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A Pediatrics Compendium > Pediatric First Aid: Musculoskeletal Disease > Flashcards

Pediatric First Aid: Musculoskeletal Disease Flashcards

1
Q

What is the weakest site in a child’s bone?

A

The physis or “growth plate”

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2
Q

Osteomyelitis

Top 3 organisms seen in INFANTS < 1 year old

A
  1. Staph aureus
  2. Strep agalactiae
  3. E. coli
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3
Q

Osteomyelitis

Top 4 organisms seen in children < 5 years old

A
  1. S. aureus
  2. Strep pyogenes
  3. Strep pneumoniae
  4. Kingella kingae
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4
Q

Osteomyelitis

Top 2 organisms seen in children > 5 years old

A
  1. S. aureus

2. S pyogenes

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5
Q

Osteomyelitis

Organism that has increased prevalence in Adolescents

A

Neisseria gonorrhoeae

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6
Q

Osteomyelitis

Organism that has increased prevalence due to puncture wounds

A

Pseudomonas

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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

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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
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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
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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

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11
Q

Septic Arthritis

What is the most common organism causing polyarticular septic arthritis?

A

Neisseria gonorrhoeae

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12
Q

Septic Arthritis

Top 3 organisms involved in Neonates

A
  1. S. aureus
  2. S. agalactiae
  3. Gram (-) enteric bacilli (K. kingae > Hib)
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13
Q

Septic Arthritis

Top 4 organisms involved with Older Children

A
  1. S. aureus
  2. S. pyogenes
  3. S. pneumoniae
  4. Gonococcus
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14
Q

Septic Arthritis

Management Steps (4)

A

Admit –> Ortho consult/intraoperative joint washout –> joint aspiration –> parenteral Abx IMMEDIATELY following aspiration

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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

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16
Q

Transient Synovitis

What MUST it be distinguished from?

A

Septic Arthritis

  • aspiration should be performed to make the distinction
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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
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18
Q

Osteomyelitis

Who is it most commonly seen in?

A

male preschool-aged children (50%)

  • increased incidence in African-American children
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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
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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
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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

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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

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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

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24
Q

Legg-Calve-Perthes Disease

What motions are most commonly limited due to pain?

A

limited hip ABDuction and INTERNAL rotation

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25
Q

Legg-Calve-Perthes Disease

What imaging is typically acquired to determine progression and extent of necrosis?

A

Anterior-Posterior and Frog-Leg Lateral x-rays

  • initial radiographs may be normal, making MRI a good option for detecting necrosis early on
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26
Q

Legg-Calve-Perthes Disease

Management

A
  • 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

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27
Q

Slipped Capital Femoral Epiphysis (SCFE)

What is it and what patient population is it commonly seen in?

A
  • 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)
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28
Q

Slipped Capital Femoral Epiphysis (SCFE)

How does it typically present and what 3 movements are lost?

A
  • pain between groin and medial knee with painful limping

- loss of INTERNAL rotation, FLEXION, and ABDuction (leg rolls into external rotation)

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29
Q

Slipped Capital Femoral Epiphysis (SCFE)

What imaging is used to aid diagnosis?

A

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)

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30
Q

Slipped Capital Femoral Epiphysis (SCFE)

How is this condition managed?

A

orthopedic consul with internal fixation with pins

removal of weight bearing from affected limbs (crutches/wheelchair)

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31
Q

Tenosynovitis (Toxic Synovitis)

What is it and how is it treated?

A
  • inflammation of tendon and tendon sheath due to trauma (penetrating wound), overuse

Tx: rest/NSAIDs; possible drainage in infectious circumstances

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32
Q

What is a Klein Line?

A

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!!
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33
Q

Juvenile Idiopathic Arthritis (JIA)

What is the difference between Polyarticular, Pauciarticular, and Systemic variants?

A

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)

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34
Q

Juvenile Idiopathic Arthritis (JIA)

What are the diagnostic criteria for this disease?

