Pediatric musculoskeletal disorders: Pathology review

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Case studies0:00–1:10

A 13 year old boy named Lucas comes to the clinic for right knee pain which gets worse when he is running, jumping or climbing stairs.
Upon further questioning, Lucas mentions that he plays basketball for his school team and recently he started training more intensely for an upcoming tournament on physical examination.
You were able to move his hip in all directions with no resistance or pain. But you noticed that his right knee has a more prominent tibial tubercle which is also tender to the touch.
Some days later, a four year old girl named Sophia is brought to the clinic by her parent earlier that day, Sophia's older sibling was swinging her by the arms.
Since then, Sophia has been experiencing pain in her right arm when she tries to move it on physical examination. You notice that Sophia is holding her arm by her body and cries when you try to move it, you decide to quickly hyperpronate her arm.
After which Sophia becomes able to use her arm again without pain. Ok.
Both Lucas and Sophia seem to have some form of a pediatric musculoskeletal condition, meaning a condition that commonly affects the muscles, bones or cartilage of individuals younger than 18 years for your tests.

Pathology1:10–1:52

The most high yield pediatric musculoskeletal disorders include developmental dysplasia of the hip leg calve Perthes disease, slipped capital femoral epiphysis, Osgood Schlatter disease, patellofemoral syndrome, radial head subluxation, and a variety of bone fractures.
Ok. Let's start with developmental dysplasia of the hip or D DH, which is also known as congenital hip dysplasia.
In DDH, the femoral head dislocates out of the acetabulum during development in utero for your exams. It's important to keep in mind that this is more common in twin or multiple pregnancies where the fetuses have to share the space within the uterus, which may put a lot of pressure on them as well as in firstborns because the mother's uterus is not as stretched out or when the fetus is lying in a breech position within the mother's uterus with its buttock near the cervix at the time of delivery.

Developmental dysplasia of the hip1:52–5:48

Another situation that can lead to DDH is oligohydramnios where there is not enough amniotic fluid to expand the uterine cavity.
So the fetus can have enough room in any case over time. As the femoral head spends a lot of time outside of the acetabulum, the acetabular ligaments and fatty tissue start expanding to fill the space that would normally be occupied by the femoral head.
At the same time, remember that during the development, the femoral head functions as a template around which the acetabulum is formed.
So without it in DDH, the acetabulum turns out shallow, making it a poor fit for the femoral head. Another thing to note is that this misalignment of the hip may eventually wear down the articular cartilage leading to the development of osteoarthritis.
In early adulthood, symptoms of developmental dysplasia of the hip may vary according to age. In a test question.
Look for a newborn or infant with legs of unequal length or asymmetric skin folds along the thigh or gluteal area. On the other hand, older kids may present with painless limping or hip pain that can radiate to the knee.
Diagnosis of developmental dysplasia of the hip in babies starts with the physical examination for your exams. You must remember two maneuvers in the Barlow maneuver.
The baby's hip and knee are flexed to 90 degrees, then abducted while applying a gentle posterior force to the femur in a baby with hip dysplasia.
This maneuver will cause the femoral head to pop out of the socket, which you'll feel is a distinct clunk indicating a positive test.
On the other hand, in the Ortolani maneuver, the baby's hip is flexed to 90 degrees, then gently abducted while placing anterior pressure on the greater trochanter.
If the femoral head is out of the socket, this maneuver will cause it to slip back into the acetabulum which would feel and sometimes sound like a clunk.
This indicates a positive Ortolani test. In addition, imaging techniques like ultrasound can be used in Children younger than four months of age.
So as to assess the position of the femoral head and the structure of the acetabulum. On the other hand, x rays are recommended for Children older than four months as the hip cartilage begins to ossify and can become easily visible on X ray.
Now, the treatment of congenital hip dysplasia depends on the age of the child and extent of the deformity. Before six months of age, abduction, splints can be used for a period of 1 to 2 months such as the palicarinus that holds the hip joint, flexed and abducted.
This helps to keep the femoral head within the socket to promote normal hip joint development. For those older than six months closed, manual reduction of the femoral head into the acetabulum can be performed under anesthesia.
If this doesn't work, open, surgical reduction might be necessary. All right, moving on to leg calve Perthes disease.
This is a hip disorder that occurs when the blood supply to the head of the femur gets disrupted. Normally, the head of the femur is supplied by three main arterial branches which are the medial and lateral circumflex arteries and the artery of ligamentum teres.
In leg Calvet Perthes disease, the blood supply to the femur is disrupted and this causes the bone to stop growing and die off a process called avascular necrosis.
The reason why this happens is not exactly known, which is why its also called idiopathic avascular necrosis of the femoral head.
However, the main risk factor to keep in mind is repeated, minor trauma to the hip joint, which might be associated with a child's hyperactivity.

