valgum angle of greater than 15 degrees. You should:
a) reevaluate in one year if still present
b) consult with an orthopedic specialist
c) instruct her to avoid the “w” sitting position
d) encourage exercise to strengthen quadriceps
b) consult with an orthopedic specialist
Valgus up to 15 degrees is common up through the age of 8 or 9 but persistence beyond that may lead to problems and degenerative changes and warrants referral.
What is the appropriate treatment for genu varum in a 15 mo child?
a) Passive exercise with each diaper change
b) Denis Browne splint at night
c) Blount brace at night
d) No treatment is warranted
d) No treatment is warranted
Genu varum, or bowed legs, is normal until approximately 18 months.
During examination of a 2 wo you note irritability when lifted, asymmetrical Moro reflex, and spasm along the right sternocleidomastoid. What does this suggest?
a) torticollis
b) sprengel deformity
c) fractured clavicle
d) Klippel-Feil syndrome
c) fractured clavicle
A fractured clavicle is not an uncommon finding following birth, especially in large babies. the spasm of the sternocleidomastoid and asymmetrical Moro reflex are classic signs of this problem.
A child with growing pains is most likely to experience:
a) a mild limp
b) bilateral lower extremity pain
c) lower extremity pain primarily during the day
d) lower extremity pain associated with decreased ROM
b) bilateral lower extremity pain
Growing pains tend to occur during rapid growth, increasing in prevalence after 5 yo. The pain is a muscular pain located bilaterally in the legs and thighs.
A 20 mo presents in the emergency room with a greenstick fracture of his left femur. PE also reveals an enlarged anterior fontanel and enlarged costochondral junction. What do these clinical findings suggest?
a) child abuse
b) osteogenesis imperfecta
c) osteoprosis
d) rickets
d) rickets
Rickets develops after several months of vitamin D deficiency and is characterized by craniotabes and enlarged anterior fontanel with delayed closing. The enlarged costochondral junction, or rachitic rosary, is a classic sign.
Which of the following represents appropriate anticipatory guidance for a child diagnosed with slipped capital femoral epiphysis?
a) avoid contact sports until pain has resolved
b) crutches to facilitate mobility during acute
phase
c) apply ice to affected area
d) range-of-motion and strengthening exercises
b) crutches to facilitate mobility during acute
phase
Treatment of slipped capital femoral epiphysis is aimed at preventing further slippage. Since the goal is no weight bearing and avoiding flexion of the hip, no sports are recommended. ROM exercises are contraindicated.
Which of the following factors most affects outcomes in patients with LCPD?
a) age
b) severity of pain and antalgic gait
c) family history of LCPD
d) bilateral involvement
a) age
Age, because younger children have more time to remodel compared with older children.
During a 2.5 yo’s PE you note large, muscular-looking calves and observe his difficulty rising from a sitting position. The Denver screening exam reveals delays in the gross motor area. Which of the following labs would be most beneficial?
a) serum calcium
b) serum magnesium
c) serum phosphorus
d) serum creatine kinase
d) serum creatine kinase
Creatinine is formed in healthy muscle tissue from creatine at a steady rate. When muscle wasting occurs, as in muscular dystrophy, creatine excretion is dramatically increased.
The appropriate managment of Osgood-Schlatter’s disease includes:
a) local injection of soluble corticosteroid
b) decreasing activity, applying ice, and taking NSAIDs
c) program of strengthening and stretching for quadriceps
d) casting in adduction for 6 weeks
b) decreasing activity, applying ice, and taking NSAIDs
Osgood-Schlatter’s disease is a benign condition resulting from overuse and is best treated with rest and supportive therapy.
You have been treating a 14 mo for torticollis since birth. the condition has not resolved. The appropriate management would be to:
a) refer for surgical consultation
b) continue with passive range of motion
c) provide environmental stimulation opposite the contracture
d) apply cervical collar at night
a) refer for surgical consultation
Most torticollis resolves by 1 year of age. When there is no response to conservative treatment surgery is the recommended course of action.
While completing the hip exam on a newborn you are able to dislocate the infants right hip. The appropriate management plan would be to:
a) triple diaper and reevaluate in 2 weeks
b) recommend positioning prone while awake
c) refer to an orthopedic specialist
d) order tight swaddling of the infant
c) refer to an orthopedic specialist
The appropriate treatment would be an evaluation by an orthopedic specialist and most likely a Pavlik harness.
