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a_ARTS > 11/9- Common Pediatric Musculoskeletal Findings > Flashcards

11/9- Common Pediatric Musculoskeletal Findings Flashcards

1
Q

Describe the pediatric skeleton vs. adult

  • What is the most metabolically active part
A
  • Bone is more porous and pliable
  • The metaphysis is the most metabolically active part of the bone
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2
Q

What is the weakest part of the pediatric skeleton?

  • When is this visualized
A

The physis (epiphyseal plate or growth plate)

  • Growth plates usually aren’t visualized until 12-24 mo
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3
Q

T/F: Remodeling and healing occurs rapidly in the pediatric skeleton

A

True

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4
Q

Describe developmental dysplasia of the hip in newborns/infants

  • Prevalence
  • Risk factors
A

Abnormal development that causes the proximal femoral head to displace from the acetabulum (but may present anytime during childhood)

  • `1/1000 live births

Risk factors:

  • Female > Male
  • First born
  • Breech
  • Caucasian descent
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5
Q

How do you test for developmental dysplasia of the hip?

A
  • Barlow test: adduct and push posteriorly (to displace)
  • Ortolani test: abduct and push anteriorly (to replace)
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6
Q

What is seen here?

A

Asymmetric skinfolds (in developmental dysplasia of the hip)

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7
Q

What is seen here?

A

Positive Galeazzi (hip displacement)

  • Lower knee is the affected knee (necrosis)
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8
Q

What should be done if there is newborn/infant developmental dysplasia of the hip?

A
  • Fitting with Pavlik harness
  • Outpatient Orthopedic consultation
  • In high risk patients (girls, + family history, breech)
  • Hip ultrasound at 6 weeks of age or frog-legged films at 4 to 6 months of age
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9
Q

What is Congenital Torticollis?

  • Incidence
  • Risk factors
  • Suspected cause
  • Signs/symptoms
A
  • Incidence 1-2 %
  • More often in breech presentation
  • Suspected trauma to SCM and resulting fibrosis

Signs/symptoms:

  • Head tilt to the side of the affected muscle by 2-4 weeks
  • “tumor” or “psudotumor” noted on exam
  • Can present with facial deformity
  • Can result in plageocephaly
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10
Q

What is seen here?

A

The facial deformity common in congenital torticollis

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11
Q

What is plagiocephaly?

A
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12
Q

What is treatment/therapy for congenital torticollis?

A
  • Stretching Exercises with OT/PT
  • Surgical release if persists 12-18 months
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13
Q

What is Congenital Talipes Equinovarus?

  • Incidence
  • Uni or bilateral
  • Gender prevalence
  • Etiologies
A

Excessively plantar flexed, rotated medially, and the sole facing inward (club foot)

  • Incidence is about 1 -3/1000
  • Almost half are bilateral
  • 2x in females
  • Multiple causes
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14
Q

What is treatment/therapy for Congenital Talipes Equinovarus?

A
  • Cereal casting every 1-2 weeks to hold foot in desired position.
  • Surgical correction
  • Combination of both
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15
Q

What is seen here?

A

Arthrogryposis

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16
Q

What are factors leading to arthrogryposis?

A
  • Neurologic deficits
  • Fetal crowding
  • Maternal illness
  • Connective tissue/skeletal defects
  • Vascular compromise
  • Muscle defects

All contribute to limitation of fetal joint mobility and then joint fixations (arthrogryposis)

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17
Q

What is Osteogenesis Imperfecta?

  • Aka
  • Prevalence
  • Signs/symptoms
A
  • It is often called “brittle bone disease.”
  • Occurs in about 1/20,000 births
  • Severely affected patients suffer multiple fractures with minimal or even no trauma
  • Infants with the worst form of OI die in the perinatal period
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18
Q

Describe the different types of Osteogenesis Imperfecta?

  • Signs/symptoms
  • Severity (lethality)
A

Type I

  • Blue sclera

Type II

  • Most lethal type

Type III

  • Most severe non-lethal form
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19
Q

What is Legg-Calve Perthes?

A

Avascular necrosis of the femoral head

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20
Q

Describe Legg-Calve Perthes

  • Gender prevalence
  • Risk factors
  • When is it commonly seen
  • Uni or bilateral
A

(Avascular necrosis of femoral head)

  • 4x in males
  • Common among first-born children
  • Common during periods of rapid growth of epiphyses (peak between 5-7 years)
  • Usually unilateral but up to 12 percent are bilateral
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21
Q

How does Legg-Calve-Perthes commonly present?

