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Paeds > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

2
Q

Normal lower limb posture (newborn, 6m, 1yr 7m, 2yr 6m, 4-6yrs)

A

Newborn = moderate genu varum

6m = minimal genu varum

1yr 7m = straight

2yrs 6m = physiological genu valgum (protective toeing-in can be present with W sitting)

4-6yrs = straight with normal toeing out

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3
Q

How is lower limb alignment measured?

A

Through centre of head of femur and centre of ankle (not along line of femur)

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4
Q

Genu varum (general - 2, 1 cause, measure)

A

General

  • Often with internal tibial torsion
  • medical referral if no improvement or increase in bowing after 2yrs

May be caused by Rickett’s disease (low vitamin D)

Measured by medial ankles together and distance between medial condyles.

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5
Q

Genu Valgum (description, measure)

A

Description

  • “knock knees”
  • tibiofemoral angle apex medial to midline of leg

Measured by medial knees together and distance between medial malleoli

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6
Q

Femoral Neck Anteversion (FNA) measurement and associated signs

A

Ryder’s test (prone with knee flexed and palpate greater trochanter at most lateral position)

Associated with excessive hip int rot and in-toeing gait (most obvious in 4-6yr olds)

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7
Q

FNA (infant, 6yo, 12yo, adult)

A 
Infant = 30-40 deg
6yo = 20-27 deg
12yo = 17-24 deg
Adult = 9-16 deg
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8
Q

Tibial component (tibiofibular torsion, thigh foot angle)

A

Tibiofibular torsion = increased external tibial torsion (may be compensating for int rot at hip

Thigh foot angle = broad range in infancy but within 6 degrees as older child

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9
Q

What can increase the appearance of in-toeing (foot posture) - 2?

A

Metatarsus adductus

Footwear

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10
Q

Rx for abnormal postures (positions/other -3, monitoring - 2)

A

Positions/other

  • sitting
  • sidelying for sleep
  • Footwear

Monitor

  • change over 6-9m period
  • use measures and photos
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11
Q

What is suggests a flexible flat foot? (what -2, why -2)

A

Flexible flat foot

  • no pain or impact on motor development
  • arch in sitting and when standing on toes

Why

  • ligamentous laxity in foot/other joints
  • Fat pad in medial arch until 3yrs old (increases appearance of flat foot
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12
Q

When to intervene for foot posture (5)

A

When

  • consider neurological status
  • outside of normal parameters
  • pain/fatigued with walking
  • less endurance than peers
  • delayed gross motor development
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13
Q

Interventions for foot posture

A

Interventions

  • Ankle boots
  • Foot stabilising splints (FSS) - impact should be apparent in alignment and gait immediately
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14
Q

FSS (usage - 4)

A
  1. Replace every 6-9 months (gradual improvement each splint)
  2. Wean off splints when approaching normal
  3. Shoes should then have heel counter and arch support
  4. Education (no evidence for long term orthotics/special footwear)
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15
Q

Idiopathic toe walking (description, causes)

A

Description

  • up to 10% of kids
  • leads to decreased knee swing, hip ext. rot. And evert foot posture in stance
  • decreased proprioception of feet (think walking on heels)

Causes

  • calves shorten with growth
  • familial trend
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16
Q

Idiopathic toe walking (clinical signs, Rx)

A

Clinical

  • consistent toe walking with lack of heel strike
  • Short/tight calves +/- hamstrings
  • flat feet
  • Poor balance
  • short stride length when running
  • normal neuro exam

Rx

  • Calf/hamstring stretching
  • Gait retraining
  • Serial casting
  • Botox (rare)
  • Sx???
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17
Q

Congenital Muscular Torticollis (description)

A

Posture of the head and neck from unilateral shortening of the SCM (head tilts towards and rotates away from affected SCM)

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18
Q

Plagiocephaly (description)

A

Asymmetrical misshapen head

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19
Q

Common co-morbidities with CMT (3)

A

Scoliosis

Foot deformities

Developmental dysplasia of the hip

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20
Q

Non-muscular causes of CMT (5)

