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Respiratory/Musculoskeletal > Pediatric Musculoskeletal Presentation > Flashcards

Pediatric Musculoskeletal Presentation Flashcards

1
Q

What is the normal progression of bowing as a child ages?

A

All children are born bow-legged (genu varum)
2-3 yrs the bowing improves and the child tends to be more knock-kneed (genu valgum).
7 yrs the child will have corrected to a more adult gait

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2
Q

What are signs that genu varum is pathologic?

A
  1. asymmetric, unilateral
  2. painful
  3. does not progress in the expected pattern
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3
Q

What are the 5 diseases included on the differential for pathologic genu varum?

A
  1. Blount’s disease
  2. Tumor (asymmetric, unilateral, pain)
  3. Infection (asymmetric, unilateral, pain)
  4. Ricketts
  5. dysplasia/dwarfisms
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4
Q

If a child presents with knee pain, what should you pay close attention to on the physical exam?

A

Hip evaluation because a lot of pediatric pathologic conditions involving the hip have referred pain to the knee

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5
Q

What is Blount’s disease?
What 4 people are most frequently affected?
What is treatment?

A

Medial proximal tibial physis does not function well and collapses.

  1. AA
  2. girls
  3. obese/overweight
  4. early walkers (<11 months)

Treatment: referral to ortho and surgery

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6
Q

What are the 3 most common types of intoeing?

A
  1. metatarsus adductus
  2. tibial torsion
  3. medial femoral torsion (MFT) or femoral anteversion
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7
Q

What is metatarsus adductus a deformity of?
What is the common cause?
How is the diagnosis made?

A

It is a deformity of the foot caused by the positioning of the fetus in the womb.

Diagnosis:
Heel bisector line- physician determines the degree the metatarsus bones are adducted by drawing a line from the heel to the forefoot.
Line between 2 and 3 toe is normal
Line between 3,4, 5 is metatarsus adductus

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8
Q

A child presents with metatarsus adductus as demonstrated by heel bisector line. You tickle their foot and it corrects. What is treatment?

A

None- it is passively correctable

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9
Q

A child presents with metatarsus adductus as demonstrated by heel bisector line. You tickle the foot and it doesn’t correct. You are able to straighten it with gentle lateral pressure. What is treatment?

A

Stretching exercises with a physical therapist because it is actively correctable

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10
Q

A child presents with metatarsus adductus as demonstrated by heel bisector line. You tickle the foot and it does NOT correct. You gently push laterally on it and it does not straighten. What is the treatment?

A

Casting or bracing if rigid and refer ortho for surgery

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11
Q

Why are you able to correct metatarsus adductus IMMEDIATELY after the baby is born if you catch it?

A

Because the baby still has some elastin from the mother and they can be stretched into the correct position

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12
Q

What is the most common cause of intoeing under the age of 3?
Over the age of 3?

A

3 = femoral anteversion or medial femoral torsion

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13
Q

How is tibial torsion diagnosed? What is the treatment?

A

Diagnosis:
look at the medial and lateral malleolus.
Normal = medial is anterior to lateral
TT = medial is posterior to lateral maleolus

Treatment:
None- this situation corrects with ambulation

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14
Q

How is femoral anteversion/MFT diagnosed and treated?

A

Diagnosis:

  • sit in a W position comfortably (discourage this bc it strains the femur)
  • when standing the childs patellas are “kissing”

Treatment:
none- gradually improves with time

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15
Q

What is the most common orthopedic injury in children under the age of 6?
What is the mean age of presentation?
Are girls or boys more affected?
What arm is usually affected?

A

Radial head subluxation- Nursemaid’s elbow

The mean presentation is 27 months.
Girls are more affected and the left arm is more frequently affected because parents are right handed.

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16
Q

A 3 year old comes into the office. He doesn’t appear to be in pain, but he is guarding his arm (flexed at elbow, pronated). He does not use this arm. There is no swelling, or tenderness to palpation over the humerus. What is your suspicion?

A

Radial head subluxation - Nursemaid’s elbow

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17
Q

What is the pathophysiology of Nursemaid’s elbow (radial head subluxation)?

A
  1. annular ligament wraps the head of the radius holding it in the capitulum.
  2. Ligament is weak and torn by longitudinal traction (kid runs into street, mom yanks him back)
  3. Torn ligament gets trapped between capitulum and radial head.
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18
Q

What is treatment for nursemaid’s elbow?

A
  1. forced supination of the wrist followed by flexion of the elbow while holding the radial head beneath the physicians thumb. Audible click = return to normal position of annular ligament
  2. forced pronation of the wrist followed by flexion or extension of the elbow
19
Q

What is the common age for a supracondylar humerus fracture? What typically causes this injury?

A

Mostly occurs in children 5-7 as the result of a fall on outstretched hands with elbows at full extension.

20
Q

A 6 year old comes in after falling on ice. She explains that she put her hands out to catch her fall. Her elbow is painful, swollen and has a decreased range of motion. What is the likely diagnosis?
What 2 structures are you concerned might have been damaged?
How do you check?
If they were damaged, what is the next step?

A

Supracondylar humerus fracture

  1. brachial artery- look for distal pulses, capillary refill, skin temperature and color
  2. ulnar nerve - motor function, pain with passive stretch of digits, paresthesias

SURGICAL EMERGENCY if damaged

21
Q

What would plain film show for supracondylar humerus fracture?

A
  1. visible fracture on AP or lateral

2. if no visible fracture, look for presence of posterior fat pad on the lateral

22
Q

A 14 year old boy comes in with knee pain. It has come on gradually and is localized at the tibial tuberosity. He says it gets worse when he is playing basketball and gets better when he is sitting down or resting. What does he likely have? What is the pathophysiology of this disorder? What is treatment?

