Musculoskeletal Complaints – Comprehensive Study Notes

Torticollis

• Definition: painful tonic contraction of the sternocleidomastoid (SCM) muscle.
• Classic posture:
  • Chin rotates to the side opposite the spasm.
  • Head tilts toward the side of the spasm.
• Etiologies
  • SCM injury (birth trauma, muscle tear).
  • Congenital cervical‐spine anomalies, spinal-cord/cerebellar tumours, syringomyelia, rheumatoid arthritis (RA).
• Management
  • $97\%$ success with gentle passive stretching if started early.
  • Investigate red flags (neurologic findings, mass, trauma) → imaging / specialist.

Congenital Limb Deformities

• Incidence: $1/1900$ live births; upper limbs > lower limbs.
• Types
  • Longitudinal deficiencies (fibula most common; tibia, femur possible).
  • Partial absence is typical; complete loss rare.
  • Associated anomalies: extra digits (polydactyly), anencephaly, other system defects.
• Treatment principles
  • Lengthen short limb or shorten the contralateral limb to equalise.
  • Surgical re-section of non-functional parts when indicated.
  • Early prosthetic fitting critical.
  • Lower-extremity: ~$12$ mo for balance/walking.
  • Upper-extremity: mitten-type as early as $6$ mo → allows developmental use.
  • 3-D–printed prostheses downloadable/ customisable (NIH & other repositories).

Metatarsus Adductus

• Common intra-uterine positional foot deformity → inward deviation of forefoot.
• Flexible variants usually resolve spontaneously.
  • Vertical medial arch crease = suggests rigid type.
• Cannot pass midline → serial casting; corrective shoes remain controversial.
• Check hips—association with developmental dysplasia.

Talipes Equinovarus (Clubfoot)

• Tri-planar deformity: plantar flexion (equinus) + heel inversion (varus) + forefoot adduction.
• Incidence: $1–4/1000$ live births; $50\%$ ↑ in boys; can be idiopathic, neurogenic, or syndromic (arthrogryposis, Larsen).
• Screen spine & limbs for additional anomalies; idiopathic form may be hereditary.
• Treatment hierarchy
  • Ponseti method = gold standard
  • Weekly manipulation + serial casts $6–8$ wk.
  • Long-term nighttime abduction brace.
  • Resistant/relapsed cases (≈$15–50\%$) → surgical soft-tissue release +/- bony procedures.

Developmental Dysplasia of the Hip (DDH)

• Spectrum: dysplastic acetabulum ↔ subluxatable hip ↔ dislocated hip.
• Predilection: left hip; risk ↑ with breech, female, positive family history, oligohydramnios.
• Neonatal exam
  • Ortolani (aBduct & lift) → feel ‘clunk’ as femoral head reduces.
  • Barlow (aDduct & push postero-laterally) → provoke dislocation.
• Ancillary findings
  • Asymmetric skin folds (nonspecific), limited abduction, positive Trendelenburg gait later.
  • Imaging: US <6 wk preferable to X-ray.
• Treatment
  • May self-resolve; if reducible ⇒ Pavlik harness (flexion + abduction) during first $4$ mo.
  • Diaper-doubling ineffective.
  • Failed harness or late diagnosis → closed/open reduction + hip spica cast $≈3$ mo.

Slipped Capital Femoral Epiphysis (SCFE)

• Adolescents $11–16$ y (boys > girls); associated with rapid growth & obesity.
• Pain in groin/thigh/knee; obligatory external rotation with flexion.
• Surgical emergency: non–weight-bearing + urgent orthopaedic referral.

Connective-Tissue / Overgrowth Disorders

Marfan Syndrome

• Mutation in fibrillin-1 → systemic connective-tissue weakness.
• Phenotype: tall habitus, arachnodactyly, joint hypermobility, scoliosis (≤$60\%$), pectus deformities, high palate, myopia/lens dislocation.
• Cardiac: $≤90\%$ risk of thoracic aortic aneurysm/dissection, mitral/aortic valve disease.
• Management: serial echocardiography, beta-blocker/ARB for aorta; ortho for scoliosis/flat foot; activity restrictions.

