Pediatric First Aid: Musculoskeletal Disease Flashcards
1
Q
What is the weakest site in a child’s bone?
A
The physis or “growth plate”
2
Q
Osteomyelitis
Top 3 organisms seen in INFANTS < 1 year old
A
- Staph aureus
- Strep agalactiae
- E. coli
3
Q
Osteomyelitis
Top 4 organisms seen in children < 5 years old
A
- S. aureus
- Strep pyogenes
- Strep pneumoniae
- Kingella kingae
4
Q
Osteomyelitis
Top 2 organisms seen in children > 5 years old
A
- S. aureus
2. S pyogenes
5
Q
Osteomyelitis
Organism that has increased prevalence in Adolescents
A
Neisseria gonorrhoeae
6
Q
Osteomyelitis
Organism that has increased prevalence due to puncture wounds
A
Pseudomonas
7
Q
Osteomyelitis
What is the most prevalent location of infection within the bone and why?
A
metaphysis of long bones
- high metabolic activity due to rapid growth
50% of hematogenous infection occurs in tibia/femur
8
Q
Osteomyelitis
What is the imaging modality of choice for aiding the diagnosis of osteomyelitis?
A
MRI
- provides detail not seen with bone scan and can visualize soft tissue abscesses
- plain films can be normal appearing for up to 14 days in 66% of patients
9
Q
Osteomyelitis
Treatment Plan and 3 scenarios for surgical drainage
A
- admit all children with osteomyelitis
- obtain cultures THEN start parenteral Abx
- consider surgical drainage if 1) abscess present, 2) pus from aspirate, or 3) no response to Abx in 24-48 hrs
10
Q
Osteomyelitis
What is the difference in Abx used in infants/younger children and older children (>5 yo)?
A
Infants/YC = Oxacillin and Cefotaxime
- penicillinase-resistant PCN and cephalosporin
Older Children = Nafcillin or Vancomycin
11
Q
Septic Arthritis
What is the most common organism causing polyarticular septic arthritis?
A
Neisseria gonorrhoeae
12
Q
Septic Arthritis
Top 3 organisms involved in Neonates
A
- S. aureus
- S. agalactiae
- Gram (-) enteric bacilli (K. kingae > Hib)
13
Q
Septic Arthritis
Top 4 organisms involved with Older Children
A
- S. aureus
- S. pyogenes
- S. pneumoniae
- Gonococcus
14
Q
Septic Arthritis
Management Steps (4)
A
Admit –> Ortho consult/intraoperative joint washout –> joint aspiration –> parenteral Abx IMMEDIATELY following aspiration
15
Q
Transient Synovitis
What is it and what age range is it most commonly seen in?
A
- reactive arthritis and MCC of hip pain in childhood; typically follows URI
Age Range: 2-5 yrs but can happen up to 10 years of age
16
Q
Transient Synovitis
What MUST it be distinguished from?
A
Septic Arthritis
- aspiration should be performed to make the distinction
17
Q
Transient Synovitis
How is it typically managed?
A
FIRST –> rule out septic arthritis
once RO, provide supportive therapy and NSAIDS
- expect complete recovery within a few weeks
18
Q
Osteomyelitis
Who is it most commonly seen in?
A
male preschool-aged children (50%)
- increased incidence in African-American children
19
Q
Osgood-Schlatter Disease
What is it and how does it develop?
A
- chronic inflammatory DO of proximal tibial physis were patellar tendon inserts on tibia
- tenderness over tibial tuberosity in adolescent with nonspecific aching knee pain exacerbated by exercise
- chronic microtrauma to tibial tuberosity secondary to overuse of quadriceps muscle
20
Q
Osgood-Schlatter Disease
Physical Exam Findings
A
- knee pain at tibial tuberosity reproduced by extending knee against resistance; tibial tuberosity swelling
- knee joint exam normal, absence of effusion or condylar tenderness
21
Q
Osgood-Schlatter Disease
Who is it most commonly seen in?
A
Boys 11-18 years old with rapid skeletal growth and participating in sports with repetitive jumping motions
22
Q
Osgood-Schlatter Disease
Management
A
relative rest and restriction of activities as tolerated
- knee immobilizer for severe cases
complete resolution through physeal closure
23
Q
Legg-Calve-Perthes Disease
What is it and what group has the highest incidence of developing it?
