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A 6-year-old has a yellow vaginal discharge. The examination is otherwise normal.

What are key

points

in the history and physical examination?

How would you approach differ if the patient were a sexually active 16-year-old?

What are similarities and differences in the approach?

Chapter 28
Neurologic Disorders
Copyright © 2017 Elsevier Inc. All Rights Reserved.
Anatomy and Physiology




Central nervous system – brain and spinal cord
Peripheral nervous system – afferent nerves and
sense organs
Extrapyramidal tract – conveys information from
cerebellum to motor cells of anterior column
Pyramidal tract – main motor pathway from
cerebral cortex to spinal nerves – voluntary
movement
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2
Autonomic Nervous System



Controls visceral activities
Comprised of sympathetic/parasympathetic
systems, with opposite effects on same organs
Sympathetic
➢
➢

“Fight or flight”
Epinephrine/norepinephrine
Parasympathetic
➢
➢
Slows activity, decreases metabolic rate
Acetylcholine
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3
Pathophysiology and
Defense Mechanisms




Nervous system related to all parts of body
Neurotransmitters include dopamine, serotonin,
glutamate
Many CNS disorders have interactive genetic,
immunologic, and infectious causative factors
Other causative factors:
➢
➢
➢
➢
➢
➢
Systemic problems – changes in physiology
Neurodegenerative disorders – loss of structure or function
Genetic problems
Structural defects
Trauma
Tumors/cancer
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4
Assessment of the Nervous System

History
➢
➢
➢
➢
➢
➢
➢

Onset
Pain and/or headache
Sensory deficits
Injury
Reflexive responses
Behavioral changes
Motor/balance changes
Medical history
➢
➢
➢
Prenatal
Birth history/neonatal course
Injuries/infections
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5
Assessment of the Nervous System

Medical history (Cont.)
➢
➢
➢
➢
➢
➢
➢

Cardiovascular/respiratory disorders
Environmental exposure to toxins
Metabolic disorders
Past neurologic diseases/tests
Drug ingestion
Urinary tract disease
Physical growth
Family disease history
➢
➢
➢
➢
Similar symptoms/pedigree
Consanguinity
Migraine history
Intellectual functioning of family members
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6
Assessment of the Nervous System

Developmental history
➢

Functional health
➢

Effects of symptoms on all areas of health promotion and safety
Social context
➢

Achievement plateau/loss of skills
Family composition, school, community
Review all systems plus:
➢
➢
Allergies, immunizations, hearing, vision, dental, skin, behavior,
nutrition,
Medications; recreational drugs
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7
Physical Examination








Growth parameters
Skin abnormalities
Anomalies
Cardiovascular system
Musculoskeletal system
Hearing/vision
Tanner stage
Hepatomegaly/splenomegaly
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8
Physical Examination

Specifics of the neurological examination
➢
Behavior and mental status
➢ Cranial nerve function
➢ Motor examination
➢ Sensory examination
➢ Reflexes
➢ Cranium examination
➢ Autonomic nervous system
➢ Meningeal signs
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9
Physical Examination







Diagnostic studies
CT/MRI
Laboratory studies for systemic disease, infection,
inflammation
Lumbar puncture
Electroencephalogram
US in infants
Polysomnography, electromyography, nerve conduction,
evoked responses, cerebral arteriography
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10
Management Strategies
Involving Anticipatory Guidance

Neurologic development
➢
➢

Educational needs
➢
➢

Many problems affect learning
Early intervention programs
Referrals for other key assessments
➢
➢
➢
➢

Timelines/markers of normal development
Implications of minor variations
Genetic implications
Physical therapy
Early intervention
Multidisciplinary teams
Medications
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11
SPECIFIC NEUROLOGIC
PROBLEMS OF CHILDREN
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12
Neurodegenerative Disorders