Legg-Calvé-Perthes disease 5:48–8:37

In any case. Over time, the femoral head becomes more fragile and prone to fractures.
Over time, the weakened bone may lose its normal round shape and become flattened so it can no longer smoothly, rotate inside the acetabulum.
Symptoms of Legg calve Perthes disease most commonly present in males between the age of three and 12 years and include a gradual onset limp with or without hip pain that typically gets worse with activity.
One high yield fact to remember for your tests is that the hip pain in leg Calvet Perthes disease can sometimes refer to the knee.
So these kids might initially complain of knee pain on physical examination. Remember that it's common to find a limited range of motion which is particularly evident for abduction as well as internal rotation of the hip diagnosis of Legg calve Perthes disease is based on imaging studies like X ray of the hip which can show fragmentation or flattening of the femoral head.
However, for your tests, keep in mind that early on in the disease, X ray can be normal. And in this case, MRI can be useful to confirm the diagnosis.
Treatment of Legg calve Perthes disease is typically conservative and may include reduced weightbearing on the affected side, physical therapy and pain management.
In severe cases with extensive damage to the femoral head surgery might be recommended. Next up is slipped, capital femoral epiphysis or skiffy for short.
Now, long bones such as the femur have a diaphysis or bone shaft, a metaphysis or neck portion on each side and an epiphysis at each end and remember that the proximal one is the femoral head between each metaphysis and epiphysis.
There is the phys or growth plate which is a cartilaginous structure that enables growth normally. As an individual is growing, the growth plate is relatively weak and vulnerable to shearing forces.
Eventually around the age of 16. In females and 19 in males, the growth plate ossifies and fuses with the epiphysis in skiffy, increased stress on the growth plate causes it to break and this leads the femoral head to slip away from the neck just like a scoop of ice cream slipping off a cone.
Now, keep in mind that the femoral head remains well held in the acetabulum by the joint capsule and the ligamentum teres.
So the movement happens at the femoral neck which gets displaced anterolaterally and superiorly and this is actually high yield.
Now, the exact cause of skiffy is unknown, but what's important to remember for your tests is that it is often associated with obesity.

Slipped capital femoral epiphysis8:37–11:50

That's because the increased weight is thought to increase the mechanical force on the growth plate causing it to break.
In addition, hormonal changes that normally occur during adolescence or with endocrine disorders like hypothyroidism can make the growth plate, weaker symptoms of slipped, capital femoral epiphysis typically present between the ages of 10 and 16 years and include hip pain that becomes worse with activity and may sometimes refer to the thigh or knee.
This can also result in limping on physical examination. Remember that these individuals often also have reduced range of motion, especially with hip movements that involve abduction and internal rotation.
Diagnosis of slipped. Capital femoral epiphysis includes imaging studies like a hip X ray to better visualize both hip joints.
The X ray should be obtained in both an anterior view as well as a lateral view with the individual sitting in a froglike position.
Some characteristic X ray findings of skiff include widening of the growth plate as well as anterolateral and superior displacement of the femoral neck relative to the head.
Treatment of skiffy generally involves decreasing weightbearing on the affected side. In addition to surgery to realign the femoral head and neck using a screw moving on to Osgood Schlatter disease.
This refers to inflammation of the tibial tubercle which is a small bony prominence at the proximal tibia. What's important to know is that the tibial tubercle serves as an apophysis or attachment site for the patellar tendon which arises from the patella in this way, contraction of the quadriceps muscles can pull the patella and tibial tubercle causing extension of the knee joint and this allows you to walk, climb stairs, run and jump and what you need to remember for your exams is that at birth, the tibial tubercle consists of cartilage.
But between the ages of nine and 15, it begins to ossify and at around the age of 18 becomes a bony tuberosity. And that's a high yield.
Fact. The cause of Osgood Schlatter disease is not exactly understood, but it's thought that intense physical activity that involves repeated sprinting and jumping like when playing basketball and volleyball can expose the tibial tubercle to constant strain and traction.
This results in inflammation, partial avulsion or tearing and fragmentation of the tibial tubercle, which is called traction apophysitis.
When this happens over a long period of time, the chronic inflammation is followed by a healing process which occurs by laying down new bone at the tibial tubercle causing it to be more prominent symptoms of Osgood Schlatter disease typically present between the age of 10 and 14 years after the growth spurt and include progressive anterior knee pain for your exams.
What's important to remember is that this pain gets worse when going up or down stairs as well as with physical activities like running, jumping and squatting on physical examination.

