Pediatric MSK Conditions

Question 1

Blount disease (idiopathic tibia vara)

Answer 1

“Bow-legged” abnormal growth in ONLY the proximal tibial apophysis results in genu varus deformity

• more common in African Americans, early walkers.
• 80% bilateral
• PAINLESS

Types:
Infantile 1-3

Juvenile 4-10

Adolescent >11 years

Question 2

Rickets causes

Answer 2

Major vitamin D deficiency that is often associated with African Americans or children who are generally less exposed to sunlight

• malabsorption of vitamin D and in the intestines or liver.
• anticonvulsants such as phenobarbital, phenytoin and antacids can lead to rickets
• can be genetic and caused by renal disease but less common.
• usually presents Bow-legged and shows tibia and femur deformities

Question 3

Rachitic Rosary

Answer 3

Ribs are pushing out of chest and are hypercurved. also present prominent knobs of ribs on xrays

Sign of rickets

Question 4

Clinical sign of rickets

Answer 4

Scoliosis, rachitic rosary, respiratory infections.

• affects BOTH femur and tibia

Question 5

Treatment of rickets

Answer 5

400 IU per day of vitamin D3 supplementation for breast fed infants (REQUIRED)

Do until the infant can drink milk on own.

Question 6

Talipes Equinovarius (Clubfoot)

Answer 6

Tarsals are hypopalstic with a usually severely inverted foot.

• 1/1000 birth caused by a trisomy in chromsome 18 and a deletion of 22q11 chromsome.
• more common in males (2:1)

Question 7

Developmental dysplasia of the hip

Answer 7

Femoral head and acetabulum form by 11 weeks gestation usually but is displaced

• often causes dislocations of the hip such as subluxation, low dislocation and high dislocation of the normal hip.
• associated with teratologic issues
• most common cause is when a child is in a frank breech position (curled up in a way where during the birth the child would come out ass first)

Question 8

Grades of DDH

Answer 8

Normal: normal

Subluxation: mild

Low dislocation: moderate

High dislocation: severe

Graded based on how far away the femoral head is away from the acetabulum

Question 9

Two maneuvers to fix DDH

Answer 9

Barlow maneuver: (posteriorly dislocate the hips and put them in normal position. Anterior-posterior and medial force)

Ortolani maneuver: (posteriorly dislocation of the hoops and put them in normal position. Lateral movements)

• must be done immediately at birth if DDH is discovered

Question 10

Asymmetrical thigh folds and brachiocephally

Answer 10

A sign of possible DDH and a frank breach pregnancy respectively

Question 11

Positive galeazzi sign

Answer 11

Knees are up at the same angle however one knee is higher than the other

• sign of untreated DDH

Question 12

Pavlov harness

Answer 12

Another way to treat DDH at a young age. Forces acetabulum to form around femoral head.

Requires a harness 24/7 for an extended period time

Question 13

Leg-calve-perthes disease (avascular necrosis of the femoral head)

Answer 13

Common in 3-12 year olds. Caused by interruption of blood supply to the capital femoral epiphysis (usually femoral artery)

Usually unilateral with 10% chance of bilateral

Signs are a atraumatic painless limp worth intermittent hip/groin pain

• X-ray usually marks this by showing very small femoral head

Question 14

Slipped capital femoral epiphysis (SCFE)

Answer 14

1/50,000 usually in age 10-16 male patients.

• high risk in African-Americans, Hispanic and polyneasian populations
• high obesity is the #1 associated risk factor
• shows reduced internal rotation and abduction of hip
• can be mild, moderate or severe based on femoral cap slippage.
• treated with screws and surgery

Question 15

Radial head subluxation (nursemaid’s elbow)

Answer 15

Common for patients under the age of 4

• usually caused by a sudden pull of the pronated arm
• causes slippage of the radial head out of the annular ligament and into the radiocapitellar joint. The annular ligament is impinged under the radial head.
• patient usually comes in with arm held close to body and refuses to use the arm

Question 16

Treatment of nursemaids elbow

Answer 16

Reduction maneuver by supination the forearm while pressing down on the radial head

If the elbow is swelling or there is history of falling get an x-ray 1st

Question 17

Pes planus

Answer 17

Normal arch is flattened until about 3 years, when normal arch develops.

• after 3 years if still flat then they have pes planus (abnormal)
• usually genetic
• ALL CHILDREN HAVE PES PLANUS UNTIL AGE 3*

Question 18

Genu varum and valgum causes

Answer 18

Often occur in growing children with rickets, skeletal dysplasia or trauma that is unresolved.

