PEDS exam 2 alteration in musculoskeletal and neuromuscular disorders

What are the difference in pediatric nervous system?

Premature infants has immature CNS, spine is mobile so higher risk for injury, myelination is completed at 2 years

What is skeletal development in children?

flexible, more porous bones, easier healing, girls’ growth plates close sooner with laxer ligaments, rapid growth results in clumsiness, boys more risk to break bone, androgens fuse the growth plates in adolescence, abundant blood supply in periosteum is faster healing

What is the skeletally immature bone?

epiphysis/physis= end of bone

diaphysis= shaft of bone

metaphysis= contains growth plate in between epiphysis and diaphysis

What are the types of neural tube defects?

Spina bifida- failure of neural tube closure that affects the spine and spinal cord

anencephaly- abscence of cerebral hemispheres

encephalocele- affects brain and meninges

risks to get these include folic acid deficiency, diabetes, maternal drug use, fever and hyperthermia

What are the types of spina bifida?

Occulta- closed by skin with hair patch, dimple, lipoma and is generally benign (may cause tethered cord)

meningocele- sac like protrusion filled with meninges and CSF, but normal cord

myelomeningocele- sac like protrusion with meninges CSF and spinal nerves

How do we diagnose spina bifida?

prenatal elevated fetoproteins, ultrasound, C-section, newborn exam, MRI/CT, myelography

What are manifestations with myelomeningocele spina bifida?

sensory, motor, bladder and bowel dysfunction, hydrocephalus, seizures, and chiari 2 malformation

How do we treat spina bifida myelomeningocele?

treat by surgery in utero (18-25 weeks preventing chiari 2 malformation and hydrocephalus) or after birth, watch for infection, assess for CSF leak, monitor for increased ICP, monitor proper voiding, PT/OT, wheelchairs, assess skin integrity

What is metatarsus adductus?

medial adduction of toes and forefoot (goes inward), most outgrow by first year of life

What is congenital clubfoot talipes equinovarus?

bony deformity of foot/ankle, unknown why it happens but diagnosed at birth

How do we diagnose clubfoot?

smaller/shorter foot, empty heel pad, midfoot media crease with shorter calf atrophy, monitor for hip dysplasia

How do we treat clubfoot?

Ponseti method serial casting causes gradual stretching, percutaneous heal cord tenotomy is a long leg cast of 3 weeks, Denis Browne bar, Ponseti sandals, may need surgery to lengthen/release Achilles tendon

What is osteogenesis imperfecta (OI)?

genetic collagen defect that leads to easy bone fractures by faulty bone mineralization and abnormal bone development (mild to severe)

What are clinical manifestations of OI?

thin sclera reveals blood vessels, progressive hearing loss from ossicle changes, fragile discolored teeth, may have short stature, scoliosis, respiratory problems and joint hypermobility

What is management for OI?

Bisphosphonates, IV pamidronate etc can help increase bone density and prevent fractures, braces, splints, PT, surgery, positioning and activity support, try to keep bones aligned and growing as normal as possible

What is developmental dysplasia of the hip (DDH)?

abnormal hip development where head of femur slips in and out of the acetabulum

How do we diagnose DDH?

barlow (in and down) and ortolani (out and up) maneuver, ultrasound, x-ray, asymmetrical gluteal and thigh folds, leg length discrepancy, limping, toe walking, waddling, limited hip abduction leading to clicking sounds

How do we treat DDH?

newborn to 6 months- Pavlik harness, surgical closed reduction and hip spica cast if

6-24 months- hip abduction orthosis and traction, surgical closed reduction and hip spica cast

older child- traction, surgical pelvic and femoral osteotomy and hip spica case

What is torticollis?

tightness of sternocleidomastoid muscle resulting in painless tilt of infants head to one side caused by in-utero position/difficult birth or hip dysplasia (can lead to plagiocephaly/fattening of one side of infants head)

How do we treat torticollis?

