Pediatric MSK Flashcards
How does growth and development influence pediatric musculoskeletal assessment and disease?
- Change from cartilage to bone
- More vascular and porous
- Ability to remodel faster
- Vulnerable to infection
- Possible infarct
- Laxity of ligaments
- Always refer to age-related normal x-rays
What is the pathophysiology of Congenital torticollis?
- SCM is very tight
- Usually congenital and due to sternocleidomastoid fibrosis
- Rarely vertebral anomaly
What is the diagnostic evaluation for Congenital torticollis?
Inspect-palpate-ROM
What is the management for Congenital torticollis?
- Stretching, referral to PT
- If persistent can lead to plagiocephaly and potential helmet use
What is the pathophysiology of Developmental dysplasia?
- Breech delivery - increased risk of developmental dysplasia of the hips
- Spontaneous dislocation due to lax hip ligaments
- Improper development of femoral head and acetabulum
What are the diagnostic evaluations of Developmental dysplasia?
- Ultrasound recommended
- Typically > 1 month old
- Femoral head ossification starts at 4-6 months so early radiographs may not be helpful
- X-ray can be an alternative if infant is >5-6 months of age
What are the clinical findings of Developmental dysplasia?
- Barlo and Ortolani testing
- Palpate and range of motion
- Older infants: Galeazzi sign and decreased range of motion
What is the management of Developmental dysplasia?
- Keep the formal head in the acetabulum
- Pavlik harness ( in 1st 4 months)
- Casting (+/- traction)
Surgery (open reduction)
What is the pathophysiology of Legg-Calvé-Perthes disease?
Avascular necrosis of the femoral head
What is the epidemiology of Legg-Calvé-Perthes disease?
- Boys > girls
- Peak ages 4-8 years
What are the clinical findings of Legg-Calvé-Perthes disease?
2-3 weeks history of limp, +/- aching
What are the diagnostic evaluations of Legg-Calvé-Perthes disease?
- PE: limited abduction
- Hip films: AP and frog
What is the management of Legg-Calvé-Perthes disease?
- Containment and limit weight bearing
- Non-surgical: Muscle strengthening/ROM, casting, can take 2 to 5 years for resolution
- Surgical: Femoral osteotomy, pelvic osteotomy
What is the epidemiology of Slipped capital femoral epiphysis?
- Boys 12 - 15 years (MC)
- Girls 10 - 13 years
- Increased in obesity
What is the pathophysiology of Slipped capital femoral epiphysis?
Femoral head (epiphysis) slips posterior and inferior at the growth plate
What are the clinical findings of Slipped capital femoral epiphysis?
- Limp, pain (acute of chronic limiting)
- Pain can be located in groin, thigh, or knee region
- PE: decreased internal rotation, abduction, flexion
What is the diagnostic evaluation of Slipped capital femoral epiphysis?
X-Ray: ice cream slipped off cone
What is the management of Slipped capital femoral epiphysis?
- Immediate management: stop weight-bearing and refer immediately
- Surgical pinning
What is the pathophysiology/3 levels of Torsional and angular deformities
- Femoral anteversion
- Tibial torsion
- Metatarsus adductus
What are the clinical findings of Torsional and angular deformities
- Physiologic causes of intoeing vary with age
- Decreased external and internal ROM
What is the diagnostic evaluation of Torsional and angular deformities
Refer to age-appropriate norms
S/sx of Femoral anteversion?
- “W” sitting
- girls > boys
- intoeing ages 3-10
S/sx of internal tibial torsion?
- MC intoeing in toddlers
- patellae straight w/ feet turned inwards
S/sx of Metatarsus adductus?
- MC foot deformity of infants
- usually flexible
convex lateral surface of foot - poss. d/t intrauterine postion
What is the epidemiology of Blount disease?
More common in early walkers, obese, African Americans
What is the pathophysiology of Blount disease?
- Inhibited growth of medical aspect of proximal tibial growth plate
- 2 types = infantile and adolescent
What are the clinical findings of Blount disease?
- Asymmetric and extreme
What is the management of Blount disease?
- Surgery if bracing fails or if onset > age 4: guided growth or tibial osteotomy
What is the epidemiology of Flatfoot (pew planus)?
> 6 years
What is the pathophysiology and tx of flexible Flatfoot (pew planus)?
- Normal variant
- If painful, consider heel cord stretches
What is the pathophysiology and tx of rigid Flatfoot (pew planus)?
- May be tarsal coalition
- Treatment: casting and resection (painful)
What is the epidemiology of Clubfoot?
75% isolated, sporadic but look for other abnormalities
What is the pathophysiology of Clubfoot?
Tendons develop abnormally
What are the clinical findings of Clubfoot?
- Rigid inverted foot
- Equinus (plantar flexion at ankle)
- Varus of heel (inversion)
- Adduction of forefoot
What is the management of Clubfoot?
- Serial casting (Ponseti) followed by bracing to prevent relapse
- May require achilles tenotomy
What is the epidemiology of Scoliosis?