A
- avascular osteonecrosis of femoral head (disrupted proximal femoral epiphysis blood supply)
- 4:1 M:F ratio; increased incidence in 4-8 yo’s due to rapid growth of epiphyses
PAINLESS LIMP is most common presentation
24
Q
Legg-Calve-Perthes Disease
What motions are most commonly limited due to pain?
A
limited hip ABDuction and INTERNAL rotation
25
Legg-Calve-Perthes Disease
What imaging is typically acquired to determine progression and extent of necrosis?
Anterior-Posterior and Frog-Leg Lateral x-rays
- initial radiographs may be normal, making MRI a good option for detecting necrosis early on
26
Legg-Calve-Perthes Disease
Management
- pediatric ortho consult
- protect joint and abduction orthoses to contain femoral head
- rest and NSAIDs
**surgery for 6-10 yo's with large areas of necrosis**
27
Slipped Capital Femoral Epiphysis (SCFE)
What is it and what patient population is it commonly seen in?
- Salter I fracture of proximal femoral growth plate with epiphysis displacement medially and posteriorly
- usually idiopathic; seen in obese younger teenagers (can occur in children of normal weight)
28
Slipped Capital Femoral Epiphysis (SCFE)
How does it typically present and what 3 movements are lost?
- pain between groin and medial knee with painful limping
| - loss of INTERNAL rotation, FLEXION, and ABDuction (leg rolls into external rotation)
29
Slipped Capital Femoral Epiphysis (SCFE)
What imaging is used to aid diagnosis?
Anterior-Posterior and Frog-Leg lateral x-rays
- Frog-Leg shows subtle displacement more clearly
- MRI is also sensitive for this condition
**ALWAYS check contralateral hip (20-40% of patients have bilateral displacement)**
30
Slipped Capital Femoral Epiphysis (SCFE)
How is this condition managed?
orthopedic consul with internal fixation with pins
removal of weight bearing from affected limbs (crutches/wheelchair)
31
Tenosynovitis (Toxic Synovitis)
What is it and how is it treated?
- inflammation of tendon and tendon sheath due to trauma (penetrating wound), overuse
Tx: rest/NSAIDs; possible drainage in infectious circumstances
32
What is a Klein Line?
line drawn on the superior border of the femoral neck on AP view of the hip
- should pass through a portion of the femoral head; if not, think SCFE!!
33
Juvenile Idiopathic Arthritis (JIA)
What is the difference between Polyarticular, Pauciarticular, and Systemic variants?
Polyarticular (35%) - 5+ joints, symmetric, large and small
Pauciarticular (50%) - <5 joints, asymmetric, large joints
- Iridocyclitis in 50%
Systemic (20%) - fever, rash, arthritis, visceral (Still Dz)
34
Juvenile Idiopathic Arthritis (JIA)
What are the diagnostic criteria for this disease?
onset under 16 yo with arthritis in 1+ joints for > 6 weeks with history of remitting and recurring symptoms
- exclusion of other causes
35
Juvenile Idiopathic Arthritis (JIA)
How is the this condition managed?
NSAIDs
ROM and muscle-strengthening exercises
- no NSAID response? --> methotrexate, anti-TNF Abs, antipyrimidine medications
36
Reiter Syndrome
What is it and the presence of what is a major determinant of disease severity?
Triad: asymmetric arthritis, urethritis, uveitis
- reactive arthritis from Gram(-) infection --> Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia, Mycoplasma
- presence of HLA-B27 is a major determinant of disease severity
37
If a child presents with arthritis, how long should routine ophthalmologic screening be performed for and why?
- perform every 3-6 months for 4 years
| - looking for signs of iridocyclitis
38
What kind of childhood fracture commonly occurs due to a FOOSH?
Torus or "buckle" fracture
- stable fracture
39
What is a Greenstick Fracture?
incomplete fracture in long bone due to tension causing bending of the malleable bone
- bone failure on tension side and bend deformity on compression side
40
What is a Toddler Fracture?
nondisplaced spiral fracture of the tibia
- often no Hx of trauma or twisting motion with planted foot --> sxs include pain, refusal to walk, minor swelling
Tx: immobilization for a few weeks
41
Salter-Harris Fracture Types
```
Type 1
Type 2
Type 3
Type 4
Type 5
```
1 - fracture through physis ONLY
2 - through metaphysis and physis (tibia/distal radius)
3 - through epiphysis and physis (knee/ankle)
4 - through all 3 (lateral condyle of humerus)
5 - crush injury of physis (proximal tibial)
- axial compression
42
What is the difference between Grade I, II, and III ankle sprains?
