Musculoskeletal & Sports Medicine Flashcards
Name 2 types of bone cysts and describe the appropriate treatment for each one.
Unicameral (Resolve Spontaneously) and
Aneurysmal (Surgically Removed)
Bone cysts are either fluid filled (unicameral) or blood filled (aneurysmal) within a bone. Both are noncancerous, typically solitary, and occur in children and young adults. They are either asymptomatic and found incidentally on imaging studies or symptomatic with pain, limping, or fracture due to weakened bone. Unicameral bone cysts are often observed because they resolve spontaneously. Aneurysmal bone cysts are more aggressive in growth and require surgical treatment.
Name the differential diagnosis for hip pain in a child.
- Infections
- Tumors
- Transient Synovitis
- Legg-Calvé-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
Any child who presents with pain in the hip, limps, or refuses to bear weight or walk must be evaluated promptly.
A 15-year-old female presents to the emergency department complaining of muscle cramps, nausea, dizziness, and weakness after playing volleyball at the beach all day long. Physical examination reveals dry mucous membranes, skin tenting, and rectal temperature of 101.0° F (38.3° C). The rest of the physical examination is unremarkable.
What is the likely cause of this patient’s illness?
Heat Illness
Heat illness occurs when the body cannot cool itself with the typical sweating mechanism. It usually occurs in hot, humid weather with strenuous activity occurring for a long period of time. Risk factors include young age, old age, illness, being overweight, alcohol consumption prior to activity, and certain medications such as stimulants. Prevention includes staying well hydrated, replenishing salt with sports drinks, and limiting time of activity.
What steps prevent overuse injuries in child athletes?
- Limit the number of teams an athlete is on in one season.
- Do not allow an athlete to play one sport year-round.
Overuse injuries can affect bones, growth plates, and soft tissues. Due to the fact that these structures grow at an uneven rate, children are at increased risk for these types of injuries. Overuse injuries are increasing in frequency due to the competitive nature of youth sports and the year-round playing of a single sport. This puts repetitive stress on specific areas of the body without allowing for adequate rest. The main symptom is pain that is not due to an acute injury and that increases with activity. Rotation of the types of sports throughout the year allows other bones and muscle groups to be used instead of stressing the same structures for a single sport.
What are the clinical findings associated with an anterior cruciate ligament (ACL) injury?
- Knee Pain
- Popping, Swelling
- Difficulty Bearing Weight
- Anterior Translation of the Tibia on the Femur
ACL tears are more common in female athletes and usually occur in sports that require jumping, sudden stops, or quick changes in direction. The most sensitive and specific test for an ACL tear is the Lachman test, which evaluates the anterior translation of the tibia on the femur. Anterior translation of the tibia, associated with a soft endpoint is indicative of a positive test. A difference of > 2 mm of anterior translation, when compared to the uninvolved knee, is diagnostic of an ACL tear, as is ≥ 10 mm of total anterior translation. Diagnosis is usually made clinically. MRI is useful to show the associated meniscus, collateral ligament injuries, and bone bruises. Surgical reconstruction is required in most cases.
A 7-year-old boy presents with:
- Pain in his left hip and knee
- Limping for several days
- Plain x-ray of the hip shows a “ratty” appearance of the left femoral head.
What is the most likely diagnosis?
Legg-Calvé-Perthes Disease
Legg-Calvé-Perthes disease is a partial or complete idiopathic avascular necrosis of the femoral head. It is most common in boys between 3 and 12 years of age, with a peak incidence at 5–7 years of age. In this case, tell the boy to not bear weight on the affected limb and refer him to an orthopedist. Generally, it resolves with time and does not require specific therapy.
What are some of the clinical findings associated with the use of androgenic steroids as performance-enhancing drugs?
Acne, Muscle Mass Increase, Gynecomastia, Small Testicles, Hypertension, Aggressive Behavior, Inhibited Growth, Elevated Liver Enzymes, Cholestatic Jaundice
The highly competitive nature of sports today results in many athletes looking for an advantage over their opponents. Unfortunately, many of these athletes turn to performance-enhancing drugs (known as “doping”) and do not take into consideration the risks of using these substances.
What is the proper management for the 2 types of bone cysts?
Unicameral: Serial Plain Films, Observation, and Fracture Prevention; Aneurysmal: Surgical Excision
Bone cysts are either fluid filled (unicameral) or blood filled (aneurysmal) within a bone. Both are noncancerous, typically solitary, and occur in children and young adults. Unicameral bone cysts are often observed with serial plain films and activity is restricted to prevent fracture. They often resolve spontaneously. Aneurysmal bone cysts are more aggressive in growth and require surgical treatment.
A newborn is found to have the following triad:
- Short neck
- Limited neck motion
- Low occipital hairline
These associated findings are noted as well:
- Deafness
- Macrocephaly
- Meningocele
What is the syndrome?
Klippel-Feil Syndrome
Klippel-Feil syndrome occurs when there is congenital fusion of any 2 or more of the 7 cervical vertebrae. It presents with the classic triad of short neck, limited neck motion, and low occipital hairline. There are 3 types, differentiated based on the extent of vertebral column malformation. Note that fusion of C2–C3 is autosomal dominant, while C5–C6 is autosomal recessive. Deafness, macrocephaly, hydrocephalus, meningocele, and intellectual disability are common.
What is the appropriate clinical evaluation and management of scoliosis?
Identify the type of scoliosis. Perform a back examination and order plain radiographs to determine the degree of curvature, which will dictate management.
Idiopathic scoliosis is the most common and is divided into 3 categories: infantile, juvenile, and adolescent. Depending on the age and sex of the child, most cases are detected by a simple back examination with forward flexion and plain radiographs. Most scoliosis cases are asymptomatic, but when the thoracic curve is > 50°, intervention may be needed due to pulmonary function abnormalities. Treatments include physical therapy, bracing, and surgery for more advanced cases.
