Musculoskeletal Disorders in Children - Review
Genu Varum
(aka Bowleg); Lateral bowing of the tibia, due to joint laxity; considered normal until 2yo
Muscular Dystrophy
(aka Duchenne's Muscular Dystrophy); A progressive genetic disorder beginning in the lower extremities and progressive in the upper extremities and torso
Genu Valgum
(aka Knock-Knee); knees are abnormally close and ankle space is increased; typically evolves to normal alignment by 7yo
Early signs of muscular dystrophy include:
- Abnormalities of gait and posture - Not keeping up with peers physically - Gower's maneuver
Management of toxic synovitis:
- Analgesics - Bed rest - Benign/self-limiting
Management of slipped capital femoral epiphysis:
- Immediate referral to Orthopedist - No ambulation permitted - Monitor other hip for SCFE
Classic signs and symptoms of LCPD
- Insidious onset of a limp with KNEE PAIN that MIGRATES TO THE GROIN/LATERAL HIP - Afebrile - Limited passive internal rotation and abduction of the hip
Classic signs and symptoms of Genu Valgum
- Knees close together - Distance between medial malleoli (ankles) is more than 3 inches - Full ROM - Awkward walk/run
Mangement of Genu Varum:
- Normal until 2yo Refer to Orthopedics if: - Continues after 2yo - Unilateral involvement - Becomes aggressively worse after first year
Classic signs and symptoms of slipped capital femoral epiphysis:
- Pain in the GROIN that REFERS TO THE THIGH AND/OR KNEE - Unable to properly flex hip as femur abducts/rotates externally
Classic signs and symptoms of toxic synovitis:
- Painful limp - Unilateral involvement - Insidious onset
Common complications of Systemic Lupus Erythematous (SLE) include:
- Pericarditis - Arthritis - Nephritis
In the newborn, a diagnosis of hip dislocation is suspected when:
- Positive Galeazzi sign or Allis' sign (unequal knee height when knees are flexed) - Postive Barlow sign (hip passively dislocated) - Positive Ortolani's "click" (click felt when reducing the hip) - confirms DDH
Management of Osgood-Schlatter Disease:
- Self-limiting - Limit activity to control pain - Knee immobilizers may provide some relief
Common signs and symptoms of nursemaid elbow:
- pain with supination - child will hold arm across their body with thumb up
Classic signs and symptoms of Osgood-Schlatter Disease
- pain/tenderness at tibial tubercle - point tenderness
Most children with Duchenne Muscular Dystrophy become wheelchair dependent by what age?
10 to 12 years of age
What curvatures of the spine are indications for surgery in the patient with scoliosis?
40 degree Thoracic curvature 50 degree Lumbar curvature
Ibuprofen can be given to a child as early as...
6 months
What is the most appropriate initial management of a newborn diagnosed with developmental dysplasia of the hip (DDH)?
A Pavlik harness (a flexion-abduction device)
What is a valuable diagnostic marker for JIA?
ANA seropositivity for antibodies
Developmental Dysplasia of the Hip (DDH)
Abnormal dislocation (luxation or sub-luxation) of the hip in which the femoral head is partially or completely displace from the acetabulum
Which test is performed when evaluating a patient for Scoliosis?
Adam's Forward Bend Test (will show asymmetry of shoulder, ribs, hips, and waistline)
What is the most common sports and musculoskeletal injury?
Ankle sprain
Legg-Calve-Perthes-Disease (LCPD)
Aseptic or avascular necrosis of the femoral head; due to vascular disruption
At what age would the PCP perform x-rays and refer a child with genu valgum?
At 7yo
A child with "growing pains" is most likely to experience...
Bilateral lower extremity pain
For the child with developmental hip dysplasia, what occurs when the child begins to walk
Child may have a limp
Nursemaid elbow
Common injury in young children resulting from swinging or pulling child's arm; radial head subluxation
What laboratory values are markedly elevated in the patient with muscular dystrophy?
Creatine kinase (reflects brain and muscle damage)
Epiphysis
Ends of long bones
An injury at which sites of the bone will most likely result in discrepancy of bone length?
Epiphysis Bone length occurs at the epiphyseal plates., which is also where blood supply enters. If blood supply is compromised, growth may be jeopardized
What is the most definitive feature for a diagnosis of "growing pains"?
Exclusion of other causes of lower extremity pain
Genu Varum is considered an abnormal finding when...
Extreme tibial bowing continues after 2yo
Elbow fractures are associated with ......
Falls, usually with straight, outstretched arms
Classic radiograph findings for an elbow fracture include:
Fat pad signs - suggestive of presence of an occult fracture
During examination of a 2 week old, you not irritability when lifted, asymmetrical Moro reflex, and spasm along the right SCM. What does this suggest?
Fractured clavicle
Grades of sprains and characteristics:
GRADE 1: - stretching but no tearing of ligament - full ROM - patient retains weight bearing activity GRADE 2: - immediate pain upon injury - partial (incomplete) tearing of ligament; some joint instability but definite end-point laxity - significant pain with weight bearing activity - limited ROM GRADE 3: - complete ligamentous tearing; joint unstable with no definite endpoint to ligamentous stressing - severe pain upon injury - profound ecchymoses/hemorrhage - unable to bear weight - no ROM
Which is a classic sign seen in developmental hip dysplasia?