A
  • Present with limp of insidious onset
  • Pain is often referred to the antero-medial thigh or knee.
  • On exam, patients may have limited internal rotation and abduction of the hip.
  • Pain may lead to disuse, which may result in atrophy of the thighs and buttock
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22
Q

What is seen here?

A

Legg-Calve-Perthes disease on radiography

  • Left = normal
  • Right = hip with perthes
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23
Q

What radiographs should be taken in Legg-Calve-Perthes evaluation?

  • What are the radiographic findings (early/intermediate/late)?
A

Should take AP and frog-leg views

Findings:

  • Early: effusion of joint and wide joint space
  • Intermediate: decreased bone density and collapse of the femoral head
  • Late: new bone replacing necrotic bone
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24
Q

How to treat Legg-Calve-Perthes disease?

A
  • Pedi ortho consulation
  • Contain femoral head in acetabulum (may require abduction splint

• < 6 yrs: if no significant subluxation and at least 40-45 degrees abduction, observation is warranted.

• > 6 yrs: containment with brace/splint until re-ossification or sugery

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25
Q

What is Slipped Capital Femoral Epiphysis?

A

Displacement of the proximal femoral epiphysis from the femoral neck through the pysis, usually posteriorly and medially

Caused by:

  • Most cases are idiopathic
  • Weak growth plates
  • Local trauma
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26
Q

Who gets Slipped Capital Femoral Epiphysis?

A
  • Between ages 6-10 yo
  • More in males
  • Obesity
  • Hypothyroidism
  • Growth hormone administration
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27
Q

What are signs/symptoms of Slipped Capital Femoral Epiphysis?

A
  • Limping with or without pain
  • Pain can radiate to groin or knee
  • lost flexion and abduction
  • child holds his/her leg in external rotation at rest
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28
Q

How is Slipped Capital Femoral Epiphysis diagnosed?

A
  • AP and frog-leg lateral
  • Bloomburg’s Sign (widening epiphysis)
  • Klein’s Line
  • Always get contra-lateral films
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29
Q

What is seen here?

A

Slipped Capital Femoral Epiphysis

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30
Q

What is shown here?

A

Slipped Capital Femoral Epiphysis

31
Q

What is Osgood-Schlatter? Symptoms?

A
  • Inflammation of the proximal tibial tubercle at the insertion of the patellar tendon secondary to traction
  • Pain and swelling at the tibial tubercle
32
Q

What populations/demographic are affected by Osgood-Schlatter?

  • Uni or bilateral
A
  • Children 9 -14 years of age who have undergone a rapid growth spurt
  • 20% of adolescents who are active in sports compared with 5% of non-athletes
  • Sports that involve running, cutting, and jumping
  • These activities place stress on the tibial tubercle through repetitive contraction of the quadriceps muscle

• Bilateral in 25-50% of cases

33
Q

What are signs/symptoms of Osgood-Schlatter?

  • How is the diagnosis made
A
  • Anterior knee pain that increases gradually over time
  • Pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by rest.
  • The diagnosis of Osgood-Schlatter disease is made by physical examination, radiographs are optional
34
Q

What are exam findings in Osgood-Schlatter?

A
  • Tenderness and soft tissue or bony prominence of the tibial tubercle
  • Pain may be reproduced by extending the knee against resistance or squatting
  • Evaluation the hip to make sure knee pain not referred pain from pathology in the hip
35
Q

What is intoeing?

  • What most commonly causes it
A
  • Commonly known as “Pigeon-toed”
  • More common than outtoeing
  • Most commonly due to:
  • Metatarsus adductus
  • Tibial Torsion
  • Medial femoral torsion
36
Q

What are the 3 rotational deformities characterized under “intoeing”?

A
  • Metatarsus adductus
  • Tibial torsion
  • Medial femoral torsion
37
Q

What is Metatarsus adductus?

  • What kind of defect is it
  • Gender prevalence
  • Correction
A
  • Intoeing originates at the foot
  • Considered a packing defect
  • Girls > Boys
  • Correction
  • Actively correctable (spontaneously corrects)
  • Passively correctable (stretching exercises)
  • Uncorrectable (casting)
38
Q

What is tibial torsion?