Which of the following would not be an appropriate indicator for developmental dysplasia of the hip in a 6 mo child?
a) Allis sign
b) Skinfold symmetry
c) Galeazzi sign
d) Ortolani maneuver
d) Ortolani maneuver
After 6 months of age the Ortolani maneuver is less reliable due to diminished laxity of the hip. After 2 months of age, soft tissue contractures may develop, making this test unreliable.
A 3 yo presents with a history of fever for the past several days, pain in his left leg, and refusal to bear weight on the left leg. 10 days ago he fell from a slide and bruised his leg. His WBC is slightly elevated. You suspect either toxic synovitis or osteomyelitis. Which finding supports a diagnosis of osteomyelitis?
a) recent injury
b) leg pain
c) non weight bearing
d) elevated WBC
a) recent injury
Osteomyelitis is frequently associated with local trauma, whereas toxic synovitis is more commonly associated with recent upper respiratory illness.
Which of the following suggests internal tibial torsion rather than internal femoral torsion in a 2 yo presenting with in-toeing?
a) sitting in “w” position
b) knees face forward when walking
c) generalized ligament laxity
d) limited external rotation of hip
b) knees face forward when walking
Observing the patella can be very helpful in differentiating internal tibial torsion from internal femoral torsion. The patella will rotate inward if the problem is above the knee. There is also general ligamentous laxity in other areas (fingers, elbows) associated with internal tibial torsion.
You examine a newborn with a deformity of her left foot consisting of a convex lateral border and a forefoot which can be abducted past an imaginary line extending from the middle of the heel through the second toe. Which of the following management strategies is most appropriate?
a) reverse last shoes
b) out flare shoes
c) stretching exercises
d) orthopedic referral
c) stretching exercises
Metatarsus adductus is a flexural deformity of the foot related most commonly to intrauterine positioning. Flexible deformities, that is, movement past the midline, can be managed with stretching exercises.
A macular, salmon to red colored rash with irregular borders and central clearing is typical of which of the following?
a) systemic juvenile arthritis
b) lyme disease
c) systemic lupus erythematosus
d) rheumatic fever
a) systemic juvenile arthritis
This is the characteristic rash associated with systemic juvenile arthritis that occurs in 25-50% of children.
A coach asks for advice on how to prevent Little League elbow in his 8 & 9 yo players. Which of the following would be incorrect advice?
a) have each child play only three innings
b) limit or eliminate curve balls
c) use ice massage before and after pitching
d) conduct slow warm-ups
c) use ice massage before and after pitching
Little league elbow or epicondylitis is a result of repetitive forearm supination and pronation. The goal is to prevent the injury by reducing the repetitive motion. Ice falsely reassures parent or coach that the injury can be prevented by applying ice before and after pitching.
Torticollis symptoms:
1) contracture of one sternocleidomastoid muscle
2) firm mass is body of contracted muscle that is palpable after 4 weeks of age then recedes
3) plagiocephaly present with progressive deformity
Galeazzi’s sign:
Knee height comparison with infant in supine position with flexed hips/knees
a) asymmetry evident in DDH
b) not helpful for detecting bilateral dislocation
Barlow’s sign:
Positive when movement of femoral head can be felt as it slips out onto the posterior lip of acetabulum.
Ortolani’s sign:
A click or clunk can be heard as femoral head enters or exits the acetabulum during the newborn period.
Developmental dysplasia of the hip (DDH) management:
Identification during newborn period essential for good prognosis.
