pediatric musculoskeletal

Question 1

developmental dysplasia of the hip: previously known as…

Answer 1

congenital dislocation of the hip

Question 2

developmental dysplasia of the hip

Answer 2

abnormal development of the hip
- maternal hormones can lead to transient lax hips

• FYI 80% female, 50% first born

Question 3

developmental dysplasia of the hip: contributing factors

Answer 3

• frank breech
• maternal hormones
• parent, sibling with DDH: 5X likelihood

Question 4

frank breech

Answer 4

buttocks presenting part with hips acutely flexed and knees extended

Question 5

degrees of DDH (list)*

Answer 5

preluxation
subluxation
dislocation

Question 6

preluxation*

Answer 6

MILD degree of ddh

femoral head remains in acetabulum (is in contact with it) but is displaced

Question 7

subluxation

Answer 7

degree of ddh; incomplete dislocation

largest %

Question 8

dislocation

Answer 8

most severe form of ddh

femoral head loses contact with acetabulum

Question 9

ddh: diagnosis when

Answer 9

ideally made in neonatal period (tx w/in 2 mo = highest success rate)

Question 10

ddh assessment techniques for diagnosis (list)

Answer 10

• ortolani test
• barlow test
• galeazzi sign
• trendelenburg sign

Question 11

ortolani test

Answer 11

diagnostic tool for ddh

apply forward pressure form behind trochanter during full abduction (careful, can do damage)

Question 12

barlow test

Answer 12

diagnostic tool for ddh

apply pressure from front during adduction

Question 13

galeazzi sign

Answer 13

diagnostic tool for ddh

shortened limb on affected side

Question 14

trendelenburg sign

Answer 14

diagnostic tool for ddh

as patient bears weight on affected hip, pelvis tilts downward on the normal side instead of upward

Question 15

ddh: classic signs (list)

Answer 15

• asymmetric gluteal folds
• limited hip abduction
• unequal knee height
• lordosis/waddling gait

Question 16

ortolani and barlow disappear after…

Answer 16

2-3 months (most reliable within this time period)

ddh

Question 17

most sensitive test after ortolani/barlow disappear

Answer 17

after 3 months, limited hip abduction

Question 18

ddh: therapeutic management goal

Answer 18

obtain and maintain safe, congruent position of the hip joint to promote normal development

begin ASAP! early intervention = favorable outcome

Question 19

pavlik harness

Answer 19

therapeutic management of ddh; hip in controlled flexion and abduction: use pavlik harness

• 0-6 months of age
• worn continuously for ~5mo
• dynamic splinting (adjust for growth)
• not rigid
• 95% effective

Question 20

spica cast

Answer 20

therapeutic management of ddh; used when hip unable to be reduced/remain aligned properly and when pavlik ineffective

Question 21

ddh: therapeutic management - 0 to 6 mo

Answer 21

pavlik harness or spica cast

Question 22

ddh: therapeutic management - 6 to 18 mo

Answer 22

• traction in prep for surgery
• surgery for closed/open reduction
• then spica cast 2-4 mo

Question 23

ddh: therapeutic management - older child

Answer 23

hip correction much more difficult, surgery much more involved

after 4 years: very difficult
after 6 years: poor outcome

Question 24

club foot

Answer 24

deformity of ankle and foot

• talipes equinovarus (tev) most common, 95%
• males affected 2x more than females
• bilateral 50% cases
• family tendency

Question 25

talipes equinovarus

Answer 25

most common form of club foot: 95% - talipes: involves ankle, foot - equino: heel is elevated like horse (plantar flexion) - varus: fixed inversion (turned in)

Question 26

club foot: diagnosis

Answer 26

readily apparent at birth | increased chance of ddh with tev!!!!

Question 27

club foot: therapeutic management (list)

Answer 27

``` serial casting surgical correction (if casting is ineffective) ```

Question 28

serial casting

Answer 28

therapeutic management of club foot - tx begins in newborn period - allows for gradual stretching - cast changed q few days 1-2 weeks, then q 1-2 weeks - usually casted for 8-12 weeks

Question 29

pmss

Answer 29

p ulse m obility s ensation s kin cast considerations

Question 30

kyphosis

Answer 30

abnormal increase in convex curve of thoracic spine

Question 31

lordosis

Answer 31

accentuation of lumbar curve

Question 32

scoliosis

Answer 32

lateral curvature + spinal rotation + thoracic hypokyphosis - most common spinal deformity - adolescent females 7:1 - genetic component but not fully understood

Question 33

idiopathic scoliosis

Answer 33

no apparent cause

Question 34

congenital scoliosis

Answer 34

associated with neuromuscular disorders

Question 35

scoliosis: clinical manifestations

Answer 35

most noticeable during preadolescent growth spurt

Question 36

scoliosis: diagnosis*

Answer 36

screening assessment (view at hip height) - adam's position, WEARING ONLY UNDERGARMENTS*, view from behind - see: asymmetric shoulder height, hip height, abnormal scapular shape - suspected? definitive tests required; even mild refer to ortho

Question 37

scoliosis: therapeutic management (list)

Answer 37

- observation - bracing + exercise - spinal fusion

Question 38

bracing

Answer 38

therapeutic management of scoliosis; can halt/slow progression until skeletal maturity (non-curative) - worn 16-23 hours a day initially - adherence is an issue - exercise used in conjunction (increase muscle strength of spine, abdomen)

Question 39

spinal fusion

Answer 39

therapeutic management of scoliosis; correction of severe curve that doesn't respond to bracing - significant pain, possible respiratory compromise (atelectasis)

Question 40

scoliosis spinal fusion: mobility considerations

Answer 40