Gigantism vs. Acromegaly

• Excess growth-hormone before epiphyseal closure → gigantism (children); after closure → acromegaly (adults $4^{th}–5^{th}$ decade).

Scoliosis

• Lateral spinal curvature; $80\%$ idiopathic. Female predominance; $30\%$ familial.
• Exam: standing alignment, Adams forward-bend, limb-length inequality.
• Treatment
  • Observe if Cobb angle <45^{\circ} (adult) or mild AIS.
  • Bracing in skeletally immature to slow progression.
  • Surgery (rods, fusion) for severe/progressive curves.

Schroth Therapy (conservative PT)

• 3-D corrective exercises, rotational angular breathing, posture retraining.
• Goals: halt curve, improve cosmetics, expand lung capacity, lessen pain.
• Works best when combined with bracing; requires certified therapists.
• FNP role: screen early, educate, refer, monitor adherence.

Lower-Limb Alignment

• Genu Varum (bow-legs) physiologic until $\approx3$ y; persistent → tibial rotation/Blount → ortho.
• Genu Valgum (knock-knee) physiologic until $\approx8$ y; short stature + valgum → consider skeletal dysplasia, rickets.

Common Foot Deformities & Conditions

• Pes planus (flat foot): normal in infants; reassure, quality shoes ± arch support.
• Pes cavus: high arch; genetic/neurologic (evaluate spine, MRI if claw toes).
• Hallux valgus (bunion): family history; wide footwear; surgery deferred to adults (high recurrence in youths).

Degenerative & Pain Syndromes

Osteoarthritis (OA)

• Non-inflammatory cartilage degeneration; weight-bearing joints, DIP/PIP (Heberden/Bouchard), C- & L-spine.
• Management: activity modification, PT/OT, assistive devices, weight loss, acetaminophen $\le3$ g/day, NSAIDs (oral/topical), intra-articular steroids ($\le4$/yr), hyaluronic acid; joint replacement for end-stage.

Fibromyalgia

• Central pain amplification; diagnosis by 2010 ACR or 2019 AAPT criteria (WPI + SS scales, $\ge3$ mo).
• Treat with patient education, graded exercise, CBT, sleep hygiene, SNRIs (duloxetine, milnacipran) or pregabalin; avoid opioids.

Sprains, Strains, Dislocations

• Sprain = ligament; strain = muscle/tendon.
• Ankle: inversion (lateral ligaments) > eversion (medial). Use PRICE, brace; high re-injury risk w/o rehab.
• Knee ligament sprains uncommon <adolescence; traumatic effusion needs ortho; atraumatic effusion → consider JRA/patellar disorders.
• Nursemaid’s elbow (radial-head subluxation): toddlers refusing flexion; reduce via supination-flexion.
• Patellar dislocation: usually lateral; extremely painful; radiographs confirm; reduction by experienced personnel only.

Fractures

• Epiphyseal (Salter–Harris): separation > true break; compare contralateral films; prompt reduction protects growth.
• Torus (buckle): cortical compression; distal radius/ulna; short cast $≈3$ wk.
• Greenstick: convex cortex broken, concave intact; must realign + snug cast; re-X-ray $7–10$ d.
• Clavicle: common, manage with sling/figure-8 strap.
• Supracondylar humerus: ages $3–6$; proximity to brachial artery → check pulses; closed reduction + pins.
• Hip fractures: groin pain, IR painful; displaced → no weight bearing; surgery within $24$ h lowers complications.
• Abuse red flags: injury pattern inconsistent with history, delay in care, changing story.

Osteomyelitis

• Starts medullary → cortical; often follows trauma.
• Hematogenous in kids (Staph $≈85\%$); exogenous with open wounds.
• Work-up: ESR (>$50$), CRP, cultures, MRI/bone scan; bone film late.
• Treat: IV broad-spectrum then targeted Abx $4–6$ wk+, surgical debridement PRN.