Osgood-Schlatter disease11:50–14:51

What you'll often see is swelling or a prominent enlargement of the tibial tubercle. Now, for the diagnosis of Osgood Schlatter disease, no imaging is needed.
If the clinical picture fits. If an X ray is done, it might show fragmentation of the tibial tuberosity for treatment of Osgood Schlatter disease.
All that's typically needed is non opiate pain medication, temporarily reducing physical activity and applying ice to the tuberosity to reduce the swelling.
Thats because the disease is usually self resolving once the individual stops growing. In the meantime, wearing a Kneepad to protect the tubercle can be helpful.
As can physical therapy. Next is patella femoral syndrome which affects the patellofemoral joint.
Normally, this joint is formed by the patella that sits onto the trochlear groove on the distal part of the femur and is covered by a slippery articular cartilage that allows for smooth movement when flexing or extending the knee.
In patellofemoral syndrome, there's inflammation that results from mechanical stress between the patella and the trochlear groove, which is often linked to overuse of the patellofemoral joint, which is common in runners.
That's why Patellofemoral syndrome is also called runner's knee. And this is a high yield fact.
And for your exams, remember that patellofemoral syndrome affects females more than males. So, in a test question, look for a female athlete.
Another less frequent cause of patella femoral syndrome is malalignment of the patella with the trochlear groove, which could be due to knee trauma or weakness of the quadriceps muscles and results in uneven distribution of the mechanical load.
Symptoms of patella femoral syndrome typically begin during adolescence and include anterior knee pain that's often described as being around or behind the patella.
The pain typically gets worse with knee flexion as in running squatting climbing stairs and prolonged sitting on physical exam.
One high yield test to remember is the patellofemoral compression test in which pressing on the patella into the trochlear groove reproduces the pain.
Now, the diagnosis of patellofemoral syndrome is mainly based on history and physical examination. However, x ray of the knee can sometimes be done to rule out other causes of knee pain such as osteoarthritis and fractures.
Treatment of patellofemoral syndrome is mainly conservative, which involves rest from physical activities like running and pain management.
By using anti inflammatory medications like nsaids. Physical therapy might also help to strengthen the quadriceps muscles which helps stabilize the patellofemoral joint.
All right. Another pediatric musculoskeletal disorder that you need to know for your tests is radial head subluxation.
Normally the head of the radius is attached to the radial notch on the ulna by the annular ligament. This allows the joint to remain stable and rotate during supination or when the forearm is turned outward as well as during pronation, which is when the forearm is turned inward.

Patellofemoral syndrome14:51–17:23

Radial head subluxation typically occurs in Children younger than five years when the annular ligament has not fully developed yet.
In a test question. Look for a case of a sudden forceful pull on the child's forearm.
This causes the annular ligament to slip over the head of the radius, preventing the radial head from spontaneously relocating into its normal place.
Symptoms of radial head subluxation typically include an inability to move the affected limb due to elbow pain that aggravates with movement.
Whats especially high yield is that the child will typically hold the affected forearm in a pronated and extended or slightly flexed position.
Diagnosis of radial head subluxation is mainly based on history and physical examination. Imaging studies like X ray can be done to rule out other causes of elbow pain, like fractures if needed.
Treatment of radial head subluxation aims at returning the radial head into its normal place to do this. You should remember two maneuvers.
The first one involves supinating the forearm while fully flexing the elbow. And the other one involves hyper pronation of the forearm which is more effective and less painful.
Ok. Moving on to pediatric bone fractures.
What's important to remember is that pediatric bones are not merely smaller versions of adult bones. In fact, they have unique characteristics such as a thicker and stronger periosteum.
Now, pediatric fractures can be classified as complete where high energy forces cause the bone to break from side to side or incomplete where the bone doesn't break completely.
And usually only one side of the bone is involved for your exams. Keep in mind that incomplete fractures are particularly common in Children due to the presence of the stronger periosteum, which can better resist forces applied to bones.
Treatment of bone fractures generally involves immobilization of the affected limb. In addition to the use of removable splints or casts to allow the bone to heal some severe or displaced fractures may require surgery.
Now, the four high yield types of pediatric fractures include torus fractures, greenstick fractures, bowing fractures and physeal fractures.
All right, let's start with torus or buckle fracture, which usually occurs following a fall on outstretched hands. Also known as a fouche injury for your exams.