Grade 1 - pain/tenderness; NO motion loss
Grade 2 - pain/tenderness; ecchymosis, some ROM loss
Grade 3 - ligament completely torn; pain/tenderness, ecchymosis, swelling, complete loss of ROM
43
Ankle Sprain Management
- RICE therapy
- joint immobilization at a right angle with Ace wrap and Jone's dressing (padded, bulky dressing)
- splinting/crutches
- NSAIDs for analgesia
- early joint use and appropriate rehab
44
Radial Head Subluxation
What age group is this condition most commonly seen in?
ages 1-4; more frequent under the age of 2
- rare after the age of 6 years (annular ligament becomes thick/strong by 5 years)
45
Radial Head Subluxation
What is the treatment of choice for this condition?
elbow placed in full supination and slowly moved to full flexion
OR
overpronation will full extension of forearm
**click at lvl of radial head signifies reduction**
46
Osteosarcoma
Where does it most common develop at and who does it mainly affect?
- mainly originates at metaphyseal regions during periods of maximal growth (osteoblast tumor)
- develops in patients age 10-20 yo
47
Why should all patients with osteosarcoma undergo CT scanning?
to detect metastatic pulmonary disease
48
Osteosarcoma
What is the typical presentation seen on radiograph?
mixed sclerotic and lytic lesions in metaphyseal region
- "suburst" pattern with periosteal elevation
49
Osteosarcoma
How is it typically treated and what kind of prognosis can patients expect?
Tx: radiation and chemotherapy
Prognosis: 75% survival in nonmetastatic dz; death usually due to pulmonary metastasis
50
Ewing Sarcoma
What is it and who does it most commonly affect?
malignant tumor arising in medullary tissue
- most common bone lesion in 1st decade; second to osteosarcoma in 2nd decade
- mainly Caucasian males
51
Ewing Sarcoma
What is the typical presentation seen on radiograph?
- calcified periosteal elevation = "onion skin" appearance
| - radiolucent lytic bone lesions in diaphyseal region
52
Ewing Sarcoma
How is it typically treated and what kind of prognosis can patients expect?
Tx: radiation, chemotherapy, surgical resection
Prognosis: small localized tumor 50-75% survival; metastatic dz has poor prognosis
53
Why should all patients with suspected Ewing Sarcoma undergo CT scanning?
determine extent of metastasis
- most commonly site of metz is the lungs
54
Osteoid Osteoma
What is it, how does it appear on radiography, and how is it managed?
- reactive bone lesion; mainly in boys with point tenderness
- osteosclerosis around small radiolucent nidus
Tx: aspirin relieves pain; surgical incision curative
55
What two locations are Osteoid Osteomas most commonly found?
Femur and Tibia
56
Enchondroma
What is it, how does it appear on radiography, and how is it managed?
- cartilaginous lesions found in tubular bones of HANDS/FEET (predilection for phalanges)
- radiolucent diaphyseal/metaphyseal lesion; "fingernail streaks in bone"
Tx: surgical curettage and bone grafting
57
Osteochondroma
What is it, how does it appear on radiography, and how is it managed?
- benign, cartilage-capped protrusion of osseous tissue arising from surface of bone; painless/hard/nontender mass
- pedunculated or sessile mass in metaphyseal region of long bones
- excision if symptomatic; rarely becomes malignant
58
What is the most common bone tumor in children?
Osteochondroma
59
Baker Cysts
What are they, how are they diagnosed, and how are they managed?
- synovium herniation in knee joint into popliteal region (lined by true synovium)
- commonly transilluminates; aspiration of mucinous fluid from popliteal fossa
- benign --> nearly always disappear; avoid surgery unless significant pain
60
Patient has Baker Cyst and leg swelling. What must be ruled out?
DVT
61
Developmental Dysplasia of the Hip (DDH)
What are Ortolani and Barlow maneuvers?
Ortolani - reduction maneuver
- slowly ABduct flexed hip
- femoral head shifts into acetabulum
Barlow - provocative maneuver
- slowly ADduct flexed hip
- dislocates the hip
62
Developmental Dysplasia of the Hip (DDH)
What is Galeazzi's Sign and what age range is it commonly positive in if patient has DDH?
- knee is lower on affected side when hips are flexed
| - typically present at 3-6 months with limited hip abduction
63
Developmental Dysplasia of the Hip (DDH)
Why are the Barlow and Ortolani maneuver's not as reliable in 3-6 month old children with likely DDH?
muscle contractures begin to develop and the tests become negative
64
Developmental Dysplasia of the Hip (DDH)
What imaging is usually acquired in children < 6 months and > 6 months?