Legg–Calvé–Perthes Disease

• Avascular necrosis of femoral head ages $4–8$ y.
• Limp, limited ROM, normal labs; serial X-rays required; manage with activity restriction; prognosis generally good but shape may remodel.

Sports Medicine

Strength & Conditioning

• Resistance training as young as $7–8$ y; maximal lifting only after Tanner V.
• Goal: $60$ min mixed activity daily (resistance, neuromuscular, integrative).

Nutrition & Supplements

• Balanced diet, adequate carbs & hydration.
• FDA regulates post-marketing; counsel on supplement safety.

Sports Physicals

• Opportunity for health promotion, injury prevention, and creation of a medical home.

Common Sports Injuries & Pathologies

• Concussion: usually resolves $7–10$ d; graded return-to-play (6 steps); any symptom recurrence → revert rest $24$ h & step back.
• Atlantoaxial instability (Down syndrome): ADI >4.5 mm → restrict contact/extremes‐neck-motion sports.
• Burners/Stingers: unilateral brachial plexus neuropraxia; remove from play; recurrent episodes → rest of day/season.
• Spondylolysis: pars stress fracture; pain with extension; treat rest, core & hamstring stretch.
• Spondylolisthesis: slippage; if surgery → no sports ≥$12$ mo.
• Low-back red flags: cauda equina (saddle anaesthesia, bowel/bladder) → emergency.
• Spinal stenosis: extension pain, neurogenic claudication; older adults; PT, epidurals, decompression.
• Disk herniation: flexion pain, +SLR; conservative first; surgery if neuro deficit.

Shoulder Disorders

• Clavicle fracture: sling $6–8$ wk.
• AC separation: +cross-arm test; rest/immobilise $1–6$ wk.
• Anterior dislocation: abducted/ER arm, squared shoulder; urgent reduction.
• Rotator cuff tears: night pain >40 y; PRICE, PT; adults often need repair.
• Adhesive capsulitis: phases freezing/frozen/thawing over $1–2$ y; women 40–65; treat PT, NSAIDs; refer if no progress >6 mo.

Elbow / Wrist / Hand

• Lateral epicondylitis (tennis elbow): wrist-extension pain; NSAIDs, brace, eccentric exercises.
• Olecranon bursitis: hot/red swelling; R/O infection, treat NSAIDs ± aspiration/injection.
• Carpal tunnel: nocturnal median-nerve paresthesias; Phalen/Tinel; neutral splint $≤3$ mo; steroid injection temporary; surgical release curative.
• Dupuytren contracture: palmar fascia nodules; affects $4^{th}/5^{th}$ digits; collagenase (Xiaflex) or surgical release.

Knee Pathology

• Osgood–Schlatter: apophysitis tibial tubercle in teens; ice, stretch, resolves at maturity.
• Meniscal tear: locking/catching, effusion; +McMurray; MRI confirm; arthroscopy if symptomatic.
• MCL/LCL sprain: local pain, +valgus/varus test; ICE, brace till stability returns.
• ACL: non-contact pivot, ‘pop’, rapidly swollen; +Lachman; reconstruction common.
• PCL: dashboard fall; pain with flexion; usually non-operative.
• Baker cyst: popliteal mass; US to R/O DVT if ruptured.
• Ottawa/Pittsburgh rules guide imaging.

Foot & Ankle Issues

• Ankle sprain: lateral > medial; R/O fracture (Ottawa rules) if malleolar pain + inability to bear weight.
• Plantar fasciitis: heel pain on first steps; calf/Achilles stretch, arch support, NSAIDs, steroid injection if refractory.

Examination Principles

• History: mechanism (traumatic/atraumatic, acute/chronic, velocity), aggravating/relieving factors.
• Systematic exam: inspection → palpation → ROM → neurovascular → special tests.
• Evaluate story consistency; mismatched injuries may signal abuse.

General Management Acronyms

• PRICE (now PEACE & LOVE in some literature)
  • Protect, Rest, Ice, Compression, Elevate – optimise healing & function.
• Return-to-play/rehab: progressive loading, sport-specific drills, proper equipment & technique.