Gray or white matter affected
Biochemical or metabolic dysfunctions leading to
anatomic insults
May affect basal ganglia, cerebellum, brainstem, spinal
cord, peripheral and cranial nerves, cerebrum
Gray matter diseases
➢
➢
➢
Involve neurons
Onset heralded by seizures, decreased cognitive function, visual
changes
Menkes syndrome, progressive infantile poliodystrophy, neuronal
ceroid-lipofuscinoses, Rett syndrome
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13
Neurodegenerative Disorders

White matter diseases
➢
➢
➢

Demyelination
Decreasing motor skills, ataxia, spasticity
Schilder disease, acute disseminating encephalomyelitis, acute
hemorrhagic leukoencephalitis, multiple sclerosis
Rett syndrome
➢
➢
➢
➢
➢
X-linked mutation
Arrests maturation of certain areas of brain
Developmental milestones plateau; begin to lose skills
Gait abnormalities, stereotypic hand movements
Disorganized breathing/apnea, seizures, paraparesis
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14
Neurodegenerative Disorders

Multiple sclerosis
➢
Chronic, relapsing disorder of CNS
➢ Demyelination of brain, spinal cord, optic nerves
➢ Rare before age 10 years
➢ Autoimmune inflammatory neurodegenerative
•
•
•
•
•
•
Unilateral weakness, ataxia, other cerebellar symptoms
Symptoms last more than 24 hours
Headache
Motor symptoms – vague parasthesias
Visual disturbance
Vertigo, dysarthria, sphincter disturbances
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15
Neurodegenerative Disorders

Multiple sclerosis (Cont.)
➢
Diagnostic studies
• Neuroimaging
• Lumbar puncture
➢
Differential diagnosis
• Brain tumor, focal encephalitis, nonviral infections, CV
disease, leukodystrophies, systemic vasculitis
➢
Management
• Disease-modifying therapies – corticosteroids, IVIG,
plasmapheresis; monoclonal antibodies
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16
Nondegenerative Disorders

Benign paroxysmal vertigo
➢
Associated with family history of migraine
➢ Rapid onset of attack lasting seconds to minutes
➢ Daily attacks in clusters over several days
➢ Acute unsteadiness, nystagmus, vomiting, nausea,
frightened/pale appearance, lethargic/drowsy, normal
neurologic exam
➢ Brain MRI to assess for tumor
➢ Reassurance once diagnosis made
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17
Nondegenerative Disorders

Cerebral palsy
➢
➢
➢
➢
➢
➢
Nonreversible disorders
Chronic, nonprogressive; impairs control of movement
May have disturbances in sensation, perception, cognition,
communication, behavior
Epilepsy, musculoskeletal problems may be present
Degree of brain injury individual
Three major types:
• Spastic – muscle stiffening and tightness
• Athetoid – involuntary, purposeless muscle movement
• Ataxic – affects balance and coordination
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18
Nondegenerative Disorders

Cerebral palsy (Cont.)
➢
➢
➢
➢
Etiology unknown in larger percentage
Pregnancy complications, traumatic deliveries
Intrauterine drug exposure, infections, congenital
brain malformations may cause
Acquired CP – meningitis, shaken baby,
nonaccidental and accidental trauma
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19
Nondegenerative Disorders

Cerebral palsy (Cont.)
➢
Clinical findings – history
•
•
•
•
•
•
•
Prenatal/natal history
Seizures
Hearing, vision problems
Change in growth parameters, head circumference
Early head injury or meningitis
Developmental milestones
Functional health problems – feeding, irritability, movement
difficulties, persistent primitive reflexes, communication
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20
Nondegenerative Disorders

Cerebral palsy (Cont.)
➢
Clinical findings – physical examination
• Dermatologic signs of syndromes
• Orthopedic exam – scoliosis, fractures, dislocations
• Neurologic exam – DTR, tone, atrophy, fasciculations,
reflexes, asymmetric movements, head size
• Vision/hearing
• Development – gross/fine motor, language, personal-social
skills
• Feeding
• Diet, height, weight, BMI
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21
Nondegenerative Disorders