  • Age group seen in
  • Gender prevalence
  • Treatment
A

Intoeing originating between knee and ankle

  • Most common cause in children < 3 yo
  • Male = Female
  • Usually spontaneous correction over first year of ambulation
  • Sometimes takes up to 8 years to completely correct!
39
Q

What is Medial femoral torsion?

  • Could be acquired how
  • Most common in what populations
  • Correction
A

Intoeing originates between the knee and the hip

  • May be acquired from sitting in the “W” position
  • Most common cause in children >3 years old
  • Usually corrects spontaneously but slowly until about 8-10 years
40
Q

What is outtoeing?

  • More or less common than intoeing?
  • Improves when
A

In utero packing defect

  • Less common than intoeing
  • Improves during the first year of walking
41
Q

What are angular deformities seen in childhood?

A
  • Genu valgum (knock-kneed)
  • Genu varum (bow-legged)
42
Q

What is normal alignment at birth? Progression?

A

Varus

  • Varus condition can worsen as child begins to stand and walk
  • Around 18-24 mo, alignment should be neutral
  • After 24 mo, alignment should progress to valgus until reaches max at 4 yrs
  • Valgus decreases toward physiologic adult alignment of slight valgus to neutral by about 7 yrs
43
Q

Describe physiologic genu varum?

  • Uni or bilateral
  • Stature/gait
A
  • Bilateral and relatively symmetric deformities
  • Normal stature
  • Normal gait
44
Q

Describe pathologic genu varum?

  • Causes
  • Seen in what diseases/conditions
A
  • Blount disease
  • Rickets
  • Skeletal dysplasia
  • Asymmetric growth:
  • Unilateral trauma
  • Infection
45
Q

Describe physiologic genu valgum

  • Uni or bilateral
  • Stature/gait
  • Other signs/symptoms
A
  • Bilateral and relatively symmetric deformities
  • Normal stature and normal gait
  • Flat feet and external tibial torsion
46
Q

Describe pathologic genu valgum

  • Uni or bilateral
  • Causes/associated conditions
A
  • Unilateral or unequal

Seen with:

  • Fracture of metaphysis
  • Fracture of physeal with growth plate arrest
  • Rickets
  • Skeletal dysplasia
47
Q

What is teratment for angular deformities (genu varum and valgum)?

A
  • Physiologic: don’t treat; will resolve over time
  • Pathologic: optimize medical management
  • If not improved, surgical intervention
48
Q

Mnemonics for genu varum/valgum?

A
  • Varum: air between the knees (or barrel of rum)
  • Valgum: gum sticking kenes together
49
Q

What is scoliosis?

  • Gender prevalence
  • Complication in severe cases
A

Scoliosis is defined as a 10’ curvature of the spine in the coronal plane, and typically accompanied by rotation

  • More in girls
  • Severe curvature may -> impairment of pulmonary function
50
Q

How is scoliosis evaluated?

A
  • Feet hip-width apart
  • Hands joined at midline
  • Stand directly behind patient
  • Bend forward 90’
51
Q

What are the 3 classifications of Scoliosis?

A
  • Ideopathic
  • Neurogenic
  • Congenital
52
Q

What are signs of scoliosis?

A
  • Uneven shoulders
  • Curve in spine
  • Uneven hips
53
Q

Describe ideopathic scoliosis

  • Etiology
  • Age ranges/classes
A

No definite etiology; it is therefore a diagnosis of exclusion

Types:

  • Infantile: 0-3 yrs
  • Juvenile: 4-9 yrs
  • Adolescent: 10+ yrs
54
Q

Describe neurogenic scoliosis

  • Seen with what conditions
  • Due to what
  • Do most have rotational component?
A

Conditions such as:

  • Cerebral Palsy
  • Myelomeningocele
  • Muscular Dystrophy
  • Neurofibromatosis

Due to muscle imbalance and lack of trunk control

Most have no rotational component

55
Q

Describe congenital scoliosis

  • Causes
  • Manifestation (time)
A

Asymmetry in the vertebrae secondary to congenital anomalies

  • Hemivertebrae
  • Failure of segmentation

Congenital scoliosis usually manifests before adolescence

56
Q

What is the management for scoliosis with a curve < 20’?