A
  1. Ocular lesions
  2. Neurological disorder (CP)
  3. Dystonic syndromes
  4. Underlying skeletal abnormality (rare)
  5. Brachial plexus lesion
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21
Q

CMT subtypes (3 and description)

A
  1. Sternocleidomastoid tumour (palpable mass in SCM but not malignant. Collagen and fibroblasts around mm fibres)
  2. Muscular torticollis (tightness or tumour)
  3. Postural torticollis (no tightness or tumour
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22
Q

Plagiocephaly + CMT (2)

A

Asymmetry from prolonged static positioning on one side (hold head in midline is 4 month TD skill)

Plagiocephaly increased since “back to sleep”

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23
Q

Rx (general - 3)

A
  1. Full exam to eliminate other causes
  2. Passive stretches of tight mm (lateral flexion and rotation
  3. Active strengthening of weak mm on unaffected side after ROM estabilished
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24
Q

E.g. Rx for Left torticollis (head tilt to left and rotation to right) - 3 subheadings

A

Stretches
- lateral flexion to right, rotation to left

Carrying

  • upright facing parent with head turned to left
  • side lying on left with right side up

Positioning
- not kept in same position too long

Picking up
- roll onto left side to encourage R side lateral flexion

Rolling to left

Playing with toys to left (side-lying pillow under head on left side but not on right)

Tummy time - head to left

Sleeping - all activity on left side (right side against wall?)

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25
Q

Outcome measures for CMT/plagiocephaly (

A

Measures

  • PROM
  • Head shape and level of ears
  • monitor over time (may regress when achieving next milestone)
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26
Q

Helmets for plagiocephaly (use, principles)

A

Use
- mould taken and worn 23hrs/day

Principles

  • about 80% cranial growth when <12m
  • redirect growth by applying pressure to most anterior and posterior prominences of cranium and spaces where growth is needed.
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27
Q

What is DDH? (description and incidence)

A

Abnormal relationship between femoral head and acetabulum (femoral head is superior and posterior to acetabulum)

7:1000 live births (more common in females)

28
Q

Risk factors for DDH (6)

A

Risks

  • Breech presentation (hips flexed and knees extended)
  • Female/first born baby
  • Large
  • Family Hx
  • Swaddling with hips in extension and adduction
  • Assoc with torticollis metatarsus adductus and TEV
29
Q

Neonate presentation (presentation - 4; testing - 2)

A

Presentation

  • screened as newborn, 6wks, 3m, 6m, 12-18m
  • Reduced hip abduction
  • limb length difference
  • asymmetrical skin folds

Testing

  • Barlow = positive, if hip joint dislocated manually
  • Ortolani test if dislocated and reduced manually
30
Q

Imaging for DDH (XR, US)

A

XR

  • not useful for babies <4m (femoral head and acetabulum not ossified)
  • good otherwise

US
- specialist interprets (expressed as % cover)

31
Q

DDH presentation in older child (5)

A

Signs

  • decreased abd, limb length and skin folds
  • Trendelenburg (unilateral) or waddling gait (bilateral)
  • Increased lumbar lordosis
  • Limp
  • Galeazzi sign (knees bent - knee height equal?)
32
Q

Conservative management of DDH (2)

A
  1. Maintain reduction of hip joint

2. Braces

33
Q

Hip spica (when, how - 4, technique - 3)

A

Used if bracing is not successful

Generally how

  • under anasthetic
  • applied by physio with surgeon maintaining reduced hip position
  • checked by MRI before discharge
  • OT organises equipment (car seat etc)

Technique

  • hip held in flexion and abduction
  • felt and padding for skin
  • nappy opening with waterproof tape
34
Q

Surgical management of DDH (when - 3, techniques -3)

A

When

  • conservative management is unsuccessful
  • late presentation
  • un-reducible without excessive force

Techniques

  • open reduction
  • femoral/pelvic osteotomy
  • held in hip spica post-op
35
Q

Long term complications of untreated DDH (6)

A
  1. OA
  2. Pain
  3. Unequal leg length
  4. Gait abnormalities
  5. Decreased agility
  6. Secondary changes (e.g. LSp)
36
Q

