The Limping Child Future of Pediatrics June 15, 2016
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DERMATOLOGY – 15% Acne Vulgaris Inflammatory skin condition assoc. with papules & pustules involving pilosebaceous units Pathophysiology: • 4 main factors – follicular hyperkeratinization with plugging of sebaceous ducts, increased sebum production, Propionibacterium acnes overgrowth within follicles, & inflammatory response • Hormonal activation of pilosebaceous glands which may cause cyclic flares that coincide with menstruation Clinical Manifestations: • In areas with increased sebaceous glands (face, back, chest, upper arms) • Stage I: Comedones: small, inflammatory bumps from clogged pores - Open comedones (blackheads): incomplete blockage - Closed comedones (whiteheads): complete blockage • Stage II: Inflammatory: papules or pustules surrounded by inflammation • Stage III: Nodular or cystic acne: heals with scarring Differential Diagnosis: • Differentiate from rosacea which has no comedones** • Perioral dermatitis based on perioral and periorbital location • CS-induced acne lacks comedones and pustules are in same stage of development Diagnosis: • Mild: comedones, small amounts of papules &/or pustules • Moderate: comedones, larger amounts of papules &/or pustules • Severe: nodular (>5mm) or cystic Management: • Mild: topical – azelaic acid, salicylic acid, benzoyl peroxide, retinoids, Tretinoin topical (Retin A) or topical antibiotics [Clindamycin or Erythromycin with Benzoyl peroxide] • Moderate: above + oral antibiotics [Minocycline 50mg PO qd or Doxycycline 100 mg PO qd], spironolactone • Severe (refractory nodular acne): oral -
Upper Extremity
Upper Extremity Shoulder Elbow Wrist/Hand Diagnosis Left Right Diagnosis Left Right Diagnosis Left Right Adhesive capsulitis M75.02 M75.01 Anterior dislocation of radial head S53.015 [7] S53.014 [7] Boutonniere deformity of fingers M20.022 M20.021 Anterior dislocation of humerus S43.015 [7] S43.014 [7] Anterior dislocation of ulnohumeral joint S53.115 [7] S53.114 [7] Carpal Tunnel Syndrome, upper limb G56.02 G56.01 Anterior dislocation of SC joint S43.215 [7] S43.214 [7] Anterior subluxation of radial head S53.012 [7] S53.011 [7] DeQuervain tenosynovitis M65.42 M65.41 Anterior subluxation of humerus S43.012 [7] S43.011 [7] Anterior subluxation of ulnohumeral joint S53.112 [7] S53.111 [7] Dislocation of MCP joint IF S63.261 [7] S63.260 [7] Anterior subluxation of SC joint S43.212 [7] S43.211 [7] Contracture of muscle in forearm M62.432 M62.431 Dislocation of MCP joint of LF S63.267 [7] S63.266 [7] Bicipital tendinitis M75.22 M75.21 Contusion of elbow S50.02X [7] S50.01X [7] Dislocation of MCP joint of MF S63.263 [7] S63.262 [7] Bursitis M75.52 M75.51 Elbow, (recurrent) dislocation M24.422 M24.421 Dislocation of MCP joint of RF S63.265 [7] S63.264 [7] Calcific Tendinitis M75.32 M75.31 Lateral epicondylitis M77.12 M77.11 Dupuytrens M72.0 Contracture of muscle in shoulder M62.412 M62.411 Lesion of ulnar nerve, upper limb G56.22 G56.21 Mallet finger M20.012 M20.011 Contracture of muscle in upper arm M62.422 M62.421 Long head of bicep tendon strain S46.112 [7] S46.111 [7] Osteochondritis dissecans of wrist M93.232 M93.231 Primary, unilateral -
Transient Synovitis Or Septic Arthritis in Early Stage?
