Pediatrics 2 > MSK > Flashcards

MSK Flashcards

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1
Q

PE for MSK

A
  • gait
  • focus on pelvis, hips, knees, ankles, feet
  • spine
  • joint swelling/asymmetry
  • palpate joints
  • ROM
  • neuro: strength, sensory, reflexes
  • limb length
  • hip dysplasia in infants
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2
Q

Diagnostic studies/labs for MSK

A
  • Radiology: XR, US, Bone scan, MRI ($$)
  • Lab: ESR, CBC, Blood culture
  • Joint aspiration: cell count, gram stain, culture, protein count
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3
Q

Joint aspiration

- technique

A
  • aseptic (don’t want skin sample)

- needle and syringe

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4
Q

Joint aspiration

- fluid analysis

A
  • gross exam: appearance, color, volume, viscosity
  • Microscopic exam: WBC #, smear, glucose, protein
  • C&S
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5
Q

Joint fluid analysis

- Non-inflammatory

A
  • Gross appearance: transparent, clear-yellow
  • WBC: <2,000/mcL
  • PMN: <25%
  • culture: neg
    ex. osteoarthritis
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6
Q

Joint fluid analysis

- Inflammatory

A
  • Gross appearance: cloudy yellow
  • WBC: 5,000-50,000/mcL
  • PMN: 50-75%
  • culture: neg
    ex. JIA, SLE, RA
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7
Q

Joint fluid analysis

- Septic arthritis

A
  • Gross appearance: opaque, yellow, purulent (like pus)
  • WBC: >100,000/mcL
  • PMN: <75-100%
  • culture: pos
    ex. staph, strep, gram-neg infections
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8
Q

Joint fluid analysis

- Hemorrhagic

A
  • Gross appearance: red and opaque (bloody)
  • WBC: <5,000/mcL
  • PMN: <25%
  • culture: neg
    ex. trauma, bleeding disorder, neoplasia
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9
Q

By what age do most kids have a “normal” adult gait pattern

A

age 3

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10
Q

Toe walking

A
  • nl 10-18 months as learn to walk
  • Can be normal up to age 3
  • Ddx: muscle spasticity/contractures (CP), muscular dystrophy, congenital tight heel cords
  • check ankle ROM and heels
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11
Q

Normal pediatric gait pattern (knees)

A
  • Genu varum normal up to age 2
  • Genu valgum normal from 2-6 (toes might point in, kids trip over toes)
  • reassure parents this is normal for the age range
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12
Q

Antalgic gait

A
  • less time on painful limb
  • knee injury, ankle sprain, etc.
  • think trauma or infection
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13
Q

Trendelenburg gait

A
  • abductor lurch
  • pelvis/shoulder drop away from affected hip
  • remember weak glue on affected side, when step on weak muscle, gives out and swings outward
  • if bilateral, will waddle
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14
Q

Circumduction gait

A
  • hemiplegic gait
  • swing affected leg in semicircle out to the side
  • think CP or neuropathy (foot drop)
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15
Q

Equinus gait

A
  • foot contact with toes or front of foot first
  • heel cord contracture or short limb
  • look like prancing pony
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16
Q

Hip pain in limping child

- <4 yo ddx

A
  • transient synovitis
  • osteomyelitis/septic arthritis
  • juvenile idiopathic arthritis
  • non-accidental injury (abuse, spiral fracture)
  • referred pain from limb
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17
Q

Hip pain in limping child

- 4-10 yo ddx

A
  • transient synovitis
  • Perthes disease
  • osteomyelitis/septic arthritis
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18
Q

Hip pain in limping child

- 10-16 yo ddx

A
  • SCFE
  • avulsion fx
  • osteomyelitis/septic arthritis
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19
Q

Growing pains

A
  • bilateral
  • non-articular, common in the shin
  • intermittent
  • worse at night (can wake from sleep)
  • M>F
  • NO limping, limited ROM
  • NO signs trauma or infection
  • Dx of exclusion
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20
Q

Growing pains

  • Dx
  • Tx
A
  • Dx of exclusion
    • watch out bc cancer can also present as night pain…
  • TX: supportive, reassurance, rest, NSAIDS if necessary
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21
Q