What is scoliosis? (1)

A

Lateral flexion and rotation of spine (descriptive term)

37
Q

Other types of scoliosis (5)

A
  1. Infantile (<2yo - most recover spontaneously)
  2. Juvenile Idiopathic (between 2-10yrs, rare)
  3. Congenital (assoc with other congenital problems such as heart and kidney)
  4. Neuromuscular (e.g. DMD, muscular weakness)
  5. Paralytic (loss of SC function)
38
Q

What is adolescent idiopathic scoliosis (AIS) - 3

A

AIS

  • idiopathic (may be genetic)
  • appears in early adolescence
  • more girls than boys (90% girls)
39
Q

AIS curves (2)

A

Named for apex of curve

Right thoracic and left lumbar are most common (cervical unaffected)

40
Q

Signs of AIS (5)

A
  1. Head not centered
  2. One shoulder higher
  3. Unequal gaps between arms and trunk
  4. Curved spine
  5. One hip higher or more prominent
41
Q

Testing for AIS (clinical, imaging)

A

Forward bend test

  • disrobe to underwear
  • rib height difference
  • measured with scoliometer

XR

  • Standing AP XR of thoraco-lumbar spine (with iliac crests
  • Parallel lines drawn on superior end plate of uppermost vertabra and inferior end plate of lowermost vertabra involved (Cobb angle measured)
42
Q

What is the Risser sign and what does it mean? (3)

A

Ossification of the iliac crest apophysis
- interprets skeletal maturity and curve progression

0 = no maturity, 5 = mature

If less than 30 deg at skeletal maturity, minimal progression is likely.

43
Q

Risk of AIS progression (3)

A

< 20 deg Cobb angle, risk = lower
> 60 deg Cobb angle, risk is much higher

Risk is lower with age (10-12 more risk than >16)

44
Q

AIS management (note, who to Rx - 2)

A

Curves progress most rapidly during peak growth (11-13)

Who to Rx

  • Minor curves (t require Rx, just regular XR follow up.
  • less than 1% have active Rx or Sx
45
Q

Bracing for AIS (aims, requirements - 3)

A

Aims to maintain curve (not improve)

Requirements

  • 5 deg progression before bracing
  • > 30 deg in skeletally immature patients
  • wear 20/24 hrs for effectiveness
46
Q

Surgical indications (5)

A
  1. Cosmesis
  2. Pain
  3. Neurological compromise
  4. Risk of respiratory compromise (thoracic >90)
  5. Curve progression despite bracing
47
Q

Aims of surgery (3)

A
  1. Correct curve (minimal fusion)
  2. Spinal balance
  3. Fuse to stable zones proximally and distally
48
Q

What is congenital talipes equinovarus (CTEV) - 3

A

“Clubfoot” (unknown aetiology)

In utero malalignment of talocalcaneal, talonavicular and calcaneocuboid joints (16-30wks)

Malalignments fixed by contracted joint capsules, ligaments, tendons

49
Q

Diagnosis of CTEV (7)

A

US prenatally or baby check postnatally

  • equinus (pointed ankle)
  • heel turned in (varus)
  • midfoot towards midline (adductus)
  • 1st MT in PF
  • deep creases (heel, medial)
  • can’t correct deformity passively
  • larger calf and foot mm
50
Q

Pathology of CTEV (bony and soft tissue - 5 each)

A

Bony

  • Normal mortise
  • Small, malformed, medially rotated talus tilted into equinus
  • calcaneus in varus and equinus
  • navicular medially displaced
  • 1st ray PF

Soft tissue

  • shortened, thickened mm (tib post, FHL, FDL, tendoachilles)
  • LL atrophy, particularly peroneals
  • smaller higher calf
  • contracture of capsule etc
  • empty heel pad
51
Q

Pirani Score (who for, scoring, components - 6)

A

For newborns and initial casting period

0 = no abn; 0.5 = moderate; 1 = severe (scored in maximally corrected position)