edicine: O M p y e c n n A e c g c r e e s s m E Emergency Medicine: Open Access Sekouris et al., Emergency Med 2014, 4:4 ISSN: 2165-7548 DOI: 10.4172/2165-7548.1000195 Short Communication Open Access Hip Pain in Children, a Diagnostic Challenge: Transient Synovitis or Septic Arthritis in Early Stage? Nick Sekouris*, Antonios Angoules, Dionysios Koukoulas and Eleni C Boutsikari Asssistant Director Orthopaedic, 'Metropolitan' Hospital, Athens, Greece *Corresponding author: Nick Sekouris, Asssistant Director Orthopaedic, 'Metropolitan' Hospital, Athens, Greece, Tel: +30 (210) 864 2202; E-mail: [email protected] Received date: April 27, 2014; Accepted date: June 13, 2014; Published date: June 17, 2014 Copyright: © 2014 Sekouris, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Short Communication symptoms, in case of SA, a destruction or dislocation of the femoral head or a widespread destruction of the femoral head and neck may be Hip pain in children is a diagnostic challenge for every practitioner visible radiographically. in emergency medicine and for any other doctor or health professional, facing this common symptom. Diagnosis may vary from Bone scintigraphy is neither sensitive nor specific enough in innocent conditions such as Transient Synovitis (TS), also mentioned distinguishing TS from SA and is not routinely used. Nevertheless, it as “irritable hip”, to hazardous for the child health diseases like Septic can diagnose multiple musculoskeletal lesions [7]. Arthritis (SA). -
Acetabular Labral Tears and Femoroacetabular Impingement
Michael J. Sileo, MD, FAAOS Sports Medicine Injuries Arthroscopic Shoulder, Knee & Hip Surgery December 7, 2018 NONE Groin and hip pain is common in athletes Especially hockey, soccer, and football 5% of all soccer injuries Renstrom et al: Br J Sports Med 1980. Complex anatomy and wide differential diagnoses that span multiple medical specialties make diagnosis difficult • Extra-articular causes: Muscle strain Snapping hip Adductor Trochanteric bursitis Iliopsoas Abductor tears Gluteus medius Compression neuropathies Hamstrings LFCN (meralgia paresthetica) Gracilis Sciatic nerve (Piriformis Avulsion injuries syndrome) Sports Hernia Ilioinguinal, Osteitis Pubis iliohypogastric, or genitofemoral nerve Intra-articular causes: Labral pathology Capsular laxity Femoroacetabular impingement Stress fracture Chondral pathology Septic arthritis Ligamentum teres injury Adhesive capsulitis Loose bodies Osteonecrosis Benign Intra-articular tumors SCFE PVNS Transient synovitis Synovial chondromatosis Soft-tissue injuries such as muscle strains and contusions are the most common causes of hip pain in the athlete It is important to be aware and suspicious of intra- articular causes of hip pain Up to 60% of athletes undergoing arthroscopy are initially misdiagnosed Delay to diagnosis is typically 7 months Labral pathology may not be diagnosed for up to 21 months Byrd et al: Clin Sports Med 2001. Burnett et al: JBJS 2006. Nature of discomfort Mechanical symptoms Stiffness Weakness Instability Location of discomfort -
Neurologic Outcomes in Friedreich Ataxia: Study of a Single-Site Cohort E415
Volume 6, Number 3, June 2020 Neurology.org/NG A peer-reviewed clinical and translational neurology open access journal ARTICLE Neurologic outcomes in Friedreich ataxia: Study of a single-site cohort e415 ARTICLE Prevalence of RFC1-mediated spinocerebellar ataxia in a North American ataxia cohort e440 ARTICLE Mutations in the m-AAA proteases AFG3L2 and SPG7 are causing isolated dominant optic atrophy e428 ARTICLE Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy revisited: Genotype-phenotype correlations of all published cases e434 Academy Officers Neurology® is a registered trademark of the American Academy of Neurology (registration valid in the United States). James C. Stevens, MD, FAAN, President Neurology® Genetics (eISSN 2376-7839) is an open access journal published Orly Avitzur, MD, MBA, FAAN, President Elect online for the American Academy of Neurology, 201 Chicago Avenue, Ann H. Tilton, MD, FAAN, Vice President Minneapolis, MN 55415, by Wolters Kluwer Health, Inc. at 14700 Citicorp Drive, Bldg. 3, Hagerstown, MD 21742. Business offices are located at Two Carlayne E. Jackson, MD, FAAN, Secretary Commerce Square, 2001 Market Street, Philadelphia, PA 19103. Production offices are located at 351 West Camden Street, Baltimore, MD 21201-2436. Janis M. Miyasaki, MD, MEd, FRCPC, FAAN, Treasurer © 2020 American Academy of Neurology. Ralph L. Sacco, MD, MS, FAAN, Past President Neurology® Genetics is an official journal of the American Academy of Neurology. Journal website: Neurology.org/ng, AAN website: AAN.com CEO, American Academy of Neurology Copyright and Permission Information: Please go to the journal website (www.neurology.org/ng) and click the Permissions tab for the relevant Mary E. -