A

He has Osgood- Schlatter. It affects boys 13-15 and girls 10-12 who are in puberty and is associated with growth spurts.

Apophysitis- forceful contraction of the quad at the tendon insertion on the proximal tibial apophysis leads to multiple tiny avulsion fractures enlarging the tibial tuberosity over time.

Treatment is rest, NSAIDs, ice, stretching
It resolves at the end of the growth spurt

23
Q

What is the overall incidence of limp in children?
What is the most common benign, self-limiting cause?
What is the most common acute, life-threatening cause?
What is the most common chronic, disabling cause?
What is the most common cause of limp OVERALL?

A

Incidence is 2/1000

Benign - transient synovitis
Acute/life-threatening - septic arthritis
chronic/disabling- Perthes disease

TRAUMA

24
Q

When taking history of a child with a limp, what 4 things should you ask about?

A
  1. age- different conditions are more common at different ages
  2. proposed mechanism of trauma (if it doesn’t fit the presentation, suspect child abuse)
  3. birth/development history (DDH)
  4. evidence of systemic illness (fever, recent viral, leukemia)
25
Q

What 3 radiologic techniques might you use on a child with a limp? What would each show?

A
  1. plain film -fracture
  2. ultrasound if suspected hip effusion, painful joint
  3. MRI if no effusion but the labs are concerning for infection
26
Q

US for painful joints, and consider a joint tap.
+ joint tap = _____________
- joint tap = ______________

If there is no effusion, but infection is suspected, do an MRI.
+ = ______________________.

A 
\+ = septic arthritis
- = transient synovitis

MRI + = osteomyelitis

27
Q

What is the cutoff for WBC, ESR, CRP, and fever for suggesting an infectious process?

A

2 of the 4 must be presents

WBC> 12,000
ESR >20
CRP >1
Fever> 38

28
Q

An 18 month child comes in refusing to bear weight on his leg. There is point tenderness over the tibia.
What is the most likely way he got this?
What will the initial radiograph show? A followup Xray?
What is treatment?

A

Toddler’s fracture- spiral, oblique, non-displaced fracture of the distal tibial shaft from rotation on a planted foot

Initial radiograph won’t show anything, but the follow up xray shows callus (healing the bone)

Treatment is casting to immobilize while it heals

29
Q

When are the 3 times you should definitely worry about child abuse?

A
  1. fracture after unwitnessed trauma
  2. story doesn’t match presentation
  3. midshaft tibial fractures
30
Q

What age group does transient synovitis usually affect?
What is the most likely etiology?
How is diagnosis made?
What is treatment?

A

Most common in boys 4-8
Viral or post viral process is the etiology, but exact mechanisms are unclear.

Diagnosis is made by confirming hip effusion with the exclusion of other conditions (septic arthritis)

Treatment: NSAIDs for pain, but it will resolve independently without sequelae in a week

31
Q

Why are kids generally more likely to get infections than adults?

A
  1. Poorly developed RES system (immune)

2. They are very vascular because they are growing which allows for easier hematogenous spread of infections

32
Q

What is the most likely organism to cause infection of the synovium and joint space in children? Neonates?

A

Kids: S. aureus
Neonates: Group B streptococcus

33
Q

How do bacterial agents cause septic arthritis? What is the treatment?

A

They hematogenously seed the joints.
Treatment is urgent or else joint destruction and growth arrest can occur.
1. Surgical washout
2. antibiotic therapy

34
Q

What are Kocher’s criteria (warning signs) for differentiating septic arthritis from transient synovitis?

A 
Septic if:
WBC >12000
ESR >40
cannot bear weight on the joint
Fever> 38.5
35
Q

What is the pathogenesis of Legg-Calve-Perthes disease (LCP)?

A

it is idiopathic avascular necrosis of the femoral head

36
Q

An active 5 year old boy with normal height and weight comes in with insidious onset of a limp. The leg is flexed and externally rotated.On exam, there is limited abduction and you cannot internally rotate at the hip.
You take an AP and frogleg radiograph and note sclerosis and flattening of the femoral head.
What is the likely cause?

A

Legg-Calve-Perthes disease

37
Q

What is the treatment for LCP disease?

A

non-weight bearing to allow healing (protect the epiphysis

38
Q

What is the spectrum of developmental dysplasia of the hip (DDH)?

A
  1. shallow acetabulum
  2. capsular laxity
  3. frank dislocation
39
Q

What are the 4 major risk factors for DDH?

A
  1. female
  2. first born
  3. breech presentation
  4. family history
40
Q

What are the three tests you do to check for DDH?

Which one is just observation? Which one dislocates the hip? Which relocates a dislocated hip?

A
  1. Galezzi- knee height is not equal when legs are flexed
  2. Barlow- dislocates the hip by adducting the legs and pushing down on the knees. Listen for a clunk if it dislocates
  3. Ortolani - relocates a dislocated hip
41
Q

When would a hip ultrasound be more effective than a plain film?

A

Up to 4-6 months you would do an US because the baby isn’t ossified enough for plain film to be useful

42
Q

What is the treatment for DDH?

A
  1. Bracing- abducted, flexed, externally rotated

2. surgery

43
Q

What is slipped capital femoral epiphysis?

A

The femoral head is displaced in relation to the neck through the epiphysis. IT CAN HALT GROWTH

44
Q

An obese African American child in early puberty comes into the office with an insidious limp. He refers pain to the thigh and knee. His foot is externally rotated and flexed at the hip.
You do an Xray and note that the femor has the appearance of ice cream falling off the cone. What is your major concern?
What is treatment?

A

Slipped capital femoral epiphysis

Treatment is immediate surgery to place metal screws to stabilize the growth plate

Respiratory/Musculoskeletal (36 decks)

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