Cerebral palsy (Cont.)
Diagnostic studies – imaging studies, chromosomal
and metabolic studies, lumbar puncture if sepsis
suspected
➢ Differential diagnosis – central vs peripheral; other
conditions causing motor involvement
➢
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22
Nondegenerative Disorders

Cerebral palsy (Cont.)
➢
Management
•
•
•
•
•
•
•
•
•
•
Referral of suspected cases
Family education/support/financial resources
Nutrition, elimination
Dentistry/drooling
Respiratory
Skin
Movement/mobility
Medications
Communication
Vision
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23
Nondegenerative Disorders

Cerebral palsy (Cont.)
➢
Management (Cont.)
•
•
•
•
➢
Osteopenia
Pain
Special education
Other treatments
Complications
• Epilepsy, autism
• Poor functional abilities if no treatment
➢
Prevention/screening
• Good prenatal care
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24
Nondegenerative Disorders

Bell palsy
➢
Sudden, acute unilateral paralysis/weakening of facial
nerve without sensory loss
➢ Viral etiology suspected
➢ Onset rapid; may last 1-9 weeks; spontaneous
remission
➢ Clinical findings – history
• Localized pain, swelling in one ear – sagging of face; URI
within previous 2 weeks/exposure to cold temperatures
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25
Nondegenerative Disorders

Bell palsy (Cont.)
➢
Clinical findings – physical examination
•
•
•
•
•
•
•
•
Unilateral motor changes – forehead, cheek, perioral
Normal blood pressure
Dribbling liquids from weak side/eating difficult
Hypersensitivity to noise
Eyelid fails to close on affected side
Lacrimation, taste, salivation impaired
No limb weakness
Herpes lesions on affected side
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26
Nondegenerative Disorders

Bell palsy (Cont.)
Diagnostic studies – not indicated
➢ Differential diagnosis – Guillain-Barre, hypertension,
infection, trauma
➢ Management
➢
• Methylcellulose eye drops
• Steroids in newly diagnosed patients
➢
Complications
• 85% recover spontaneously
• Incomplete – lack of salivation, lacrimation; contractures
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27
Nondegenerative Disorders

Epilepsy and seizure disorders
➢
Misfiring of cortical neurons of brain
➢ Convulsive – episodes of involuntary contraction of
voluntary muscles
➢ Recurrent, unprovoked = “epilepsy”
➢ Multiple etiologies – genetic, symptomatic, idiopathic
conditions
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28
Nondegenerative Disorders

Epilepsy and seizure disorders (Cont.)
➢
Clinical findings – history
•
•
•
•
•
•
Description of seizure
Underlying medical diagnoses
Previous CNS infection/birth trauma
Intrauterine infection, trauma, bleeding
Toxic exposure, drug use
Anticonvulsant medication stopped abruptly, doses missed,
change in brands
• Recent head injury
• Family history of seizures
• Milestones
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29
Nondegenerative Disorders

Epilepsy and seizure disorders (Cont.)
➢
Clinical findings – physical examination
•
•
•
•
•
•
•
•
Focal abnormalities/weakness
Seizure activity during exam
Hypertension
Systemic disease
Cardiovascular disorder
Neurocutaneous disease
Signs of head trauma
Transillumination of skull in infants
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30
Nondegenerative Disorders

Epilepsy and seizure disorders (Cont.)
➢
Clinical findings – diagnostic studies
•
•
•
•
•
•
•
•
•
CBC, LFTs
Metabolic screen later in workup
Blood glucose
Urine/serum toxicology
Lumbar puncture if 2 SD above mean
Hydrocephaly, megalencephaly, subdural hematoma,
tumor, skull thickening
Microcephaly
➢
➢
➢
Head circumference 2 SD below mean
Normal shape; may have overlapping sutures
Delayed development, neurological problems
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59
Disturbances of Head Growth