Differential Diagnosis of Juvenile Idiopathic Arthritis
pISSN: 2093-940X, eISSN: 2233-4718 Journal of Rheumatic Diseases Vol. 24, No. 3, June, 2017 https://doi.org/10.4078/jrd.2017.24.3.131 Review Article Differential Diagnosis of Juvenile Idiopathic Arthritis Young Dae Kim1, Alan V Job2, Woojin Cho2,3 1Department of Pediatrics, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea, 2Department of Orthopaedic Surgery, Albert Einstein College of Medicine, 3Department of Orthopaedic Surgery, Montefiore Medical Center, New York, USA Juvenile idiopathic arthritis (JIA) is a broad spectrum of disease defined by the presence of arthritis of unknown etiology, lasting more than six weeks duration, and occurring in children less than 16 years of age. JIA encompasses several disease categories, each with distinct clinical manifestations, laboratory findings, genetic backgrounds, and pathogenesis. JIA is classified into sev- en subtypes by the International League of Associations for Rheumatology: systemic, oligoarticular, polyarticular with and with- out rheumatoid factor, enthesitis-related arthritis, psoriatic arthritis, and undifferentiated arthritis. Diagnosis of the precise sub- type is an important requirement for management and research. JIA is a common chronic rheumatic disease in children and is an important cause of acute and chronic disability. Arthritis or arthritis-like symptoms may be present in many other conditions. Therefore, it is important to consider differential diagnoses for JIA that include infections, other connective tissue diseases, and malignancies. Leukemia and septic arthritis are the most important diseases that can be mistaken for JIA. The aim of this review is to provide a summary of the subtypes and differential diagnoses of JIA. (J Rheum Dis 2017;24:131-137) Key Words. -
Musculoskeletal Clinical Vignettes a Case Based Text
Leading the world to better health MUSCULOSKELETAL CLINICAL VIGNETTES A CASE BASED TEXT Department of Orthopaedic Surgery, RCSI Department of General Practice, RCSI Department of Rheumatology, Beaumont Hospital O’Byrne J, Downey R, Feeley R, Kelly M, Tiedt L, O’Byrne J, Murphy M, Stuart E, Kearns G. (2019) Musculoskeletal clinical vignettes: a case based text. Dublin, Ireland: RCSI. ISBN: 978-0-9926911-8-9 Image attribution: istock.com/mashuk CC Licence by NC-SA MUSCULOSKELETAL CLINICAL VIGNETTES Incorporating history, examination, investigations and management of commonly presenting musculoskeletal conditions 1131 Department of Orthopaedic Surgery, RCSI Prof. John O'Byrne Department of Orthopaedic Surgery, RCSI Dr. Richie Downey Prof. John O'Byrne Mr. Iain Feeley Dr. Richie Downey Dr. Martin Kelly Mr. Iain Feeley Dr. Lauren Tiedt Dr. Martin Kelly Department of General Practice, RCSI Dr. Lauren Tiedt Dr. Mark Murphy Department of General Practice, RCSI Dr Ellen Stuart Dr. Mark Murphy Department of Rheumatology, Beaumont Hospital Dr Ellen Stuart Dr Grainne Kearns Department of Rheumatology, Beaumont Hospital Dr Grainne Kearns 2 2 Department of Orthopaedic Surgery, RCSI Prof. John O'Byrne Department of Orthopaedic Surgery, RCSI Dr. Richie Downey TABLE OF CONTENTS Prof. John O'Byrne Mr. Iain Feeley Introduction ............................................................. 5 Dr. Richie Downey Dr. Martin Kelly General guidelines for musculoskeletal physical Mr. Iain Feeley examination of all joints .................................................. 6 Dr. Lauren Tiedt Dr. Martin Kelly Upper limb ............................................................. 10 Department of General Practice, RCSI Example of an upper limb joint examination ................. 11 Dr. Lauren Tiedt Shoulder osteoarthritis ................................................. 13 Dr. Mark Murphy Adhesive capsulitis (frozen shoulder) ............................ 16 Department of General Practice, RCSI Dr Ellen Stuart Shoulder rotator cuff pathology ................................... -