Radial head subluxation17:23–19:31

Remember that this type of fracture commonly affects the metaphysis of long bones because it's where the bone is most porous And thus the weakest spot torus fractures typically occur following an axial or longitudinal force that compresses one side of the bone called the compression or concave side.
This leads the bones, periosteum and cortex on that side to buckle and produce a bulge. Hence the name torus, which is a Latin word that means a bulge or protuberance.
In contrast, the other side of the bone called the tension or convex side remains intact. For diagnosis.
On an X ray. A torus fracture can often be seen as a small bulge on one side of the bone.
Next, there's the greenstick fracture which typically occurs due to a bending force that creates more stress on the convex side of the bone called the tension side than the concave side called the compression side.
So in contrast with torus fractures, with greenstick fractures, the force can cause the cortex and periosteum on the tension side to break.
While the compression side will remain intact, just like when you try to break a green stick or twig diagnosis of greenstick fracture can be confirmed with an X ray which would clearly show an incomplete fracture with a breach on one side of the bone while the other side would be intact.
Finally, we have bowing fracture, also known as plastic deformity. This occurs when the bone shaft is exposed to a longitudinal force that exceeds the bone's ability to return to its normal shape but is not strong enough to break it.
This causes the bone to bend and assume a more curved or bone shape. So for your exams remember that this is actually a shape deformity and not a true fracture.
However, it's often associated with microscopic fractures in the periosteum of the bone to diagnose a bowing fracture. An X ray would show bowing or increased curvature of the bone.
Now, fractures can also affect the growth plate, also known as the pisis. The main problem is that physeal fractures can impair bone growth and lengthening sometimes leading to growth arrest and asymmetrical length of the limbs.

Pediatric fractures19:31–20:50

The salter Harris system is used to grade growth plate injuries from 1 to 5 where fractures with lower numbers can usually be treated without surgery and are less likely to cause growth arrest and fractures.
Graded with a higher number often need surgery and can lead to long term damage. Physio fractures are not ones to sit around and wait on the faster an injury is recognized and evaluated by a specialist.
The better the chances of a good outcome. All right, as a quick recap, pediatric musculoskeletal disorders include developmental dysplasia of the hip, which can occur when the femoral head dislocates out of its acetabulum in utero.
This is more common with multiple pregnancies, first borns and breech presentation and presents with leg length, discrepancy, asymmetric skin folds along the thigh or buttocks, painless, limping or hip pain, leg calve Perthes disease occurs when the blood supply to the head of the femur gets disrupted, leading to avascular necrosis.
This can occur due to repeated minor trauma and presents with hip pain that may refer to the knee as well as limited hip abduction and internal rotation.

Torus fracture20:50–21:57

Next is slipped. Capital femoral epiphysis where the femoral head and neck slip away from each other.
This most commonly occurs in adolescents with obesity being a major risk factor and causes hip pain that can refer to the thigh or knee limping and limited hip abduction and internal rotation.
Osgood Schlatter disease or traction. Apophysitis refers to inflammation and fragmentation of the tibial tubercle, which often occurs with sports that include running and jumping and causes anterior knee pain and tubercle enlargement.
Patellofemoral syndrome results from inflammation of the patellofemoral joint. This is associated with malalignment of the patella with the trochlear groove or overuse of the joint as in running and presents with anterior knee pain that gets worse with knee flexion.
Radial head subluxation occurs when the annular ligament slips over the head of the radius, preventing the radial head from spontaneously relocating into its normal place, which could result from a fall or a pull on the child's forearms when it's pronated and extended and causes the child to hold the affected forearm pronated and extended or slightly flexed.

Greenstick fracture21:57–22:45

Finally, pediatric fractures include torus or buccal fractures due to an axial or longitudinal force that breaks the compression side, greenstick fractures due to a bending force that breaks the tension bowing fractures, also known as plastic deformity due to a longitudinal force to the bone shaft that causes the bone to bend and growth plate or physeal fractures which can impair bone growth and lengthening, resulting in asymmetrical growth of the limbs and angular deformity.
Ok. Back to our cases.

Bowing fracture22:45–23:28

Lucas is a 13 year old boy who presents with right knee pain that gets worse with running and jumping. This should make you think of a musculoskeletal disorder of the knee itself or a disorder that affects the hip joint where the pain could refer to the knee.
The fact that Lucas hip joint shows full range of motion and no pain should help you exclude hip joint pathologies. Now, a big clue is his intense basketball training, which is a risk factor for traction apophysitis.
And the key here is the presence of a prominent and tender tibial tubercle which indicates that Lucas has Osgood Schlatter disease.
On the other hand, Sophia is a four year old girl who presents with right arm pain after her sibling was swinging her by the arms.

Physeal fractures23:28–24:15

This combined with the fact that Sophia holds her arm extended and pronated by her body and that her arm pain was relieved after hyperpronation makes this a straightforward case of radial head subluxation.

Review24:15–27:10

Summary27:10–23:42

Pediatric musculoskeletal disorders: Video, Causes | Osmosis