PT, gentle stretching several times a day, turn head toward unaffected side and hold, can wear tubular orthosis for torticollis collar

What is blounts disease (tibia vara)?

progressive bowing of legs, risks are early walkers, obesity, family hx, and black children (treated by bracing or surgery)

What is cerebral palsy?

chronic non-progressive motor dysfunction, leads to permanent disability with uncoordinated/involuntary movements, poor sucking, seizures, voiding problems, abnormal muscle tone, body movement and posture (may be intellectual too)

What are the types of cerebral palsy?

spastic- poor control of motion and balanse with paralysis in certain areas

dyskinetic- abnormal involuntary movement, athetoid, dystonic

ataxic- lack of coordination with purposeful movement, wide based gait

mixed- combination of spastic and dyskinetic

How do we treat cerebral palsy?

speech therapies, orthopedic surgeries, PT/OT, medications for spasticity and seizure control, nutrition support, chart for an optimal developmental course

What are rickets?

softening and weakening of bones due to vitamin D deficiency leading to affected bone growth

Who is at risk for rickets?

limited sun exposure, GI/kidney disorders, premature baby bc of lack of calcium in pregnancy, and calcium/phosphorus imbalance

What are signs of rickets?

bowed legs, bone pain, cavities, delayed growth, weak muscle tone

How can we manage rickets?

correct calcium/phosphorus imbalance at separate times, get sunlight, vitamin D supplement, if breastfed, get started on iron, vitamin D after birth, fish/liver, processed milk

What is slipped capital femoral epiphysis (SCFE)?

teens/pre-teens, hip-disorder where the ball of the femur stays in the hip joint so the bone slips behind it

What are signs of SCFE?

limp on affected side, both hips, pain ALL TIME in hip/groin/thigh/knee, cannot bear weight on affected legs, loss of hip abduction/flexion/internal rotation (results in shorter affected leg)

How do we fix SCFE?

surgery to reposition with removal of pin once hip is fused into place, X-ray, physical exam, non-weight bearing, crutches if needed

What is leg-calve-Perthes disease?

YOUNG children, boys, but unknown case, self-limiting avascular necrosis of the femoral head (ball/epiphysis of femur does not get blood supply?

What are the signs of Perthes disease?

limp on affected side that gets worse with activity, soreness, ache, stiffness in hip/groin/thigh/knee, limited ROM in hip

What is the treatment for Perthes disease?

X-ray, MRI, NSAIDS, PT, rest, limit weight bearing, spica cast or abduction brace, surgery only if brace is unsuccessful

What is scoliosis?

spinal deformity from growth spurt, spina bifida, vertebral defect (congenital, infantile, juvenile, adolescent)

What are the signs of scoliosis?

uneven shoulder/hip height, rib cage sticks out on one side, impaired lung function, back pain, balance problems

How do we diagnose scoliosis?

Adams forward bend test, scoliometer, physical assessment, x-ray, Cobb angle

How do we manage scoliosis?

Less than 20 degrees is a monitor

20-40 is a brace to slow the progression of the curve but cannot solve what has occurred

greater than 40 is spinal fusion surgery when child is done growing OR expandable growing rods/halo traction if not done growing and need surgery

How do we manage pain post op scoliosis surgery?

continuous PCA, NSAIDS IV, lie flat immediately, log roll every two hours, ambulate by day 2, hemovac, urinary retention/ileus, hypotension

What are types of fracture?

Closed- without a break in the skin

open- bone visible through skin

complicated- damage to organs from bone fragments

comminuted- break or splinter in more than 2 fragments

greenstick- incomplete, bent past its breaking point

transverse- straight line across the bone

spiral- twisting of bone

buckle- compression, bulging area of bone from a fall/pressure

What are growth plate/physeal injuries?

Type 3 or 4 means a vertical line going through the growth plate will affect growth

What are signs of fractures?

muscle tightness, swelling, pain, diminished function, deformity, bruising, crepitus

How do we treat fractures?

reduction to realign the bone, immobilization like a cast above/below the joint to keep it immobile and restoring, ice, pain meds, reduce swelling

What is traction?

BRYANTS with ace wrap, legs straight up and BUCKS weights need to be suspended with legs at an angle (traction fatigues the muscles so the bone is properly aligned

What is compartment syndrome?

Increased pressure in the fascia that compromises circulation to enclosed muscle/nerves from a fracture

Pressure, Paralysis, Pallor, Paresthesia/tingling, Pain that is uncontrolled, and Pulselessness (late finding)

How do we treat compartment syndrome?

fasciotomy, avoid cold, do not elevate and split the cast

What are overuse syndromes?

soft tissue injury from repeated trauma to one area affecting ligament/tendon, using muscle faster than bones are growing (risks= same sports year-round)

What are signs of overuse syndromes?

decreased strength or speed or ability in sport, pain pattern, and swelling

How do we treat overuse syndromes?

rest, ice, compression, elevation, limit activity, take NSAIDS, encourage other sports

What are dislocations?

displacement of the bone from the joint where there is pull and twist, may have pain in elbow/wrist with refusal to use limb, hip is from fall, shoulder is sports related