Developmental Dysplasia of the Hip (DDH)

A
  • dislocation or instability of the hip joint
  • F > M
  • bones (shallow socket) and soft tissue (stretched capsule)
  • can occur any time from conception to skeletal maturity
  • **screen all newborns for this
  • L more common than R dt position in utero
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22
Q

Developmental Dysplasia of the Hip (DDH)

- risk factors

A
  • Native American
  • Fam hx of DDH
  • Female
  • first-born child
  • breech
  • oligohydramnios
  • swaddled often in adduction
  • Neuromuscular disorders (CP)
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23
Q

Developmental Dysplasia of the Hip (DDH)

- Signs and Sx

A
  • asx at birth, usually note when start walking
  • Shortening of leg (femur is behind the socket)
  • painless limp
  • Trendelenburg Gait (or waddling)
  • excessive lordosis of low back, hip flexion contracture
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24
Q

Developmental Dysplasia of the Hip (DDH)

- Exam

A
  • Screen ALL newborns
  • Provocative maneuvers:
  • Barlow and Ortolani
  • limited ABduction, shortened limb (Galeazzi sign), increased thigh folds
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25
Developmental Dysplasia of the Hip (DDH) | - Barlow and Ortolani
- Barlow: adduct thigh, push posterior, trying to dislocate hip. Dislocation if positive - Ortolani: hold contra hip still, abduct femur and pull anterior, trying to relocate if out. Will clunk into place in positive test
26
Developmental Dysplasia of the Hip (DDH) | - Imagine
US - in newborns, babies <6 mo bc un-ossified bone - Shows shape of socket and position of femoral head XR - not necessary if exam is positive - Only if >6 mo - femur will be dislocated posteriorly
27
Developmental Dysplasia of the Hip (DDH) | - Treatment
- Goal is containment - Keep femur head in socket will help deepen socket as child grows - Abduction brace or casting :( - ortho referal!
28
Transient Synovitis
- Transient inflammation of hip (sterile effusion) - MC cause limping 2-7 yo (peak 4-5) - Limp +/- pain - M>F - Cause unknown, often assoc. with recent viral illness
29
Transient Synovitis | - Signs and Sx
- Recent URI, pharyngitis, gastroenteritis - NO fever - Limp worse at end of day - Toddler may refuse to walk - if pain, usu unilateral groin, proximal thigh, +/- knee
30
Transient Synovitis | - Dx
- dx of exclusion (must rule out trauma and infection) - Pain with ROM and palpation - Normal XR, CBC - ESR may be elevated - Joint fluid: clear/straw colored, neg culture
31
Transient Synovitis | - Tx
- Bed rest if severe pain - +/- NSAIDs - Expect improvement in 3-14 days
32
Septic Arthritis | - cause
- Hematogenous seeding | - Adjacent osteomyelitis
33
Septic Arthritis | - Sx
- Acute onset pain/limp - guarding of joint - usu hip or knee - hx of trauma - 90% monoarticular
34
Septic Arthritis | - Exam
- Peak <2 yo - Febrile, SICK kid: malaise, anorexia, apprehension - Tenderness, warmth, swelling - Hip held in flexion, abduction, external rotation - Resists ROM
35
Septic Arthritis | - Dx
CBC - WBC >15,000 ** - Elevated ESR - Pos blood culture in 40% US guided hip aspiration - Fluid cloudy/pus - >50,000 WBC - pos culture in 50% XR - Normal will appear nl - late shows bone resorption
36
Septic Arthritis | - two MC organisms
- Staph aureus | - GBS
37
Septic Arthritis | - Treatment
- Hospital admission and supportive care - Ortho consult STAT - Immobilize joint with splint - IV abx X 2w + oral abx (Vanc and Cefotaxime) - Sx if needed: joint drainage and irrigation
38
Septic Arthritis | - Complications
- AVN | - Degenerative joint disease
39
Juvenile Idiopathic Arthritis - define - age - dx
- chronic arthritis >6 weeks - <16 yo - Dx of exclusion, must r/o: Lyme, malignancy, infection, psoriasis, IBD, Strep, bleeding dz, vasculitis