< 6 months = ULTRASOUND
- acetabulum/proximal femur cartilaginous
> 6 months = RADIOGRAPHS
- proximal femoral epiphysis ossifies by 4-6 months
65
Developmental Dysplasia of the Hip (DDH)
What treatment is available for these age ranges:
Newborn - 6 months
6 months - 3 years
> 3 years
N-6 = Pavlik harness (several months)
- flexion and abduction of hip
6 mo-3yr = skin traction (3 weeks) prior to closed/open reduction
> 3 yrs = surgery to correct acetabulum/femur deformities
66
Do double/triple diapers help with DDH correction?
NO!
67
What is the triad associated with Osteogenesis Imperfecta?
What oral complication is seen with this disease?
fragile bones, blue sclera, early deafness
Oral = Dentinogenesis Imperfecta
- normal enamel, dysplastic dentin
68
Osteogenesis Imperfecta (OI)
How is this disease inherited and what does the mutation affect?
Autosomal DOMINANT
- mutations that encode for Type I collagen
69
Osteogenesis Imperfecta (OI)
What treatment is available and what is the long-term prognosis for patients?
Tx: bisphosphonates, surgical correction of deformities, trauma prevention
Prognosis: poor; most pts in wheelchair by adulthood
70
Osteogenesis Imperfecta (OI)
What radiographic findings are typically seen in these patients?
- osteopenia, thin cortices, bone bowing
| - Wormian bones ("floating" intrasutural bones of skull)
71
What is Klippel-Feil Syndrome and what 3 tests should be performed for further work-up?
- congenital fusion of a variable number of cervical vertebrae (failure of C-spine segmentation)
Tests: renal U/S, hearing test, lateral flexion-extension radiographs
**associated with renal anomalies, scoliosis, spina bifida, deafness**
72
What is the difference in management of Congenital Torticollis vs Acquired Torticollis?
Congenital: PT for stretching
Acquired: warm soaks, analgesics, passive stretch, collar
73
What is the inheritance of Duchenne Muscular Dystrophy/Becker Muscular Dystrophy vs Myotonic Muscular Dystrophy?
DMD/BMD = X-linked Recessive
MMD = Autosomal Dominant
74
How elevated is Creatinine Kinase compared to normal in patients with DMD?
What is seen on muscle biopsy?
50-100x higher than normal
Biopsy: degeneration/variation in fiber size and proliferation of connective tissue. NO DYSTROPHIN.
75
What is the difference in age and severity of symptoms between Duchenne and Becker Muscular Dystrophies?
DMD = loss of ambulation by 8-12 yo; rapid progression
- pelvic girdle before shoulder girdle
BMD = late childhood, typically 5-15 yo; slow progression
- inability to walk occurs after 16 yo
76
What areas are typically affected in Myotonic Muscular Dystrophy?
What areas experience involuntary clenching?
muscle weakness of voluntary muscles
- FACE, DISTAL LIMBS, DIAPHRAGM
involuntary clenching of HANDS/JAW, PTOSIS, and respiratory difficulty
77
How does Limb Girdle Muscular Dystrophy present and what is seen on biopsy?
Autosomal Recessive; high sporadic incidence
- pelvic girdle before shoulder girdle (asymmetrically)
Bx: dystrophic muscle changes with NORMAL DYSTROPHIN
78
What are the two types of Limb Girdle Muscular Dystrophy?
Pelvifemoral (Leyden-Mobius)
Scapulohumoral (Erb's Juvenile)
79
Facioscapulohumeral Muscular Dystrophy
How is it inherited and how does it present?
Inheritance: Autosomal Dominant
S&Sxs: diminished facial movements (no eye closing, whistling, or smiling); weakness of shoulder girdle (no arms over head)
- slow progression; normal life span
80
Dermatomyositis/Polymyositis
What pediatric population is typically affected and what are the common signs/symptoms?
Pop: 5-14 yo females
S/S: symmetric proximal muscle weakness
- violaceous rash (symmetric/erythematous) on extensors, upper eyelids (HELIOTROPE), knuckles
81
Dermatomyositis/Polymyositis
What 3 enzymes reflect the activity of disease and what is used to distinguish these from neuropathic causes of muscle weakness?