A

onset under 16 yo with arthritis in 1+ joints for > 6 weeks with history of remitting and recurring symptoms

  • exclusion of other causes
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35
Q

Juvenile Idiopathic Arthritis (JIA)

How is the this condition managed?

A

NSAIDs
ROM and muscle-strengthening exercises

  • no NSAID response? –> methotrexate, anti-TNF Abs, antipyrimidine medications
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36
Q

Reiter Syndrome

What is it and the presence of what is a major determinant of disease severity?

A

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
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37
Q

If a child presents with arthritis, how long should routine ophthalmologic screening be performed for and why?

A
  • perform every 3-6 months for 4 years

- looking for signs of iridocyclitis

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38
Q

What kind of childhood fracture commonly occurs due to a FOOSH?

A

Torus or “buckle” fracture

  • stable fracture
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39
Q

What is a Greenstick Fracture?

A

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
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40
Q

What is a Toddler Fracture?

A

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

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41
Q

Salter-Harris Fracture Types

Type 1
Type 2
Type 3
Type 4
Type 5
A

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

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42
Q

What is the difference between Grade I, II, and III ankle sprains?

A

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
Q

Ankle Sprain Management

A
  • 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
Q

Radial Head Subluxation

What age group is this condition most commonly seen in?

A

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
Q

Radial Head Subluxation

What is the treatment of choice for this condition?

A

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
Q

Osteosarcoma

Where does it most common develop at and who does it mainly affect?

A
  • mainly originates at metaphyseal regions during periods of maximal growth (osteoblast tumor)
  • develops in patients age 10-20 yo
47
Q

Why should all patients with osteosarcoma undergo CT scanning?

A

to detect metastatic pulmonary disease

48
Q

Osteosarcoma

What is the typical presentation seen on radiograph?

A

mixed sclerotic and lytic lesions in metaphyseal region

  • “suburst” pattern with periosteal elevation
49
Q

Osteosarcoma

How is it typically treated and what kind of prognosis can patients expect?

A

Tx: radiation and chemotherapy

Prognosis: 75% survival in nonmetastatic dz; death usually due to pulmonary metastasis

50
Q

Ewing Sarcoma

What is it and who does it most commonly affect?

A

malignant tumor arising in medullary tissue

  • most common bone lesion in 1st decade; second to osteosarcoma in 2nd decade
  • mainly Caucasian males
51
Q

Ewing Sarcoma

What is the typical presentation seen on radiograph?

A
  • calcified periosteal elevation = “onion skin” appearance

- radiolucent lytic bone lesions in diaphyseal region

52
Q

Ewing Sarcoma

How is it typically treated and what kind of prognosis can patients expect?

A

Tx: radiation, chemotherapy, surgical resection

Prognosis: small localized tumor 50-75% survival; metastatic dz has poor prognosis

53
Q

Why should all patients with suspected Ewing Sarcoma undergo CT scanning?

A

determine extent of metastasis

  • most commonly site of metz is the lungs
54
Q

Osteoid Osteoma

What is it, how does it appear on radiography, and how is it managed?

A
  • reactive bone lesion; mainly in boys with point tenderness
  • osteosclerosis around small radiolucent nidus

Tx: aspirin relieves pain; surgical incision curative

55
Q

What two locations are Osteoid Osteomas most commonly found?

A

Femur and Tibia

56
Q

Enchondroma

What is it, how does it appear on radiography, and how is it managed?

A
  • 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
Q

Osteochondroma

What is it, how does it appear on radiography, and how is it managed?

A
  • 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
Q

What is the most common bone tumor in children?

A

Osteochondroma

59
Q

Baker Cysts

What are they, how are they diagnosed, and how are they managed?

A
  • 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
Q

Patient has Baker Cyst and leg swelling. What must be ruled out?

A

DVT

61
Q

Developmental Dysplasia of the Hip (DDH)

What are Ortolani and Barlow maneuvers?

A

Ortolani - reduction maneuver

  • slowly ABduct flexed hip
  • femoral head shifts into acetabulum

Barlow - provocative maneuver

  • slowly ADduct flexed hip
  • dislocates the hip
62
Q

Developmental Dysplasia of the Hip (DDH)

What is Galeazzi’s Sign and what age range is it commonly positive in if patient has DDH?