``` day of surgery: log roll q2' (no twisting/bending!!) pod 1: elevate HOB, sit at side of bed pod 2: sit in chair for 1' x2 pod 3: ambulate 3x - turn q2 ```

Question 41

osteomyelitis

Answer 41

acute or chronic bone infection usually caused by bacteria, can lead to bone destruction, abscess formation, and dead bone boys > girls

Question 42

osteomyelitis: etiology

Answer 42

- exogenous source (puncture wound, open fracture, surgical contamination) - hematogenous source (bloodborne bacterium)

Question 43

osteomyelitis: clinical manifestations

Answer 43

- severe pain - limited movement - fever - restlessness, irritability

Question 44

osteomyelitis: diagnostic eval

Answer 44

- hx sx - leukocytosis - increased esr + blood culture, joint aspirate culture - x-ray: changes evident only after 2-3 weks

Question 45

leukocytosis

Answer 45

increased wbc

Question 46

osteomyelitis: therapeutic management

Answer 46

- IV abx for at least 4 weeks | - followed by oral antibiotics

Question 47

septic arthritis

Answer 47

bacterial infection of the joint, usually hematogenous spread - staph aureus most common causative agent - most common joints affected: knees, hips, ankles, elbows

Question 48

septic arthritis: most common causative agent

Answer 48

staph aureus

Question 49

septic arthritis: most common joints affected

Answer 49

hips, knees, ankles, elbows

Question 50

septic arthritis: clinical manifestations

Answer 50

severe joint pain swelling, tissue warmth, erythema systemic illness may be present (fever, malaise, ha, n/v, irritability)

Question 51

septic arthritis: diagnosis

Answer 51

- joint aspiration! | - early xray only reveals soft tissue involvement (but important for baseline)

Question 52

septic arthritis: treatment

Answer 52

- IV abx based on gram stain 3-4 wks - adequate, timely drainage of infected synovial fluid - immobilization of joint (pain control) - pain management after 5 days tx, begin PT. extensive PT allows maximum functioning

Question 53

muscular dystrophy

Answer 53

genetic, gradual, progressive degeneration of muscle fibers - progressive weakness, wasting of skeletal muscles - variable: age of onset, rate of progression, muscle groups affected

Question 54

duchenne muscular dystrophy

Answer 54

most severe, most common, most aggressive type of md - x linked inheritance - death usually by 30

Question 55

duchenne muscular dystrophy: clinical manifestations

Answer 55

- onset between 3 to 5 years - usually lose ambulation ability by 12 - cause of death usually respiratory tract infection or cardiac failure (all muscles affected!)

Question 56

duchenne muscular dystrophy: diagnostic eval

Answer 56

- elevated serum cpk enzymes - muscle biopsy - gower sign

Question 57

gower sign

Answer 57

classic presentation of dmd; difficulty rising from sittin

Question 58

cpk enzyme

Answer 58

creatine phosphokinase: enzyme found mainly in the heart, brain, and skeletal muscle. elevated serum levels in dmd

Question 59

duchenne muscular dystrophy: therapeutic management

Answer 59

NO CURATIVE TREATMENT | - genetic counseling (think of pregnancy spacing, sons)

Question 60

osteogenesis imperfecta*

Answer 60

characterized by bone fragility, fractures, deformity, blue sclera*, hearing loss, discolored teeth; autosomal dominant most common osteoporosis syndrome in children; usually normal lifespan!

Question 61

blue sclera: think...

Answer 61

osteogenesis imperfecta!

Question 62

osteogenesis imperfecta: therapeutic management

Answer 62

primarily supportive!! - strengthen muscles = prevent contractures - light resistance exercise - handle carefully (fracture prevention) - limited benefit from pharm - family support!

Question 63

osteogenesis imperfecta: therapeutic management

Answer 63

primarily suppotive!! - strengthen muscles = prevent contractures - light resistance exercise - handle carefully (fracture prevention) - limited benefit from pharm - family support!