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PCM IV Exam II > Peds MSK- Limping Child > Flashcards

Peds MSK- Limping Child Flashcards

1
Q

The Limping Child- approach

A

History: Your child is not invisible! Talk to them
** Age
Pain or weakness
Night pain pattern/worsening often seen in neoplasm
Trauma or other mechanism of injury

Physical exam
** Gait
Inspection
No only area with pain/weakness but all areas associated with gait
Palpation/ROM
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2
Q

PE of limping child

A
  • observe gait—barefoot, minimially clothed for stance and gait
  • inspection/palpation of abdomen, pelvis, back & extremities—as well as joints for ligamentous instability
  • neurovascular status—strength, sensation, reflexes
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3
Q

Normal Gait by age:

A

Walk without support by 12-15 months
Coordination with reciprocal arm swing by 2 years
Require musculoskeletal development of lower back, pelvis & lower extremities
Neurologic growth-coordination/balance
Myelinization in cephalocaudal pattern
Adult gait pattern attained by 8-10 years of age

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4
Q

Gait assessment

A

Normal Gait
Stance phase
Weight-bearing phase
Heel strike –> Plantar flex –> Toe-off

Swing phase
Toe-off –> Heel strike
Rotation and tilting of pelvis and stability of lumbar spine and abdomen

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5
Q

Abnormal gait

A 
Antalgic
Trendelenburg limp
Waddling
Stiff-legged
Toe walking
Steppage
Stooped
Generalized muscle weakness
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6
Q

major causes of limping kid by age

A

0-4 yrs- hip dysplasia or transient/ toxic

4-10 yrs- transient/ toxic synovitis, legg-calve-perthes disease, juvenile idiopathic arthritis

10-18 yrs- slipped capital femoral epiphysis, gonococcal arthritis, stress fracture

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7
Q

Developmental hip dysplasia

A 
Age: 0-4 yrs.
Abnormal formation of hip joint
Cause: unknown
Incidence: 3-4 per 1,000
5-9X more common in females
Risk factors: crowding, genetics

femoral head unstable within acetabulum

  • may be loose in socket or completely dislocated
  • may occur during fetal development, at delivery or after birth
  • risk factors-genetic component, anything causing crowding of the fetus—large birth, oligohydraminos; female, first born, breech
  • 5-9X more common in females
  • left hip> right
  • more common with other ortho problems (torticollis, metatarusadductus, clubfoot) or connective tissue d/o (Larsen syn)
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8
Q

antalgic =

A

limp

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9
Q

Barlow

A

pull baby’s leg down while internal rotation

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10
Q

Ortolani

A

Rotate baby’s thigh out, lower leg in (checking hip dysplasea)

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11
Q

Galeazzi sign

A

knees don’t line up when bent (babies with hip dysplasia)

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12
Q

Toddler’s fracture

A

Def: Spiral fracture of tibia under age of 5 years
Common childhood fx
Sudden twisting of tibia
Often difficult to visualize on x-ray
Sx: pain, refusal to walk, minor swelling/warmth over site, pain with palpation
Tx: long-leg cast; heal within 3-4 wks

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13
Q

Physeal fracture

A 
Growth plate injuries are fractures
Age: 0-16 yrs girls; 0-18 yrs boys
Weakest area of growing bone
15% of all childhood fractures
Boys>girls
Salter-Harris classification
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14
Q

Salter-Harris classification

A 
S: Slip (epiphysis separated from shaft)
A: Above
L: Lower
T: Through (epiphysis & metaphysis)
R: Rammed
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15
Q

Stress fracture

A

Small crack in bone
Often from overuse, high impact sports
Weight bearing bones
2nd/3rd metatarsal most common
Age: 10-18 years
Sx: pain that increases with weight bearing activities, reduced with rest, tenderness to touch
Tx: rest, possible surgery depending on site

When muscles are overtired, they are no longer able to lessen the shock of repeated impacts. When this happens, the muscles transfer the stress to the bones. This can create small cracks or fractures

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16
Q

Osteomyelitis

A

Inflammation of bone marrow & adjacent bone
Age: all
Children: hematogenous spread
Location: metaphysis of long bones
Sx: local inflammation & fever, irritability, lethargy, bone tenderness & dec. ROM
Adults: subacute/chronic forms, secondary to open wounds
Tx: IV antibiotics (4-6 wks min.)