40
Juvenile Idiopathic Arthritis | - three types
- Oligoarticular - Polyarticular - Systemic
41
Oligoarticular Juvenile Idiopathic Arthritis
- MC - onset <6 yo - F>M - ≤ 4 joints - Knees, ankles, wrist, elbow - NEVER hips - Lab: possible ANA+ - Good prognosis - Uveitis complication = screen Q3Months
42
Polyarticular Juvenile Idiopathic Arthritis
- ≥ 5 joints - Large and small joints - Symmetric - 1-6 yo and 11-16 yo
43
Polyarticular Juvenile Idiopathic Arthritis | - two subtypes
- RF Negative: younger, gradual onset, multiple joints, ANA+ most - RF Positive: older, abrupt onset, aggressive, +/- RA nodules, poorer prognosis, persists into adulthood, F>M
44
Systemic Juvenile Idiopathic Arthritis
- Daily spikes of high fever - Recurring evanescent erythematous rash (w/ the fever) - +/- hepatosplenomegaly and lymphadenopathy - M=F - Very ill, leukocytosis, anemia, high ferritin, elev CRP/ESR - Specialist STAT
45
Systemic Juvenile Idiopathic Arthritis Complications
- Macrophage activation syndrome: coagulopathy, pancytopenia, liver failure, encephalopathy - pericarditis
46
Juvenile Idiopathic Arthritis | - Treatment
- NSAIDs: 1st line - Intraarticular steroids if only 1-2 joints - DMARDS (methotrexate and biologics)
47
Legg-Calve-Perthes Disease
- idiopathic AVN of proximal femur - Flattening and collapse of femoral head - 4-8 yo - M>F - 90% unilateral
48
Legg-Calve-Perthes Disease | - pathogenesis
- Ligamentum teres not developed yet = poor blood supply | - From 4-7 yo, femoral head depends entirely on lateral epiphyseal vessels
49
Legg-Calve-Perthes Disease | - Stages of development
1: bone death d/t interrupted blood supply 2: revascularization and repair, new bone laid atop dead bone 3: distortion and remodeling. Epiphysis collapses and femoral head flattens
50
Legg-Calve-Perthes Disease | - Signs and Sx
- Painless limp ≥ 3 weeks - insidious onset - sx worse at end of day - activity worsens limp - if pain: aching groin, proximal thigh, +/- knee
51
Legg-Calve-Perthes Disease | - Exam
- Limited hip ROM with guarding - shortened limb - Trendelenburg gait - Provocative maneuver: roll tests (positive if guarding or spasm) - Test: lay on belly, see if legs fall apart equally
52
Legg-Calve-Perthes Disease - XR - lab
- XR with frog leg view ** - Must compare to contralateral hip - looking for small epiphysis and wide articular surface - Early AVN: crescent sign (changes of a subcentral fracture) - if inconclusive, CT or MRI - ESR slightly elevated
53
Legg-Calve-Perthes Disease | - Treatment
- Ortho referral! - <50% femoral head: observation - >50% femoral head: brace or cast to contain femoral head, sx for severe deformities
54
Legg-Calve-Perthes Disease | - Prognosis
- Younger = better | - >10, very high risk of osteoarthritis
55
Slipped Capital Femoral Epiphysis (SCFE)
- instability of proximal femoral growth plate = displaced femoral head from femoral neck - Unilateral 70% - L>R - M>F (2-3X) - AA ethnicity - Obesity increases risk
56
Slipped Capital Femoral Epiphysis (SCFE) | - signs and sx
- Hip, medial thigh, knee pain ** - Painful limp - Antalgic gait with foot out - Limb shortening - Decreased ROM: internal rotation, abduction. Obligate external rotation with flexion
57
Slipped Capital Femoral Epiphysis (SCFE) | - XR
- AP, Lateral, Frog-leg view ** Always bilateral - Displacement of femoral head, medial displacement on AP view - "ice cream scoop falling off cone" - Widening epiphyseal line
58
Slipped Capital Femoral Epiphysis (SCFE) - Complications - Treatment
- AVN, DJD - NWB and traction - Surgical stabilization, internal fixation
59
Osgood-Schlatter Disease
- Anterior knee pain in kids - Overuse injury - 11-13 year old, active - M>F - Pain worse with jumping, kneeling, running
60
Osgood-Schlatter Disease | - Pathophys
