Pediatric MSK Disorders

Question 1

Pediatric Fractures

Answer 1

• Distal radius/Clavicle = Most common
  
  • Clavicle = boards; distal radius = Emond
• Usually do well
• Children are not small adults
• Frequent trauma = frequent fractures
• S/sxs:
  
  • Kids don’t sprain ligaments → think about physeal fracture: especially wrists
• When to Refer:
  
  • Pattern of injury unclear
  • -Abuse suspected
  • -All open fractures
  • -All fractures involving joints
  • -All swollen elbows/knees
  • -All physeal injuries
  • -All displaced or dislocated injuries

Question 2

Septic Arthritis in a Child

Answer 2

• More aggressive than osteomyelitis
• S/sxs:
  
  • Pain & tenderness, Fever, malaise
  • Limp
  • Erythema, effusion, decreased ROM
• Kocher Criteria (Hip):
  
  • -Temp > 101.3F
  • -WBC > 12,000
  • -ESR > 40, normal = 0-20
  • -inability to ambulate
  • *C-reactive protein >2.5 mg/L
  • *used to accurately predict likelihood of septic hip in a child with a limp
• Dx:
  
  • Labs: CBC, ESR, CRP, Cultures
  • Arthrocentesis: gram stain
  • ***arthrocentesis before abx
• Tx:
  
  • Seek assistance immediately

Question 3

Legg-Calves-Perthes

Answer 3

• aka Coxa Plana
• Definition:
  
  • idiopathic avascular osteonecrosis of the proximal femoral head in children due to ischemia of capital femoral epiphysis
• Risks:
  
  • males 4-8yo _(L_ittle Cids),delayed skeletal maturity (short stature), family hx, low birth weight, breech presentation
• S/sxs:
  
  • limping for weeks (worse with continued activity)
  • -hip or knee pain (**hip problems can present as knee pain in kiddos**)
• PE:
  
  • Effusion around the hip
  • -Restricted ROM (loss of abduction & internal rotation)
  • -Trendelenburg sign: stability of the hip and particularly the ability of the hip abductors (gluteus medius and gluteus minimus) to stabilize the pelvis on the femur
• Dx:
  
  • Xray: **must get frog-leg lateral (in all kids you work up for hip pain)**
  • -Early: may be normal, increased density of the femoral epiphysis, widening of the cartilage space
  • -Advanced: crescent sign (microfractures with collapse of the bone)
• Tx:
  
  • Earlier diagnosis = better outcome, if caught early = good outcome
  • -Observation: activity restriction with ortho f/u (self-limiting with revascularization), PT, brace/cast, NSAIDs
  • -Surgical: pelvic osteotomy if advanced disease

Question 4

Slipped Capital Femoral Epiphysis (SCFE)

Answer 4

• Definition:
  
  • displacement of the femoral neck from the femoral head (epiphysis) through the physis d/t weakness of the perichondrial ring. Bilateral 25% of the time.
• Risks:
  
  • African-American, males 10-15yo (during growth spurt), kids that are big for their age, obese, family hx
• S/sxs:
  
  • Painful limp that worsens with activity
  • -Ipsilateral dull, achy hip, thigh, knee or groin pain
• PE:
  
  • Externally rotated leg on the affected side
  • -Loss of internal hip rotation
  • -Upper BMI
• Dx:
• Xray:
  
  • **Must get frog-leg lateral
  • -Anterior displacement of femoral neck with external rotation
• Tx:
  
  • Refer to ortho for surgery → may require pinning
  • -Non-weight bearing with crutches followed by internal fixation with pinning

Question 5

Transient Synovitis (Toxic Synovitis)

Answer 5

• Definition:
  
  • acute, nonspecific, inflammation of the joint synovium, MCC of acute hip pain in children 3-10yo
• Etiology:
  
  • post-viral URI, allergic, trauma
• S/sxs:
  
  • *Acute Onset
  • -Limp
  • -Hip pain +/- spasms
  • -Afebrile or low-grade fever (will not meet Koch’s criteria)
• PE:
  
  • Limited ROM of the hip
• Dx:
  
  • Dx of exclusion. Need to r/o septic arthritis
  • Diagnostics:
  • -Labs: ESR < 20, WBC may be elevated
  • -Xray: normal
• Tx:
  
  • Refer to ortho for aspiration or inpatient observation
  • -Supportive care with NSAIDs, RICe, and activity restriction

Question 6

Nursemaid’s Elbow

Answer 6

• Definition:
  
  • subluxation of the radial head. Most common elbow injury in children < 5 yo
• Pathophys:
  
  • associated with increased ligamentous laxity
• Etiology:
  
  • pulling on the forearm when the elbow is extended & the forearm is pronated → annular ligament slips proximally & becomes stuck between the radius & ulna
• S/sxs:
  
  • Child will react & cry after injury, but then the pain subsides
  • -child is reluctant to use the arm, but is not in distress
• PE:
  
  • Extremity held by the side with elbow slightly flexed & forearm pronated
  • -Tenderness over the radial head
  • -Resistance on attempted supination
• Dx:
  
  • XR will be normal
• Tx:
  
  • Reduction: examiner’s thumb is placed over the radial head & the forearm fully supinated → snap
  • -Immobilization is not required