Enzymes: ESR, CK, aldolase
- Electromyography (EMG) is used to distinguish between myopathic vs neuropathic causes
82
Dermatomyositis/Polymyositis
First-line treatment and Refractory treatment (3)
First-line: Prednisone
Refractory: IVIG, cyclosporine, methotrexate
83
What is the inheritance pattern of Marfan and Ehlers-Danlos?
What proteins are dysfunctional in each?
Both are Autosomal Dominant
```
MDz = Fibrillin
EDDz = Collagen
```
84
Tall stature, long/thin digits (arachnodactyly), hyperextensible joints, high arched palate, dilation of aortic root, spontaneous pneumothorax, ectopia lentis.
Marfan or Ehlers-Danlos?
Marfan Syndrome
Ectopia Lentis = lens dislocation
85
Child normal at birth but develops skin hyperelasticity, fragile skin/blood vessels, joint hypermobility, tissue rupture.
Marfan or Ehlers-Danlos?
Ehlers-Danlos Syndrome
86
What is the common age of onset for scoliosis in boys and girls?
Who does it affect more often?
```
Boys = 11-12 yo
Girls = 9-10 yo
```
- 4-5x more common in females
87
When does screening for scoliosis begin?
6-7 years old
88
What is the treatment for scoliosis based on these angles of curvature:
< 20 degrees
20-40 degrees
> 40 degrees
< 20 = PT and back exercises (strengthen muscles)
20-40 = orthopedic back brace
- brace does not dec curve; only stops further progression
> 40 = spinal fusion
89
What is the prognosis for scoliosis based on these angles of curvature:
> 60 degrees
< 40 degrees
> 60 = poor pulmonary function; large thoracic curves associated with decreased life spans
< 40 = usually does not progress; small curves well-tolerated
90
What is Kyphosis and what is seen on x-ray?
posterior curvature of the spine
x-ray: anterior wedging of at least 5 degrees of three or more adjacent thoracic vertebral bodies
91
Where does acquired spondylosis most commonly occur at?
What about congenital?
Acquired = L5 (85%)
Congenital = Cervical spine
92
What is the most common cause of low back pain in adolescent athletes?
Spondylolysis
93
Spondylolisthesis Displacement %
```
Grade I
Grade II
Grade III
Grade IV
Grade V
```
I = < 25% displacement
II = 25-50% displacement
III = 50-75% displacement
IV = 75-100% displacement
V = complete displacement
94
Management of Spondylolisthesis
< 30% displacement
> 50% displacement
< 30% = no sports restrictions but routine follow-up
> 50% = in situ posterior spinal fusion or bracing
95
What is Diskitis and who does it typically affect?
pyogenic infection of intervertebral disc space (uncommon primary infection of nucleus pulposus --> secondary involvement of cartilaginous end plates/vertebral body)
- most spontaneously present before 10 yo
96
What part of the spine does diskitis most commonly occur at and what organism is the most responsible cause?
lumbar spine
S. aureus
97
What is the best imaging for diagnosis of diskitis and how is it treated?
Imaging: MRI, elevated ESR
Tx: IV Abx; surgery if abscess
98
What other disease does Renal Osteodystrophy resemble?
Rickets
99
Renal Osteodystrophy
What is it and what are typical signs/symptoms?
bone disease due to defective mineralization due to RENAL FAILURE
S/S: growth retardation
- muscle weakness
- bone pain
- skeletal deformities
- slipped epiphyses
100
Renal Osteodystrophy
How does serum calcium, phosphorus, Alk Phos, and PTH change due to disease?
Calcium: normal to low
Phosphorus: normal to elevated
Alk Phos: elevated
PTH: normal
101
Renal Osteodystrophy
How is it treated and what is the overall goal of treatment?
Tx: low-phosphate formula
- enhance focal phosphate excretion with oral CALCIUM CARBONATE (binds phosphate in GI tract)
Goal: normalize serum calcium/phosphorus lvls and keep PTH in normal range (200-400 pg/mL)
102
Osteochondritis Dissecans
What is it and how does it present?
avascular necrosis of bone adjacent to articular cartilage (typically as an overuse injury)
S/S: vague pain (ankle/knee)
- palpate defect below articular cartilage in flexed position
- loose body in the joint
103
Osteochondritis Dissecans
Where does it most commonly occur at in the body?
lateral portion of medial femoral condyle
104
Osteochondritis Dissecans
How is it diagnosed and treated?
Dx: x-ray shows subcondylar osteonecrosis
- MRI may also help with diagnosis
Tx:
- < 11 yo --> observe with serial radiographs for healing
- adolescents --> excision of small fragments; replacement/fixation of large fragments