- Adolescence
- Girls > boys
What is the pathophysiology of idiopathic Scoliosis?
- MC
- Usually no pain
What are some causes of Scoliosis?
- Vertebral malformation (hemivertebrae) or disease (tumor)
- Neuromuscular disease
- Spinal cord disease (tethered)
What are some clinical findings of Scoliosis?
- Unequal shoulder and pelvic height
- Rib prominence on forward bending
What is the diagnostic evaluation of Scoliosis?
10 degree Cobb angle
What is the management of Scoliosis?
- Observation in most cases
- Bracing (20-50 degrees)
- Surgery (greater than 50 degrees)
What is the epidemiology of Kyphosis?
Similar frequency boys and girls
What is the pathophysiology of Kyphosis?
Congenital - progressive
What are the clinical findings of Kyphosis?
Postural - flexible
What are the diagnostic evaluations of Kyphosis?
- Scheuermann disease
- Early teens during rapid growth
- Often in pain
- > 3 adjacent wedge-shaped vertebrae
- Usually thoracic
- Refer
What is the management of Kyphosis?
- Brace
- Surgery >80 degrees
What is needed during the evaluation of a fracture?
- History
- Physical
- Imaging
- Stability of fracture
- Alignment
- Biomechanics of injury
What is the usual management of a fracture?
Casting and/or referral
What is the evaluation of a Radial head subluxation?
- Sudden jerk to forearm <3 years old
- Radiographs not needed
What is the management of a Radial head subluxation?
- Manipulation
- Normal use in 5-10 minutes
What is the evaluation of a brachial plexopathy (stinger or burner) sports injury?
Neck-shoulder traction, direct blow, and compression
What is the management of a brachial plexopathy (stinger or burner) sports injury?
- Work up if bilateral or persistent
- Return to play once asymptomatic with full range of motion
- Tend to reoccur
What are S/Sx of Little Leaguer’s shoulder?
Excessive overhead throwing can cause proximal humeral epiphysitis
What are S/Sx of Little Leaguer’s elbow?
- Overuse injuries can occur in any of the elbow’s 6 ossification centers
- Traction apophysitis - widening - avulsion
What is the evaluation of Little Leaguer’s shoulder and elbow?
- History
- Physical exam: palpate and check range of motion, neurovascular integrity
- Radiographs if bony lesions suspected
What is the management of Little Leaguer’s shoulder and elbow?
- Complete rest 4-6 weeks, ice, NSAIDs
- PT, splinting
- Refer if not improving
What are S/Sx of Spondylosis?
- Back stress + hypertension
- Separation in vertebral pars interarticularis (90% L5)
- Pain w/ lumbar extension
What are S/Sx of Spondylolisthesis?
- Instability due to spondylolysis can lead to anterior slippage of vertebral body
- Limited forward bend and straight leg lifting
- May feel a “step-off” at slippage
What is the management of Spondylosis and Spondylolisthesis?
- Pain relief, restrict activity, physical therapy
- Follow until growth complete
- Remove from aggravating sport
- Surgical fusion if: slippage >25%, progressive, and has neurologic symptoms
What is the pathophysiology of Osgood-Schlatter disease?
- Tibial traction apophysitis
- Adolescent with knee pain during and after activity
- Boys > girls
What is the evaluation of Osgood-Schlatter disease?
Point tenderness of tibial tubercle, knee joint stable
What is the management of Osgood-Schlatter disease?
- Ice, prn analgesia
- Rest/decreased activity
- Bracing during activity
- Resolves once physically mature
What is the pathophysiology of Sever Disease?
- Calcaneal apophysitis
- Heal pain
- Limp in pre-pubertal children
What is the evaluation of Sever Disease?
- Painful posterior calcaneus
- +/- tight heel cord
What is the management of Sever Disease?
- Ice, change activity, heel cord stretching, shoe modification
- Outgrown as growth plate closes
What is the etiology of Osteomyelitis?
- Source of most bone infections in the blood
- MC sites: femur and tibia
What are the clinical findings of Osteomyelitis?
- Pain and reduced function
- Redness and swelling
- Fever
What are the diagnostic evaluations of Osteomyelitis?
- Increased ESR
- Increased CRP
- CBC: sometimes WBC > 12,000 cells/uL
- Blood culture
- Plain films
- Bone scan, MRI if needed
What is the management of Osteomyelitis?
- IV antibiotics until CRP decreased by 50%, then oral for 4-6 weeks
- Staph aureus, consider MRSA
- May need surgical debridement
What is the etiology of Septic arthritis?
Bacterial source:
- Blood stream
- Cellulitis
- Puncture wound
What are the clinical findings of Septic arthritis?
- Painful single join
- Swelling
- Erythema
- Warmth
- Fever (+/-)
What are the diagnostic evaluations of Septic arthritis?
- Aspirate joint ASAP
- Blood tests:
□ ESR and CRP elevated
□ CBC may be abnormal
□ Blood culture
What is the management of Septic arthritis?