Components

  1. Curvature of lateral border (CLB)
  2. Medial crease (MC)
  3. Lateral head of talus (LHT)
  4. Posterior crease (PC)
  5. Emptiness of heel (EH)
    - cheek = 1; nose = 0.5; forehead = 0
  6. Rigidity of equinus (RE)
52
Q

Dimeglio Grade (who for)

A

For initial assessment and older children/relapsed feet

53
Q

Ponseti Method Rx (general - 4, casting - 5, post casting - 2)

A

General

  • Correct all components simultaneously (except equinus)
  • Average of 5 casts (changed weekly)
  • Start soon after birth
  • Manipulation (at least 60s prior to casting)

Casts

  1. forefoot supination and 1st ray extn
  2. abduction of forefoot using talar head as fulcrum
  3. further abd
  4. further abd to 70 deg
  5. percutaneous tenotomy to correct equinus and foot dorsiflexed (cast for 3wks)

Post-casting

  • boot and bar worn full time for 12wks
  • worn 14-16hrs/day until 4yrs
54
Q

When to perform a tenotomy? (3)

A
  1. anterior calcaneus can be abducted from under talus
  2. foot can be abducted 60 deg from frontal plane
  3. neutral/slightly valgus calcaneum
55
Q

How is a percutaneous tenotomy performed? (4)

A

Performed

  • local anaesthetic
  • PT holding for surgeon
  • tendon palpated 1cm above calcaneum then divided
  • – 10-15 deg gained
  • Long leg cast with knee flexed 90 deg
56
Q

Bracing with boots and bar (general - 3)

A

Fit

  • open toed, high topped
  • shoulder width apart
  • slight bend in bar to hold 5-10 deg DF
57
Q

Managing relapses (cause, techniques - 4)

A

Noncompliance is most common cause (B+B)

Rx

  • don’t ignore, cast immediately and return to B+B
  • Equinus relapse (recast with long leg, may need to do tenotomy again)
  • Varus relapse (recast and resume B+B)
  • Dynamic supination (need TATT or SPLATT)
58
Q

Assessment for foot deformities (sub - 3; obj - 5)

A

Sub

  • Pregnancy (breech etc)
  • Birth Hx (complications, delivery etc)
  • Family and med Hx

Obj

  • Hips (DDH)
  • Head shape and neck ROM (torticollis and plagiocephaly)
  • Spine (scoliosis, spina bifida)
  • Development
  • Rotational profile (hip IR/ER etc)
59
Q

Postural Talipes Equinovarus (clinical - 2, Rx - 3)

A

Clinical features

  • no structural abn
  • foot held in PF and inv but full passive ROM

Rx

  • improves over time
  • reassure parents
  • stretches and don’t swaddle too tightly
60
Q

Metatarsus Adductus (clinical - 3, Ax -

A

Clinical features

  • Base of 5th MT is prominent
  • “searching” big toe (20%)
  • Assoc with internal tibial torsion

Assessment

  • Pirani for forefoot
  • Passive forefoot abduction (should be full PROM)
  • AROM (stimulate abd by stroking lateral border)
61
Q

Metatarsus Adductus (Rx - 3)

A

Rx

  • most are passively correctable (active stim and stretch into abd)
  • most resolve spontaneously
  • can do serial casting then if limited passive abd
62
Q

Talipes calcaneovalgus (TCV) - Description, Ax - 2, Rx - 2

A

Ankle in DF and forefoot abd (heel valgus)
- improves with time (normal by 16)

Ax

  • Most have full PROM
  • DD - vertical talus

Rx

  • if full PROM, encourage PF and inversion with stroking
  • if limited PROM, long leg cast then splint
63
Q

Congenital Vertical Talus (CVT) - Description - 5

A

Looks like TCV but rigid and doesn’t improve (very uncommon)

  • from fixed dorsal dislocation of navicular on talar head and neck (talus in extreme PF)
  • calcaneal equinus and valgus
  • forefoot DF and abd at midtarsal jt
  • peroneals and tib ant contracted
64
Q

CVT Ax (3), Rx (2)

A

Ax

  • Other comorbidities
  • AROM/PROM
  • Photos

Rx

  • serial casting with reverse Ponseti?
  • Sx

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