Galeazzi sign - asymmetrical knee height while infant is supine with hips/knees flexed
What is a classic sign/symptom of a child with muscular dystrophy?
Gower's maneuver - child "walks" hands up legs to attain standing position when getting up (suggestive of pelvic girdle weakness and loss of truncal space)
Systemic-onset JIA is most commonly associated with:
High, daily intermittent spiking fevers and rash
Management of scoliosis:
If no pain and less than 25 degrees curvature - OBSERVE If painful and greater than 25 degrees curvature - REFERRAL TO ORTHOPEDICS
Sports injuries are commonly associated with which risk factor?
Improper/poor training
Osgood-Schlatter Disease
Inflammation of the tibial tubercle as a result of repetitive stressors in patients with immature skeletal development
What is a common characteristic of Legg-Calve-Perthes disease?
Insidious (gradual and cumulative) onset of limp with knee and groin pain
Tibial torsion is commonly associated and can be treated with:
Internal rotation of lower extremities; observation
What is a characteristic feature of polyarticular JIA disease?
Involvement of 5 or more inflamed joints
What is the most common rheumatoid disease of childhood?
Juvenile idiopathic arthritis (JIA)
What suggests internal tibial torsion rather than internal femoral torsion in a 2yo child presenting with an in-toeing gait?
Knees face forward when walking
Scoliosis
Lateral curvature of the spine that is idiopathic and most common in adolescence
A healthy 6yo child presents with a limp and knee pain. The PNP finds limited passive internal rotation and abduction of the hip joint. The most likely diagnosis is.....
Legg-Calve- Perthes disease
Radiographic findings of disease progression and sphericity of the femoral head is helpful in the diagnosis and follow-up of
Legg-Calve-Perthes disease
Aggressive treatment of LCPD is indicated when:
More than one-half femoral head is involved and in children older than 6yo
A rapid growth spurt is associated with which musculoskeletal disorder?
Osgood-Schlatter Disease
Dislocation of the hip in a 6mos child may present with.....
Positive Galeazzi sign
Management of Sprains:
RICE: - rest - ice - compression - elevation
Ottawa Ankle Rule
Radiographs are indicated if: - There is pain near the malleoli - Bone tenderness is present at the posterior edge of the distal 6cm or the tip of either malleolus - Patient is unable to bear weight for at least 4 steps at a time
14yo has knee pain that increases with activity and is relieved with rest. The PNP diagnoses Osgood-Schlatter disease. What is appropriate management?
Reduce activity, use of ice to the knee, and Ibuprofen
While completing the hip examination on a newborn infant, you are able to dislocate the infant's right hip. What is the appropriate management plan?
Referral to orthopedic specialist for possible developmental hip dysplasia - related to a positive Barlow sign
Initial treatment of a grade I sprain includes:
Rest, ice, compression, elevation (RICE) and NSAIDs
What is the main goal in management/treatment of LCPD
Restore range of motion while maintaining femoral head within the acetabulum
Which disorder develops after several months of vitamin D deficiency?
Rickets
Toxic Synovitis
Self-limiting inflammation of the hip, most likely due to a viral or immune disease
A patient with insidious onset painful limp, unilateral involvement, and FEVER presents to the office. The PCP should consider which differential (other than toxic synovitis):
Septic Arthritis
What is the most beneficial laboratory test when doing a workup for a child with suspected muscular dystrophy?
Serum creatine kinase
Slipped Capital Femoral Epiphysis (SCFE)
Spontaneous dislocation of femoral head (capital epiphysis) both downward and backward; occurs WITHOUT severe or sudden force/trauma
Ankle sprain
Stretching and/or tearing of the ligaments around the ankle, typically involving the lateral ligament complex; usually forced inversion or eversion
For a patient with "nurse-maid's elbow", if the risk for fracture is low or absent, what is an appropriate recommendation?
Supination and flexion of the forearm maneuver
What musculoskeletal disorder is associated with adduction of the forefoot?
Talipes equinovarus congenita (CLUBFOOT)
Management of scoliosis depends on the severity of the curvature of the spine. What characteristics would require surgical intervention?
Thoracic curvature greater than 50 degrees Lumbar curvature greater than 40 degrees
What is the goal of treatment for slipped capital femoral epiphysis?
To stabilize or improve the position of the femoral head
Which diagnosis is associated with contracture of one of the sternocleidomastoid muscles?
Torticollis
A 4yo boy is brought in by his mother who is concerned about a sudden onset and painful limp for 2 days. Today he has a low-grade fever. What diagnosis is most likely?
Transient synovitis of the hip
Growth in muscle length is related to growth in length of.....
Underlying bone
What is appropriate anticipatory guidance for a child with slipped capital femoral epiphysis?
Use of crutches to facilitate mobility during acute phase
A 14yo with JIA currently taking Methotrexate. He is not up-to-date on vaccines. Which vaccine would be cautioned?
Varicella. Patients receiving DMARDS are at risk for developing serious complications of varicella-zoster infection
What is the hereditary nature of Muscular Dystrophy?
X-linked recessive gene transmitted by unaffected female carriers