- IV antibiotics, then po (follow CRP)
- Staph and Strep coverage
- May need repeated drainage
- Course typically 3 weeks
What is the etiology of Transient synovitis?
- Joint inflammation in response to preceding viral or bacterial infection elsewhere
What are the clinical findings of Transient synovitis?
- Afebrile with limp after URI
- Peak age 3-8 years
What are the diagnostic evaluations of Transient synovitis?
- Normal labs and imaging
- Send out viral cultures and viral panel
What is the management of Transient synovitis?
- Rest
- Pain management
- Close follow up
What is the etiology of Juvenile idiopathic arthritis (or RA)?
- Arthritis in >1 joint for >6 weeks in a child
- Autoimmune inflammation that targets the synovium
What are the clinical findings of Juvenile idiopathic arthritis (or RA)?
- Joint pain
- Stiffness
- Erythema
- Swelling
What are the three types of Juvenile idiopathic arthritis (or RA)?
- Oligoarticular < 5 joints (MC)
- Polyarticular > 5 joints
- Systemic
What are the diagnostic evaluation for the Oligoarticular type of Juvenile idiopathic arthritis (or RA)?
- Medium to large joints (knee, ankle, wrist)
- Early childhood and pre-adolescent
What are the diagnostic evaluation for the Polyarticular type of Juvenile idiopathic arthritis (or RA)?
- Small to medium joints (hands, feet, ankles, wrists)
- Usually symmetrical
- Early childhood and adolescence
What are the diagnostic evaluation for the Systemic type of Juvenile idiopathic arthritis (or RA)?
- Starts with recurring fever and rash, malaise
- Organ involvement
- Polyarticular arthritis weeks-months
- Across childhood
What is the management of Juvenile idiopathic arthritis (or RA)?
- Primary care
- Rheumatology
- Meds: NSAIDs and limited corticosteroids
- Ophthalmology
- Physical therapy: range of motion and splinting
What are some distinguishable characteristics of a benign Osteochondroma?
- MC benign bone tumor (10-20 years)
- MC in males
- Begins in childhood and grows until skeletal maturity
What are the diagnostic findings of a benign Osteochondroma?
Often pedunculated, grows away from growth plate.
- Often involves medullary tissue
What is the management of a benign Osteochondroma?
Observation
What is the pathophysiology of a malignant Osteosarcoma?
- Bone pain
- Swelling
- Pathologic fracture
What are some distinguishable characteristics of a malignant Osteosarcoma?
- MC bone malignancy
- MC in adolescents (80% occur <20 years)
- Produces osteoid (immature bone)
- 90% occur in the metaphysis of long bones (MC in femur –> tibia, humerus
- MC mets to the lungs (usually the cause of death
What are the clinical manifestations of a malignant Osteosarcoma?
- Bone pain/joint swelling
- Palpable soft tissue mass
What are the diagnostic findings of a malignant Osteosarcoma?
- Radiographs: “hair on end” or “sunray/burst” appearance of the soft tissue mass
What is the management of a malignant Osteosarcoma?
- Limb-sparing resection (if not neovascular)
- Radical amputation (if neovascular)
- Chemotherapy as adjuvant treatment
What are some distinguishable characteristics of a malignant Ewing Sarcoma?
- Giant cell tumor
- MC in children
- MC in males 5-25 yrs
- Sites: Femur (MC) and pelvis
What are the clinical manifestations of a malignant Ewing Sarcoma?
- Bone pain
- +/- palpable mass
- +/- joint swelling
- +/- fever
- Bone MC site of metastasis
What are the diagnostic findings of a malignant Ewing Sarcoma?
- Lytic lesion
- Layered periosteal reaction “onion skin” appearance on radiographs
What is the management of a malignant Ewing Sarcoma?
Options include chemotherapy, surgery and radiation therapy
What are some characteristics of benign and pathologic musculoskeletal pain?
- Difficult for children to localize so may present in non-specific manner
- Prevalence of pain increases with age
When does the likelihood of pathology increases with benign and pathologic musculoskeletal pain?
- The younger the child
- The more activity is limited by pain
- If the pain awakens child from sleep
What are some S/Sxs of benign musculoskeletal pain?
- At rest pain decreases
- Simple analgesia and massage for nighttime pain relief
- Absent joint swelling
- Hypermobile joints
- Absent bony tenderness
What are some S/Sxs of pathologic musculoskeletal pain?
- At rest pain present
- Simple analgesia and massage for nighttime pain gives no change
- Present joint swelling
- Stiff joints
- Present bony tenderness
What are S/Sxs of Osteogenesis Imperfect?
- Tibial fracture
- Long-standing complaints of back pain
- Bruises easily
- Blue sclera
- Angular Cheilitis
When does the anterior fontanelle line close?
1-3 yrs
When does the posterior fontanelle line close?
2-3 mos after birth
When does the sphenoidal fontanelle line close?
6 months after birth
When does the mastoid fontanelle line close?
6-18 months after birth