Staphlococcus aureus implicated in most pts with hematogenous spread

17
Q

Septic arthritis

A

Infection with the joint space
Age: all
Bacterial, viral, (fungi or parasite)
Intense synovitis is the result of the inflammatory response
Sx: monoarticular, erythema, swelling, pain, dec. ROM
Knee most common
Tx: IV/PO antibiotics (4-6 wks)

18
Q

Transient/Toxic synovitis

A

Sx: “irritable hip syndrome”: acute hip pain, dec. ROM
Hip in flexion/abduction & ext. rotation
Age 0-10 yrs
Dx of exclusion
30% of all non-traumatic limp in kids
Cause: ?viral, post-viral URI
Tx: self limited (5-7 days), NSAIDS

19
Q

Legg-Calve-Perthes disease (LCP)

A

aka Perthes disease or idiopathic osteonecrosis of the femoral head
Age 4-10 years
Lack of blood flow to femoral head=necrosis
Bone collapses—flattens
Blood supply returns after several months
New bone replaces old
Boy>girls–4:1
Typically thin, active boys
Sx: slight limp, pain in knee, thigh or groin, limited ROM, leg length discrepancy
Tx: meds/reduce activity to dec. pain; splinting or surgery to keep hip stable? ROM important!

20
Q

Slipped capital femoral epiphysis (SCFE)

A

Noninflammatory condition; femoral neck displaced from femoral head: slips
Initially bilateral 20-40%, if unilateral, the other side slips in 30-60%
Age: 10-14 years
Typically overweight boys: shear stress
Association with endocrine disorders, 1° hypothyroid and HGH deficiency
Sx: insidious, complaint of pain in hip and limp
Tx: surgical stabilization

21
Q

Juvenile idiopathic arthritis (JIA)

A

Chronic joint pain for min. of 6 wks & age onset under 16 yrs. 1+ joints
Sx: joint effusion, pain, limited ROM, warmth over the joint
Morning stiffness; hip involvement unusual
Prevalence: 16-150 per 100,000
Cause: unknown (?immune/environment)
7 subtypes

22
Q

Lyme arthritis

A

2nd most frequent presenting sx (rash #1; erythema migrans)
May occur months or years after infection
Sx: Episodic initially
- 2/3 monoarthritis of knee
Age: 10-18 yrs.
Cause: Borrelia burgdorferi transmitted by tick
Prevalence: US–northeast, midwest, south & west costal areas
Boys=girls

Tx: IV/PO antibiotics, NSAIDs
- Good response if diagnosed

23
Q

Gonococcal arthritis

A

Septic arthritis of the joint caused by gonococcus
Age: 10-18 yrs (sexually active)
Sx: same as septic arthritis
Dx/Tx: aspiration of joint fluid; IV/PO antibiotics (at least 1 week)

24
Q

Growing pains

A

Intermittent nonarticular pains in childhood
Diagnosis of exclusion
Sx: Typically pain at night & limited to calf, thigh or shin
- pain is short-lived and resolved with heat, massage, or mild analgesics
- Pain free during the day

Cause: unknown

Tx: reassurance to parents/child

25
Q

Organisms involved with septic arthritis/osteomyelitis

A

The most common causative organism is Staphylococcus aureus then nongroup A beta-hemolytic streptococci

Common organisms by age group:
Neonate
- Group B Streptococcus, Staphlococcus aureus, gram-negative bacilli

