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Pediatrics 12

  1. Fractures in children
  2. Definition: break or disruption in bone continuity
  3. Etiology: usually due to mobility and immature motor and cognitive skills, trauma, osteogenic diseases, birth injuries, child abuse
  4. Pathophysiology
    1. fractures are seldom complete breaks (bone is so flexible) (illustration)
    2. many types: greenstick, spiral, oblique, transverse, comminuted, pathologic.
    3. classification: simple (closed) or compound (open); complete or incomplete
    4. pediatric risks
      1. external hemorrhage creates risk of critical blood loss
      2. break at epiphyseal plate (growth plate between epiphysis and metaphysis)
  5. Findings: swelling, pain, bruising, edema, muscle rigidity, diminished functional use of affected part
  6. Diagnostics: x-rays, laboratory testing
  7. Management: cast or traction to realign, possible surgery (illustration  )
  8. Concerns: bone healing and alignment, neurovascular status, pain, bone growth, compartment syndrome

Structural Musculoskeletal Disorders

    1. Clubfoot (illustration)
      1. Etiology: congenital malformation of one or both feet
      2. Findings: plantar-flexed foot/feet, with inverted heel and adducted forefoot.
      3. Management: serial manipulation and casting after birth; possible surgery
    2. Genu varum (bowleg) and genus valgum (knock knee)
      1. Etiology: congenital
      2. Findings
        1. bowlegs (genu varum) common in infants and toddlers
        2. knock knees common in preschool age and older.
      3. Management: most resolve spontaneously - pathologic forms may require night splints, manual manipulation, casting or surgery.
    3. Hip dysplasia
      1. Definition: developmental dysplasia of the hips (DDH), or dislocation
      2. Etiology: congenital, pre- and post-natal positioning
      3. Pathophysiology: head of femur is improperly seated in acetabulum in hip (illustration)
      4. Clinical manifestation
        1. limited abduction
        2. short femur on affected side (Galeazzi's sign)
        3. asymmetry of gluteal skin folds,
        4. waddling gait (bilateral dislocations)
        5. for children already walking, increased laxity
      5. Diagnostics
        1. physical exam/screening at birth
        2. check for Ortolani maneuverand Barlow's test
        3. radiographic studies
      6. Management: Pavlik harness, spica cast, traction, surgery, Bryant's traction
      7. Concerns: compliance, skin integrity, avascular necrosis from improper positioning of harness
    4. Scoliosis (illustration)
      1. Definition: lateral curvature of the of spine and rotation of vertebral bones
      2. Etiology
        1. idiopathic
        2. associated with neuromuscular disorders or trauma (paralytic)
        3. congenital
        4. most commonly diagnosed during adolescent growth spurt
      3. Pathophysiology
        1. dependent on type (idiopathic, congenital, paralytic)
        2. curved spine deforms rib, body develops compensatory curve to maintain posture and balance.
      4. Findings
        1. visible curve (either C or S shaped curves)
        2. "rib hump," or asymmetric rib cage
        3. legs are different lengths
        4. waist angles uneven
      5. Diagnostics: screening, radiographic studies
      6. Management:
        1. initially, exercise and bracing to hold curve (Milwaukee brace - rarely used, Boston brace - plastic shell, or TLSO - custom-molded jacket)
        2. if curve progresses, surgery
      7. Concerns
        1. body image/self esteem, pain and discomfort
        2. compliance with exercises and bracing; skin integrity, airway clearance
        3. Infectious Musculoskeletal Conditions
    5. Osteomyelitis: bacterial bone infection
      1. Etiology: endogenous (in-body) sources, or direct entry via open fracture or external fixation devices
      2. Pathophysiology (illustration)
        1. microbe affects metaphysis of long bone; inflammation
        2. pus forms and spreads along the shaft of the bone
        3. new bone starts to form, but existing cortex loses blood vessels and necrotic area will detach (sequestrum)
        4. "honeycombed" areas contain infective material
      3. Findings
        1. pain, localized tenderness, erythema over involved bone
        2. decreased range of motion at affected bone
        3. irritability, restlessness, fever
      4. Diagnostics
        1. laboratory: blood cultures
          1. erythrocyte sedimentation rate (ESR) will increase
          2. increased white blood cells
          3. blood culture
        2. radiographic studies (often negative for ten to 14 days); bone scan
      5. Management
        1. IV antibiotics; may require long-term IV access
        2. bed rest
        3. possible immobilization with splints or cast
        4. possible surgery
      6. Concerns: monitor antibiotic levels, pain, limited range of motion

Other Musculoskeletal Disorders

    1. Juvenile rheumatoid arthritis (JRA)
      1. Definition: inflammation of joints
      2. Etiology: auto-immune with probable genetic predisposition
      3. Pathophysiology
        1. trigger inflames synovium
        2. effusion of the joint and increased fluid
        3. erosion and fibrosis of the articular cartilage
        4. further deterioration occurs with bone erosion
        5. decrease in joint's range of motion and function
      4. Findings
        1. may have sudden inability to walk on one leg
        2. intermittent joint pain, stiffness, swelling
        3. decreased range of motion, morning stiffness
      1. Diagnostics
        1. laboratory testing - no definitive serologic tests
          1. increased ESR and CRP: c-reactive protein (sign of rheumatic fever)
          2. anemia
          3. leukocytosis in early stages
          4. HLA testing (human leucocyte antigen)
        2. radiographic testing and x-rays -- widening of joint spaces followed by gradual fusion and articular destruction
      2. Management
        1. treatment objectives
          1. preserve joint function
          2. prevent physical deformities
          3. relieve findings
        2. medications: nonsteroidal anti-inflammatory drugs (NSAIDs), slow acting antirheumatic drugs (SAARDs), corticosteroids, immunosuppressives, cytotoxic agents
        3. other: PT and OT, rest/activity, positioning, splinting, ultrasound, electrical stimulation, heat, whirlpool; surgery for joint replacement
      3. Concerns
        1. compliance with therapy
        2. contractures
        3. pain/discomfort
        4. family and child support services, body image, decreased mobility
        5. altered growth and development due to deceased activity, decreased ability to perform ADLs
    2. Osgood-Schlatter disease
      1. Etiology: idiopathic - possibly due to repetitive stress from sports related activity plus overuse of immature muscles and tendons. Usually self-limiting.
      2. Findings
        1. knee pain/tenderness
        2. edema of tibial tubercle
        3. exacerbated by running and jumping
      3. Diagnostics: physical exam, history, radiographic studies
      4. Management
        1. avoid certain activities
        2. use elastic bandage on affected knee
        3. rest, ice, NSAID's
    3. Legg-Calve-Perthes disease: osteochondritis
      1. Definition: aseptic necrosis of femoral head
      2. Etiology: unknown - possible growth disorder
      3. Pathophysiology
        1. disturbance in blood supply
        2. ischemic aseptic necrosis of femoral head, usually self-limiting (illustration)
      4. Findings
        1. insidious onset
        2. intermittent painful limp on one side
        3. increased pain after extended period of activity
        4. decreased range of motion
      5. Diagnostics: history, radiographic studies, bone scan, MRI
      6. Management
        1. bed rest
        2. non weight-bearing range of motion
        3. containment devices such as braces, casts, traction
        4. possible surgery
      7. Concerns: permanent deformity, decreased activity, skin integrity