- Repetitive quadriceps contractions - patellar tendon pulls on growth plate of tibial tubercle - tibial tubercle is immature, susceptible to injury
61
Osgood-Schlatter Disease | - Dx
- Exam: sufficient for dx - TTP, swelling over anterior knee at tibial tuberosity - Often bilateral - XR can be dx but is not needed
62
Osgood-Schlatter Disease | - tx
- Time, reassurance - Conservative: ice after play, NSAIDs PRN - Avoid sports for 2-3 mo to heal - activity mods upon return - occasional knee immobilization
63
Nursemaid's elbow
- MC elbow injury <5 yo - Subluxation of radial head dt laxity of annular ligaments** - MOA: jerk on child's arm with elbow extended, child forcefully lifted up by hand, elbow extended and forearm pronated
64
Nursemaids Elbow | - Signs and Sx
- HPI: child cries immediately after injury and then appears comfortalbe - Reluctant to use affected arm - Extremity held by side, palm down, elbow slightly flexed, forearm pronated - TTP only with palpation of radial head
65
Nursemaids Elbow | - Tx
- Thumb over radial head, supinate the forearm - If no "snap" of reduction, flex the elbow - should feel snap when reduced - child should use arm within a few minutes
66
Scoliosis
- 2-3% prevalence - multifactorial etiology - Lateral curve >10 deg - R thoracic curve MC - F>M - 10-13 yo - rotation of vertebrae, sometimes kyphosis/lordosis
67
Scoliosis | - Exam
- asymmetry of shoulders and iliac height - Scalpular prominence - Normal gait and neuro - Screen with adams test (bend forward) - follow with scoliometer
68
Scoliosis | - XR
- AP and lateral - Use Cobb angle to measure curve magnitude - MRI only if neuro sx
69
Scoliosis | - Tx
- Observation while child is growing - 20-40 deg: brace with progressive curves - >40: sx fusion of vertebrae (at near skeletal maturity) - Emotional support
70
Osteogenesis Imperfecta
- "brittle bone" dz - Genetic defect Type 1 collagen** = osteoporosis - AD inheritance, rare - Classic triad: Fragile bone w/ pathologic fx, early deafness, blue sclera
71
Osteogenesis Imperfecta - dx - management
- genetic testing to confirm - bisphosphates - physical rehab, bracing - fracture management
72
Osteosarcoma
- MC primary bone tumor - "immature" bone produced by malignant mesenchymal stem cells - Long bones MC - Sites of rapid bone growth: distal femur, proximal tibia, proximal humerus ** - 10-20 yo - M=F
73
Osteosarcoma | - Clinical findings
- Localized pain and swelling - limp - often noticed after minor injury - Dec ROM, TTP, skin warmth, +/- palpable mass - Pathological fx - Lung mets (usually =death)
74
Osteosarcoma | - DX
- XR: sunburst pattern** - Bx: required to confirm dx - Lab: elev. alk phos
75
Osteosarcoma | - Tx
- Pre op chemo - limb sparing sx or amputation - post op chemo
76
Ewings Sarcoma
- malignant tumor of neural crest cell origin* - 10-25 yo - EEE: Extremities, Extensive, Entire shaft
77
Ewing Sarcoma | - Signs and sx
- femur and pelvis MC - localized pain and swelling - soft tissue mass surrounds bone - fever, weight loss, fatigue - metastatic dz common
78
Ewing Sarcoma | - Dx
- XR: lytic destruction, unclear borders, layered "onion skin" appearance ** - bone scan - CT/MRI - Bx: req for dx
79
Ewing Sarcoma | - Tx
- sx - chemo - radiation
80
Fx of growth plate
- Very common - can lead to premature growth arrest, unequal bone length, limb length discrepancy - Premature arrest of part of physics = angular deformity - MC: distal tibia and distal femur
81
Salter Harris Classification
I: separation through physis. Good prognosis II: fx through metaphysics (above). Good prognosis III: fx through epiphysis and into joint (lower). Worse dt joint involvement IV: Fx across metaphysics, physis, epiphysis (through). Worse prognosis than III V: crush injury to physis. rare and bad...
Pediatrics 2
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