Tremor, Abnormal Movement and Imbalance Differential
Types of involuntary movements Tremor Dystonia Chorea Myoclonus Tics Tremor Rhythmic shaking of muscles that produces an oscillating movement Parkinsonian tremor Rest tremor > posture > kinetic Re-emergent tremor with posture Usually asymmetric Pronation-supination tremor Distal joints involved primarily Often posturing of the limb Parkinsonian tremor Other parkinsonian features Bradykinesia Rigidity Postural instability Many, many other motor and non- motor features Bradykinesia Rigidity Essential tremor Kinetic > postural > rest Rest in 20%, late feature, only in arms Intentional 50% Bringing spoon to mouth is challenging!! Mildly asymmetric Gait ataxia – typically mild Starts in the arms but can progress to neck, voice and jaw over time Jaw tremor occurs with action, not rest Neck tremor should resolve when patient is lying flat Essential tremor Many other tremor types Physiologic tremor Like ET but faster rate and lower amplitude Drug-induced tremor – Lithium, depakote, stimulants, prednisone, beta agonists, amiodarone Anti-emetics (phenergan, prochlorperazine), anti-psychotics (except clozapine and Nuplazid) Many other tremor types Primary writing tremor only occurs with writing Orthostatic tremor leg tremor with standing, improves with walking and sitting, causes imbalance Many other tremor types Cerebellar tremor slowed action/intention tremor Holmes tremor mid-brain lesion, unilateral Dystonia Dystonia Muscle contractions that cause sustained or intermittent torsion of a body part in a repetitive -
Musculoskeletal Infections V1.1: ED Evaluation
Musculoskeletal Infections v1.1: ED Evaluation Approval & Citation Summary of Version Changes Explanation of Evidence Ratings PHASE I (E.D.) Abbreviations: Inclusion Criteria · Suspected septic arthritis and/or Septic Arthritis (SA) osteomyelitis in children > 3 months old Osteomyelitis (OM) Musculoskeletal (MSK) Exclusion Criteria · Permanent implanted orthopedic hardware ! · Symptoms at site contiguous with pressure ulcer/chronic wound For patients who · Suspected necrotizing soft tissue infection · Suspected axial skeletal involvement (i.e. are hemodynamically skull, spine, ribs, sternum) Kocher Criteria unstable or with sepsis · Chronic recurrent multifocal osteomyelitis physiology, also refer to · Immunocompromised patient (e.g. BMT, Predictors for SA of the hip: Septic Shock Pathway oncology, transplant) · Non-weight-bearing · Temp > 38.5C · ESR ≥ 40 mm/hr · WBC > 12,000 cells/mm3 Caird et al. introduced a fifth ED Team Assessment predictor for SA of the hip: · CRP > 2.0 mg/dL Evaluate for signs/symptoms suggestive of a primary MSK Infection ! Initial Workup Delayed diagnosis Labs: Order CBC with diff, CRP, ESR of hip SA can lead to avascular necrosis Microbiology: Consider aerobic + anaerobic blood cultures of the femoral head Imaging: Order x-ray of the involved bone/joint Low Clinical Suspicion Moderate/High Clinical Suspicion Alternative for SA and/or OM: for SA and/or OM: Unifying Diagnosis · Consider hip US if hip SA remains · Consult Orthopedics on the differential · Order hip US if hip SA is suspected · Consider alternative -
Children with Lower Limb Length Inequality
Children with lower limb length inequality The measurement of inequality. the timing of physiodesis and gait analysis H.I.H. Lampe ISBN 90-9010926-9 Although every effort has been made to accurately acknowledge sources of the photographs, in case of errors or omissions copyright holders arc invited to contact the author. Omslagontwcrp: Harald IH Lampe Druk: Haveka B.V., Alblasserdarn <!) All rights reserved. The publication of Ihis thesis was supported by: Stichling Onderwijs en Ondcrzoek OpJciding Orthopaedic Rotterdam, Stichting Anna-Fonds. Oudshoom B.V., West Meditec B.V., Ortamed B.Y .• Howmedica Nederland. Children with lower limb length inequality The measurement of inequality, the timing of physiodesis and gait analysis Kinderen met een beenlengteverschil Het meten van verschillen, het tijdstip van physiodese en gangbeeldanalyse. Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de Rector Magnificus Prof. dr P.W.C. Akkermans M.A. en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woen,dag 17 december 1997 om 11.45 uur door Harald Ignatius Hubertus Lampe geboren te Rotterdam. Promotieconmussie: Promotores: Prof. dr B. van Linge Prof. dr ir C.J. Snijders Overige leden: Prof. dr M. Meradji Prof. dr H.J. Starn Prof. dr J.A.N. Verbaar Dr. B.A. Swierstra, tevens co-promotor voor mijn ouders en Jori.nne Contents Chapter 1. Limb length inequality, the problems facing patient and doctor. 9 Review of Ii/era/ure alld aims of /he studies 1.0 Introduction 11 1.1 Etiology, developmental patterns and prediction of LLI 1.1.1 Etiology and developmental pattern 13 I. -