A 15-year-old male wants to play football at his local high school. His mother is concerned about her son getting hurt and sustaining a brain injury.
Besides a history and physical examination, what is an additional assessment now recommended for all athletes prior to participation in contact sports?
Computerized Neurocognitive Function Assessment
Computerized neurocognitive function assessment prior to participation in contact sports is growing in favor among athletic organizations. It is good to have this baseline cognitive assessment prior to any traumatic brain injury. Postconcussion assessments can then be compared for any changes in symptoms and/or cognition. It provides an objective comparison in order to improve return-to-play decisions.
What is the appropriate diagnostic evaluation for developmental dysplasia of the hip (DDH) in patients of various ages?
> 6 Months of Age: Plain Radiographs of Both Hips
Ultrasonography of both hips is the preferred method of evaluation in infants < 4–6 months of age because the femoral head has not yet ossified and cartilage and soft tissues are better delineated on ultrasound. In older infants and children, plain hip radiographs are appropriate because the femoral heads are ossified and no longer cartilaginous.
A 14-year-old female gymnast presents to the pediatrician’s office for an annual check-up. She states she has missed her period for several months and has lost some weight due to her strict diet. Physical examination reveals a thin, muscular female but nothing else of note. A urine pregnancy test is negative.
What condition is this gymnast likely experiencing?
Female Athlete Triad
The “female athlete triad” is a combination of energy deficiency (most often from disordered eating), menstural dysfunction, and decreased bone density. It is especially common in sports where a low body weight is favorable. A history of menstrual dysfunction is the earliest symptom; it should prompt you to get a detailed history of the patient’s diet and exercise. Lab work to test for pregnancy and thyroid dysfunction is usually warranted. Get a bone density study in patients with < 6 menses in 12 months and history of ≥ 2 stress fractures. Treatment requires a multidisciplinary team approach that includes the pediatrician, coach or trainer, nutritionist, and psychologist.
A 16-year-old male basketball player has noticed a painless, enlarging mass at his right quadriceps muscle over the past several weeks. He denies fever, weight loss, night sweats, or other constitutional symptoms. He admits to getting hit a lot during his basketball activities. Physical examination reveals a fixed palpable mass in the proximal anterior right thigh but minimal tenderness to palpation. Both hip and knee joints have full range of motion.
What is the likely diagnosis for this condition?
Traumatic Myositis Ossificans
Traumatic myositis ossificans is characterized by extraskeletal ossification following blunt soft tissue trauma. It typically presents as a painless, enlarging mass, most often located in the quadriceps, brachialis, or deltoid muscles. The mass is typically located away from a joint and is rounded and well circumscribed. Evaluation with plain x-rays reveal mature peripheral ossification with a distinct margin surrounding a radiolucent center of immature osteoid and primitive mesenchymal tissue. This peripheral maturation is the reverse of that seen with a neoplasm. Also in neoplasm, the bony mass is always slightly separated from the long shaft of the bone.
A 15-year-old boy presents after colliding with another player during a soccer game. He complains of knee pain, and his right knee is slightly swollen. You perform the duck walk test (patient is asked to squat down and walk like a duck), which causes reproducible pain in the medial joint line.
What is your diagnosis?
Meniscal Tear
Meniscal injuries are common, and tears usually occur due to twisting injuries while the foot is planted. Often symptoms are vague and nonspecific. Isolated meniscal tears usually cause localized pain and moderate effusion, whereas more diffuse pain and significant effusion occur if there is an associated injury to a cruciate ligament or a fracture. Diagnosis is made by asking the patient to do the duck walk; repeated passive knee flexion and extension with tibial internal and external rotation will produce pain and possible “clicking.” Note that x-rays of the knee are normal, but these injuries are clearly visible on MRI.
A patient presents with knee pain and swelling. The valgus stress test shows medial instability.
What is your diagnosis?
Medial Collateral Ligament (MCL) Injury
MCL tears are common injuries among athletes. Such a tear occurs in contact sports when the lateral knee sustains a blow causing valgus stress or in activities that require significant torque of the leg (e.g., basketball, football, tennis). Symptoms include pain, swelling, and instability over the medial knee. Most MCL injuries can be diagnosed clinically, with tenderness to palpation over the MCL and valgus laxity with high-grade injuries. Treatment is usually nonsurgical and includes rest, ice, NSAIDs, bracing, and physical therapy.
A 4-year-old boy presents with:
- Bilateral thigh and calf pain that is worse in the evening and occasionally awakens him from sleep
- No fever
- No limping
- No mobility problems
- No joint involvement
What is the most likely diagnosis?
Growing Pains
This is the classic presentation for growing pains. The key is that this is muscle pain, not joint pain. Even though it awakens the child from sleep, it is not an unusual finding. The pain is typically worse in the afternoon or evening. There are no systemic symptoms, so there is no fever. Limping and other mobility problems are not associated with this disorder. Lab is generally not necessary, but perform it if there is something atypical about the findings to exclude possible organic etiologies before making the diagnosis of benign leg pain.
What conditions are most commonly associated with congenital scoliosis?
Neuromuscular Diseases and Congenital Rib/Vertebral Anomalies
Although most cases of scoliosis are idiopathic, most of the remainder are due to neuromuscular diseases and/or congenital rib/vertebral anomalies. Cardiopulmonary compromise generally occurs if the scoliosis is severe. Ideally, congenital forms of scoliosis are diagnosed early in childhood. If found, bracing usually corrects or limits progression of the curve. Surgical intervention is often required when scoliosis is congenital or caused by neuromuscular weakness.