Infant (1-3 m.o.)
- Streptococcus sp., Staphlococcus sp., Haemophilius influenza

Child
- S. aureus, S. pneumoniae, group A Streptococcus

Adolescent
- As above plus Neisseria gonorrhoeae

Sickle cell disease
- As above plus Salmonella

Puncture wound
- As above plus Pseudomonas

26
Q

Diagnosis: Septic Arthritis

A

Pathogen enters joint space (infant-hematogenous spread, older children cut in skin)

  • Results in synovitis
  • Leukocytes accumulate releasing cytokines (TNF-alpha, IL-1, etc)
    • Can destroy articular cartilage

Acute monoarticular joint swelling

Knee is most common site

Septic arthritis of hip associated with highest risk of avascular necrosis
- Due to increased joint pressure on blood vessels supplying cartilage & femoral head

Definitive diagnosis by aspiration and culture of synovial fluid
- Radiology not diagnostic but supportive-may not be apparent until 10 days into illness

27
Q

Treatment: Septic Arthritis

A

Most important prognostic factor for good outcome is early antibiotic treatment
Cefotaxime IV (Claforan)
Due to the high incidence of MRSA in the United States (62% of all skin infections), ID should be consulted for most appropriate regional antibiotic (guided by local resistance pattern)
With clinical improvement, change to PO abx
Total treatment 4-6 wks
Low dose steroids have been shown to reduce residual joint sx with hematogenous spread

28
Q

Dx: Slipped capital femoral epiphysis (SCFE)

A

Noninflammatory condition
Typically overweight boys
Endocrine disorders
- Can be associated with hypothyroidism, or pituitary deficiencies

Acute slip

  • Preceding hx of minor trauma
  • Present with pain & inability to walk
  • Subacute/chronic slip
  • Sx are typically insidious—pain in affected hip or limp
29
Q

SCFE Treatment

A

Non-weight bearing until assessed by ortho
Tx: surgical fixation with central screw or bone graft epiphysiodesis
Most patient have good prognosis
- Risk for acute chondrolysis or avascular necrosis

30
Q

Risk factors for developmental hip dysplasia

A 
Female
Breech
First born (nulliparous)
Oligohydraminos
Think about what would restrict intrauterine position
31
Q

A previously healthy 4 y/o female is referred to the ED by her PCP with a hx of 2 weeks of low grade fevers, malaise & hip pain. Her temp. is 38.4 C. She refuses to bear weight on her right leg. There is no evident joint inflammation, and her spleen tip is palpable. Labs reveal WBC 42,000, Hgb 8, platelet count 88,000. most likely diagnosis?

A

Acute lymphocytic leukemia

32
Q

Acute lymphocytic leukemia key points

A

Looks infectious from fever

JIA would have longer duration, able to bear weight and would see joint swelling (no seen in this case)

Kawasaki dz does have prolong fevers but usually higher and monoarticular joint pain not common
- More likely rash, mucosal sx and/or polyarthritis

Joint pain points to septic arthritis, osteomyelitis, toxic/transient synovitis or cancer (in this age group)

CBC reveals elevated WBC and low HgB and plts

  • If infectious cause (septic arthritis/toxic synovitis) would see elevated WBC but not low Hgb and plts
  • This is picture of WBC crowding out the other cell lines
  • – Likely to see blasts on differential
33
Q

A 12 y/o male is brought to the physician with vague hip pain & limp for 5 weeks. There is no history of trauma & he is otherwise well. Weight is 85 kg, height 162cm. BMI 32.4. Temp. is 37.4, heart rate 78, respiratory rate 24. Physical exam reveals limited flexion & internal rotation of the right hip. Which of the following is the most appropriate next step to diagnose the patient’s condition?

Serum calcium
CBC
Ultrasound of the hip
Arthrocentesis
X-ray of the pelvis
A

X-ray of the pelvis

Key points:
Prolonged limp, no trauma, position of leg/restriction and high BMI all point to boney abnormality since no joint swelling indicated
Serum calcium and CBC would not be diagnostic as the question is asking
Ultrasound again would show soft tissue structures and fluid but not bone abnormality
Arthrocentesis would look a fluid in joint space but history not indicating joint swelling

PCM IV Exam II (8 decks)

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