1) US prior to 6 mo to assess hip stability and acetabular development
2) X-ray after 6 mo to assess femoral head/acetabulum relationship
3) goal is to restore contact between femoral head and acetabulum
4) subluxation (femoral head rests in acetabulum and can be partially dislocated with manipulation) has a high incidence of spontaneous improvement; reexamine 3-4 weeks after birth
5) if dislocated prior to 6 mo stabilize with an abduction-flexion device (Pavlik harness); if ineffective surgical reduction indicated
6) if dislocated after 6 mo surgical reduction indicated
Talipes Equinovarus Congenita:
Club foot
Serial casting at birth for 3-6 months
May require surgery to lengthen achilles
Metatarsus Adductus:
Supple in-toeing deformity
Parents stretch forefoot in all planes of motion with every diaper change for 4-6 months
Metatarsus Varus:
Ridged in-toeing deformity
Serial casting or bracing the first year of life then outflare shoes during the day until no chance of recurrance
Surgical intervention required after 4 yr if persists
Tibial torsion:
Abnormal bowing of the tibia
Usually not pathological
When sitting with knees bent at 90 degree angle and patellae pointing directly forward feet will point inward with internal tibial torsion or outward with external rotation of the tibia
Most children have spontaneous correction with growth
Genu varum:
Bowleg
Present if space between knees is greater than 2 inches when ankles are approximated
Physiologic bowing of up to 20 degrees is normal until 24 months old
Bowing usually resolves spontaneously by 24 months
Refer if present after 2 yr or if unilateral
Genu valgum:
Knock-knee
Present when knees are together and space between ankles is greater than 3 inches when standing
Normal knee alignment usually occurs spontaneously by 8 years old
Refer if present after 7 yr or if unilateral
Transient (toxic) synovitis of the hip symptoms:
1) Painful limp or hip/groin pain with acute or insidious onset
2) Usually unilateral
3) Usually preceded by an URI
4) Afebrile or low grade fever
5) Range of motion of hip causes pain, particularly internal rotation
6) No obvious signs with inspection or palpation
7) Males affected twice as often as females
Transient (toxic) synovitis of the hip management:
1) hospitalize until septic arthritis is ruled out
2) X-ray normal or slightly widened joint space medially
3) US useful in determining effusion
4) joint fluid aspiration normal
5) analgesics for pain
6) bedrest/non-weight bearing
7) benign, self-limiting illness
Legg-Calve-Perthes Disease (LCPD) symptoms:
Avascular necrosis of the femoral head
1) insidious onset of limp with knee pain that is activity-related and resolves with rest
2) pain in groin and lateral hip
3) pain less severe than toxic synovitis or septic arthritis
4) afebrile
5) most common in Caucasian boys 4-9 yr
6) limited or resistant to passive internal rotation and abduction of hip joint
Legg-Calve-Perthes Disease (LCPD) management:
1) X-ray demonstrates disease progression and sphericity of femoral head (used for definitive diagnosis)
2) goal is to restore ROM while maintaining femoral head within acetabulum
3) observation only (1-3 years) if full ROM preserved, child is less than 8 yr or less than 1/2 of the femoral head is involved
4) aggressive treatment (surgical intervention) if more than 1/2 of femoral head is involved or child is older than 8 yr
Idiopathic scoliosis management:
If curve is 25 degrees and child is not skeletally mature bracing may be indicated; close follow up for possible progression if still growing.
If curve is 25 degrees and child is skeletally mature no further evaluation or treatment is indicated.
Curves of 40-50 degrees should be evaluated for surgical intervention.
Curves >50 degrees are likely to increase even if skeletally mature.
Symptoms of fracture:
1) edema
2) erythema
3) ecchymosis
4) pain
5) obvious angulation
6) bony point tenderness
7) decreased ROM
Symptoms of sprain:
Grade I:
1) ligament strength is not compromised
2) minimal pain and swelling
3) full ROM
4) no increase in joint laxity
Grade II:
1) portion of ligament torn
2) clinically significant pain and swelling
3) impairment of ROM
4) detectable increase in joint laxity
Grade III:
1) complete tear of ligament
2) marked laxity when ligament is stressed
3) may require surgery to repair ligament
Slipped Capital Femoral Epiphysis symptoms:
Spontaneous dislocation of femoral head from femoral neck that typically occurs during an adolescent growth spurt. More common in males, African-Americans, and obese/sedentary adolescents.
1) limp
2) various degrees of pain in groin, thigh, and knee
3) may have acute, severe pain with inability to walk or move hip
4) unable to properly flex hip as femur abducts/rotates externally
5) loss of internal rotation of hip when hip flexed 90 degrees
Slipped Capital Femoral Epiphysis managment:
1) X-ray confirms diagnosis and demonstrates degree of slipping between femoral head and neck
2) treatment goal is to prevent further slippage, promote closure of the physis, and avoid osteonecrosis
3) NO AMBULATION IS ALLOWED
4) surgery (in-situ pin fixation) to stabilize upper femur
5) monitor other hip for SCFE