A
  • knee is lower on affected side when hips are flexed

- typically present at 3-6 months with limited hip abduction

63
Q

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?

A

muscle contractures begin to develop and the tests become negative

64
Q

Developmental Dysplasia of the Hip (DDH)

What imaging is usually acquired in children < 6 months and > 6 months?

A

< 6 months = ULTRASOUND
- acetabulum/proximal femur cartilaginous

> 6 months = RADIOGRAPHS
- proximal femoral epiphysis ossifies by 4-6 months

65
Q

Developmental Dysplasia of the Hip (DDH)

What treatment is available for these age ranges:

Newborn - 6 months
6 months - 3 years
> 3 years

A

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
Q

Do double/triple diapers help with DDH correction?

A

NO!

67
Q

What is the triad associated with Osteogenesis Imperfecta?

What oral complication is seen with this disease?

A

fragile bones, blue sclera, early deafness

Oral = Dentinogenesis Imperfecta
- normal enamel, dysplastic dentin

68
Q

Osteogenesis Imperfecta (OI)

How is this disease inherited and what does the mutation affect?

A

Autosomal DOMINANT

  • mutations that encode for Type I collagen
69
Q

Osteogenesis Imperfecta (OI)

What treatment is available and what is the long-term prognosis for patients?

A

Tx: bisphosphonates, surgical correction of deformities, trauma prevention

Prognosis: poor; most pts in wheelchair by adulthood

70
Q

Osteogenesis Imperfecta (OI)

What radiographic findings are typically seen in these patients?

A
  • osteopenia, thin cortices, bone bowing

- Wormian bones (“floating” intrasutural bones of skull)

71
Q

What is Klippel-Feil Syndrome and what 3 tests should be performed for further work-up?

A
  • 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
Q

What is the difference in management of Congenital Torticollis vs Acquired Torticollis?

A

Congenital: PT for stretching

Acquired: warm soaks, analgesics, passive stretch, collar

73
Q

What is the inheritance of Duchenne Muscular Dystrophy/Becker Muscular Dystrophy vs Myotonic Muscular Dystrophy?

A

DMD/BMD = X-linked Recessive

MMD = Autosomal Dominant

74
Q

How elevated is Creatinine Kinase compared to normal in patients with DMD?

What is seen on muscle biopsy?

A

50-100x higher than normal

Biopsy: degeneration/variation in fiber size and proliferation of connective tissue. NO DYSTROPHIN.

75
Q

What is the difference in age and severity of symptoms between Duchenne and Becker Muscular Dystrophies?

A

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
Q

What areas are typically affected in Myotonic Muscular Dystrophy?

What areas experience involuntary clenching?

A

muscle weakness of voluntary muscles
- FACE, DISTAL LIMBS, DIAPHRAGM

involuntary clenching of HANDS/JAW, PTOSIS, and respiratory difficulty

77
Q

How does Limb Girdle Muscular Dystrophy present and what is seen on biopsy?

A

Autosomal Recessive; high sporadic incidence

  • pelvic girdle before shoulder girdle (asymmetrically)

Bx: dystrophic muscle changes with NORMAL DYSTROPHIN

78
Q

What are the two types of Limb Girdle Muscular Dystrophy?

A

Pelvifemoral (Leyden-Mobius)

Scapulohumoral (Erb’s Juvenile)

79
Q

Facioscapulohumeral Muscular Dystrophy

How is it inherited and how does it present?

A

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
Q

Dermatomyositis/Polymyositis

What pediatric population is typically affected and what are the common signs/symptoms?

A

Pop: 5-14 yo females

S/S: symmetric proximal muscle weakness
- violaceous rash (symmetric/erythematous) on extensors, upper eyelids (HELIOTROPE), knuckles

81
Q

Dermatomyositis/Polymyositis

What 3 enzymes reflect the activity of disease and what is used to distinguish these from neuropathic causes of muscle weakness?