Common Pediatric MSK Complaints-When to Keep When to Refer
Common Pediatric MSK Complaints – when to keep, when to refer Michael J Conklin, MD I have no disclosures Content Low risk wrist fx’s Finger fractures Limping child Ankle sprains/fractures Back Pain Low risk wrist injuries Boutis randomized 96 kids 5-12 yoa into cast or splint group Transverse or greenstick fx’s of distal radius with <15 deg angulation Splint or cast 4 weeks and activity modification for 2 more weeks No difference in outcomes Scaphoid fx Before 15 yoa, 0.4% of pediatric fractures 0.45% of peds upper extremity fx’s 0.6/10,000 per year Snuff Box tenderness Initial films may be negative Most tx’d non-op with thumb spica cast Scaphoid – what to do If Snuff-box tender, place thumb spica splint and refer Finger fractures - Evaluation Tenderness/ swelling Deformity – coronal or rotational Resting cascade of digits Flexor and extensor tendon function Order xray of finger not hand Salter II phalanx fxs Minimally displaced Salter II of Phalanx – buddy tape or splint No need to refer Salter II phalanx fxs When more displaced, reduction is necessary. Then buddy tape Phalangeal neck fx Phalangeal neck fracture – can be unstable - Refer Seymour fx Seymour fx – Occult open fx – blood under nail plate or cuticle Needs local washout, nailbed repair and abx (Keflex) Refer Mallet finger Avulsion of extensor tendon from distal phalanx Refer Volar plate avulsion fx “Jammed finger” Hyperextension Dorsal extension block splint for 1 week then buddy tape No need to refer Limping Osteochondroses – Sever’s, Osgood- Schlatters Fractures that may be difficult to see on xray: Toddler’s fracture (tibia), Calcaneal tuberosity, Ist Metatarsal, Cuboid SCFE Transient synovitis Osteomyelitis/septic arthritis Evaluation History – Where is the pain? Duration? Fevers? Injury? Exam – gait evaluation, Trendelenberg gait vs. -
Use of Osteopathic Manipulative Treatment to Manage Compensated Trendelenburg Gait Caused by Sacroiliac Somatic Dysfunction
Editor’s Note: Corrections to this article were published in the March 2010 issue of JAOA—The Journal of the CASE REPORT American Osteopathic Association (2010;110[3]:210). The corrections have been incorporated in this online version of the article, which was posted January 2011. An expla - nation of these changes is available at http://www.jaoa .org/cgi/content /full/110/3/210-a. Use of Osteopathic Manipulative Treatment to Manage Compensated Trendelenburg Gait Caused by Sacroiliac Somatic Dysfunction Adam C. Gilliss, DO; Randel L. Swanson, II, OMS III; Deanna Janora, MD; and Venkat Venkataraman, PhD Gait dysfunctions are commonly encountered in the pri - In the present case report, we provide evidence that com - mary care setting. Compensated Trendelenburg gait is a gait pensated Trendelenburg gait may represent a secondary gait dysfunction that was originally described in patients with dysfunction stemming from somatic dysfunction of the weakness of ipsilateral hip abduction. This condition is sacroiliac joints. We also describe evidence of osteopathic thought to result from neuronal injury or myopathy. No manipulative treatment (OMT) resulting in quantitative treatment modalities currently exist for compensated Tren - improvements in the gait cycle. delenburg gait. The authors present a case in which osteo - pathic manipulative treatment may have improved a Tren - Traditional and Osteopathic Gait Theory delenburg gait dysfunction in a man aged 65 years with The gait cycle is divided into two main phases—stance and multiple sclerosis. Evidence of this improvement was swing, each consisting of numerous subphases. 2,3 Traditionally, obtained with the GaitMat II system for measuring the human gait cycle is considered to have six determinants that numerous gait parameters.