A

PT and exercises to strengthen back muscles

57
Q

What is the management for scoliosis with a curve 20-40’?

A

(Immature skeleton): back brace to prevent further curve progression

58
Q

What is the management for scoliosis with a curve > 40’?

A

Spinal fusion to correct deformity

59
Q

What is the concern in management for scoliosis with a curve > 60’?

A

Associated with poor pulmonary function

60
Q

Describe periosteum in pediatrics vs. adults

A
  • Osteogenic potential
  • More metabolically active than adult
  • Active periosteum may result in:
  • Callus formation
  • Union of fractures
  • Remodeling
  • Periosteum is thicker and stronger:
  • Limits fracture displacement
  • Reduces likelihood of open fractures
  • Maintains fracture stability
61
Q

What is a buckle (torus) fracture?

  • Commonly occur where
  • Management
A
  • Often occur at the junction between the porous metaphysis and the denser diaphysis
  • Commonly in distal radius after fall on an outstretched hand (also seen in the distal tibia, fibula, and femur)
  • Stable fracture that can be managed with splinting and a single orthopedic follow-up visit
62
Q

What is seen here?

A

Buckle (torus) fracture

63
Q

What is a plastic deformation fracture?

  • What cuases it
  • Commonly seen where
  • Management
A
  • Longitudinal force exceeds the bone’s ability to recoil
  • Microscopic fractures dissipate the impact energy
  • Commonly seen in the ulna, the radius, and sometimes in the fibula
  • If < 20’ or if the deformity occurs < 4 yo, the angulation often corrects itself
64
Q

What is seen here?

A

Plastic deformation fracture

65
Q

What is a greenstick fracture?

  • Management
A

Fracture line does not extend completely through the width of the bone

• May be the most significant risk factor for repeat fracture

  • occurring in as many as 84 – 100% of forearm re-fractures

• Closed reduction and casting

66
Q

What is seen here?

A

Greenstick fracture

67
Q

What is a physeal (growth plate) fracture?

  • What causes it?
A
  • Growth plates are susceptible to fracture and represent a weak point in pediatric bone
  • Tensile strength of pediatric bone is less than that of the ligaments
  • Physis will separate or fracture before disruption or “spraining” of an strong and flexible ligament
68
Q

What is seen here?

A

Physeal (growth plate) fracture

69
Q

What is the Salter-Harris classification for pediatric trauma?

A

I- Separation through the physis; usually through areas of hypertrophic and degernating cartilage cell columns

II- Fracture through a portion fo the physis that extends through the metaphyses

III- Fracture through aprotion of hte physis that extends throught he epihpysis and into the joint

IV- Fracture across the metaphysis, physis and epiphysis

V- Crush injury to the physis

70
Q

What is the Salter-Harris classification for physeal fractures?

A

S- straight across (type I)

A- above (type II)

L- lower or beLow (type III)

T- two or through (type IV)

ER- erasure of growth plate or cRush (type V)

71
Q

Case 1

  • You are called to the delivery of a term female with decreased amniotic fluid.
  • Baby will be delivered via c/s for breech presentation.

Which of the following will be an important part of her newborn exam secondary to her risk factors?

A. Finding a Klein Line

B. Babinski Sign

C. Ortolani Maneuver

D. Moro Reflex

A

A. Finding a Klein Line

B. Babinski Sign

C. Ortolani Maneuver

D. Moro Reflex

72
Q

Case 2

  • A 9 year old boy is brought by his mother to your office because she noticed he has been limping for the last 2 weeks.
  • He reports unilateral knee pain after he began an exercise program prescribed to him by you after you calculated his BMI in the 90th percentile.
  • On exam he holds his leg in external rotation and has pain with flexion of the hip. Knee exam is normal.

What is the most-likely diagnosis?

A. Osgood Schlatter

B. Slipped Capital Femoral Epiphysis (SCFE)

C. Subluxation of the patella

D. Legg-Calve-Perthes

A

A. Osgood Schlatter

B. Slipped Capital Femoral Epiphysis (SCFE)

C. Subluxation of the patella

D. Legg-Calve-Perthes

73
Q

Case 3

What type of Salter Harris Fracture is shown?

A. Type I

B. Type II

C. Type III

D. Type IV

E. Type V

A

A. Type I

B. Type II

C. Type III

D. Type IV

E. Type V

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