A

Enzymes: ESR, CK, aldolase

  • Electromyography (EMG) is used to distinguish between myopathic vs neuropathic causes
82
Q

Dermatomyositis/Polymyositis

First-line treatment and Refractory treatment (3)

A

First-line: Prednisone

Refractory: IVIG, cyclosporine, methotrexate

83
Q

What is the inheritance pattern of Marfan and Ehlers-Danlos?

What proteins are dysfunctional in each?

A

Both are Autosomal Dominant

MDz = Fibrillin
EDDz = Collagen
84
Q

Tall stature, long/thin digits (arachnodactyly), hyperextensible joints, high arched palate, dilation of aortic root, spontaneous pneumothorax, ectopia lentis.

Marfan or Ehlers-Danlos?

A

Marfan Syndrome

Ectopia Lentis = lens dislocation

85
Q

Child normal at birth but develops skin hyperelasticity, fragile skin/blood vessels, joint hypermobility, tissue rupture.

Marfan or Ehlers-Danlos?

A

Ehlers-Danlos Syndrome

86
Q

What is the common age of onset for scoliosis in boys and girls?

Who does it affect more often?

A 
Boys = 11-12 yo
Girls = 9-10 yo
  • 4-5x more common in females
87
Q

When does screening for scoliosis begin?

A

6-7 years old

88
Q

What is the treatment for scoliosis based on these angles of curvature:

< 20 degrees
20-40 degrees
> 40 degrees

A

< 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
Q

What is the prognosis for scoliosis based on these angles of curvature:

> 60 degrees
< 40 degrees

A

> 60 = poor pulmonary function; large thoracic curves associated with decreased life spans

< 40 = usually does not progress; small curves well-tolerated

90
Q

What is Kyphosis and what is seen on x-ray?

A

posterior curvature of the spine

x-ray: anterior wedging of at least 5 degrees of three or more adjacent thoracic vertebral bodies

91
Q

Where does acquired spondylosis most commonly occur at?

What about congenital?

A

Acquired = L5 (85%)

Congenital = Cervical spine

92
Q

What is the most common cause of low back pain in adolescent athletes?

A

Spondylolysis

93
Q

Spondylolisthesis Displacement %

Grade I
Grade II
Grade III
Grade IV
Grade V
A

I = < 25% displacement

II = 25-50% displacement

III = 50-75% displacement

IV = 75-100% displacement

V = complete displacement

94
Q

Management of Spondylolisthesis

< 30% displacement
> 50% displacement

A

< 30% = no sports restrictions but routine follow-up

> 50% = in situ posterior spinal fusion or bracing

95
Q

What is Diskitis and who does it typically affect?

A

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
Q

What part of the spine does diskitis most commonly occur at and what organism is the most responsible cause?

A

lumbar spine

S. aureus

97
Q

What is the best imaging for diagnosis of diskitis and how is it treated?

A

Imaging: MRI, elevated ESR

Tx: IV Abx; surgery if abscess

98
Q

What other disease does Renal Osteodystrophy resemble?

A

Rickets

99
Q

Renal Osteodystrophy

What is it and what are typical signs/symptoms?

A

bone disease due to defective mineralization due to RENAL FAILURE

S/S: growth retardation

  • muscle weakness
  • bone pain
  • skeletal deformities
  • slipped epiphyses
100
Q

Renal Osteodystrophy

How does serum calcium, phosphorus, Alk Phos, and PTH change due to disease?

A

Calcium: normal to low
Phosphorus: normal to elevated
Alk Phos: elevated
PTH: normal

101
Q

Renal Osteodystrophy

How is it treated and what is the overall goal of treatment?

A

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
Q

Osteochondritis Dissecans

What is it and how does it present?

A

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
Q

Osteochondritis Dissecans

Where does it most commonly occur at in the body?

A

lateral portion of medial femoral condyle

104
Q

Osteochondritis Dissecans

How is it diagnosed and treated?

A

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

A Pediatrics Compendium (47 decks)

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