Question 19

Metatarsus adductus

Answer 19

Metatarsus and forefoot varus deformity

Bones are turned frontal half and the foot is bent into standard position to treat

Question 20

Transient mono articular synovitis (Toxic synovitis)

Answer 20

• Common cause of limping in children*
• often associated after having a viral respiratory bug and causes pain in the hip
• Can only be diagnosed by R/O septic arthritis and osteomyelitis of the hip
• aspiration of the hip joint will show no bacterial culture
• idiopathic etiology

Question 21

symptoms and Treatment of transient mono articular synovitis

Answer 21

70% of children with this have an upper respiratory tract viral infection within the last 2 weeks

• biopsies and aspirations of joint shows synovial hypertrophy, but NO infection
• usually with ages 3-8 yrs

Treatment:
NSAIDS and limit activity with bed-rest for 1-2 weeks.

Question 22

Erb’s-Duchenne paralysis or palsy

Answer 22

Damage to C5-C6 nerve root

• clinical sign is cant abduct and pronate arm
• arm is internally rotated and there is an absent Moro reflex

Question 23

Klumpkes paralysis

Answer 23

Damage to the C7-T1 roots

• presents with supinate arm, elbow bent and wrist extend
• will usually present with horners syndrome due to damage of T1*

Question 24

Osgood schlatter disease

Answer 24

Microfractures of the osgood schlatter apophysis, often due to lots of activity and usually found in boys

Causes tendonitis and pain when flaring up and cause a visible bump on the distal patella region

• 10-15 years most common

Question 25

Sever disease

Answer 25

Common cause of heel pain in active young people

• mean age is 9 for girls and 11-12 for boys
• 60% bilateral and is caused by the force of the calf through the Achilles’ tendon causing a microfracture in the calcaneal apophysis
• imaging will show increased Density of the calcaneal apophysis (back of calcaneal will show radioopaque)

Question 26

Clinical signs of SCFE

Answer 26

Affected leg shows marked reduced internal rotation, flexion and abduction

If hip on affected side is flexed, the thigh and leg with rotate externally

Pain and limp will be present

Question 27

Osteosarcoma

Answer 27

Most common primary malignant in children and adolescent between age 10-14 years

• still common in under 10 years old, but Ewing sarcoma is the most under 10 yrs*

Highly malignant pleomorphic and spindle felled neoplasm.

Presents with pain limb and swelling and is often missed

Forms from primitive bone forming mesenchyme and located at distal femur/proximal tibia

Sunburst patterns w/ Codman triangle

Question 28

Xrays in children for cancer

Answer 28

Not usually recommended at all. However if the child presents with unilateral pain in a very select and specific area, it is justified.

Question 29

Ewing sarcoma

Answer 29

3-20 years old.

Neural crest derived tumor that is based on a chromosomal translocation of 11:22

Most common in diaphysis of long bones and the pelvis.

Present with fever, weight loss, and possibly bone breaking with minimal stress.

Can be painful or not

Appears as blue cells under microscope

Question 30

Osteochondroma

Answer 30

Usually painless and appear as a bony outgrowth that is hard.

Most common sites are distal metaphysis of femur, proximal humerus and proximal tibia.

Treatment is excision since it is benign.

Question 31

Osteoid osteoma

Answer 31

Painful bone tumor that is usually benign

Commonly found in femur and tibia

Sign is a small radiolucent Indus with radioopaque sclerotic surroundings

Question 32

Osteoblastoma

Answer 32

Generally Benign tumors of spine in children

Pain is prolonged and is especially prevalent at night. Can produce scoliosis if untreated

Question 33

Diskitis

Answer 33

Infection/inflammation of IVD space and does not become osteomyelitis

Organism behind infection most of the time is staph aureus however, TB is possible and salmonella but only in sickle cell patients

Found in children <7 years with most common age being 3 yr
Usually in lumbar spine

Symptoms: back/ ab pain with irritability and typically holds spine in straight position
also lose lumbar lordosis due to paravertebral muscle spamming

Question 34

What is always a red flag in children?

Answer 34

Back pain over a week long (especially if it flares up at night)

Question 35

Aneurysm bone cyst

Answer 35

Sharp lyric and sclerotic margined Bone cancer (1B) that usually develops in the proximal tibia/ distal femur (near growth plates)

Can be REALLY large and contains blood in the wound and is always larger than the epiphyseal cartilage