Craniosynostosis
Congenital – early closure/absence of one or more
sutures
➢ Syndromic – accounts for 25% of cases
➢ Growth along open sutures produces deformity
➢ Secondary synostosis – outside forces put pressure
growing cranium – plagiocephaly
➢ Physical examination – cranial symmetry for first year,
symmetry of neck rotation
➢
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60
Disturbances of Head Growth

Craniosynostosis (Cont.)
➢
➢
➢
Diagnostic studies – CT scan; MRI if neurological
exam abnormal
Differential diagnosis – normal frontal metopic suture
prominence
Management – refer to neurosurgeon
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61
Central Nervous System Infection


Bacteria, viruses, fungi, spirochetes, protozoa,
parasites can cause
Clinical findings – history
➢
URI or GI symptoms with fever
➢ Increasing lethargy/irritability
➢ Recent head injury/surgery
➢ Immunodeficiency disease
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62
Central Nervous System Infection

Clinical findings – physical examination
Systemic signs – fever, malaise
➢ CNS signs – headache, stiff neck/spine, N/V, changes
in mental status
➢ Kernig/Brudzinski signs
➢ Bulging fontanelle/papilledema
➢ Cranial nerve palsies
➢ Findings differ by age
➢

Diagnostic studies – blood cultures, CBC, UA,
chemistry, lumber puncture
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63
Central Nervous System Infection

Management and complications
➢
➢
➢
➢
Refer as rapidly as possible
Aggressive management of hypovolemia,
hypoglycemia, hyponatremia, acidosis, shock,
increased ICP
Post-infection auditory evaluation
Blindness, hydrocephaly, CP, developmental delays
may occur
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64
The Hypotonic Infant





“Floppy” infants droop when picked up
History of abnormal in utero movements
Seizures, abnormal pain response, muscle
wasting, absent reflexes may occur
If CNS involved, is usually serious
Refer to specialists, geneticist
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65
Reye Syndrome



Encephalopathy often associated with virus
Sever vomiting progresses to irrational behavior,
to stupor/coma, to apnea, fixed pupils,
decorticate posturing
Immediate referral with hospital admission
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66
Tethered Cord





Caudal end of spinal cord fixed below L2 level
Abnormal stretching, damage to nerve cells,
fibers, blood vessels
Neurologic deterioration will occur
Often associated with spina bifida
MRI of spine to diagnose
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67
Arnold-Chiari Malformation




Type I – downward elongation of caudal end of
cerebellar vermis into foramen magnum
Type II – herniation can lead to brainstem and
upper cervical cord compression and necrosis
Diagnosis by MRI
Never attempt LP in child with Arnold-Chiari
malformation
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68
Myelomeningocele





Posterior neural tube and vertebral column not closed
Protrusion of both spinal cord and meninges
Spina bifida cystica – myelomeningocele
Spina bifida occulta – no herniation; open column
Clinical findings
➢
➢
➢
➢
➢
Poor intake of folic acid in pregnancy
Saclike cyst containing meninges/spinal fluid
Flaccid paralysis of lower extremities
Absence of DTRs; lack of pain/touch response
Constant urinary dribbling
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69
Myelomeningocele

Management and complications
➢
➢
➢
➢

Prognosis
➢
➢

Serial cranial US to monitor for hydrocephaly
Surgical resection/closure of structures at birth
Multidisciplinary supportive management
Genitourinary management
Normal intelligence in 70%
Functional mobility depends on level/degree
Prevention
➢
Folic acid supplementation for all females of childbearing age
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70
Myasthenia Gravis


Autoimmune disorder; decreased AChRs
Physical examination
➢
Ptosis, extraocular muscle weakness
➢ Dysphagia
➢ Muscle weakness of neck flexors, limb-girdle muscles
➢ Rapid muscle fatigue

Diagnostic studies
➢
➢
Short-acting cholinesterase inhibitor
EMG
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71
Myasthenia Gravis



Differential diagnosis – hypothyroidism,
polymyalgia rheumatica, MS, progressive
external ophthalmoplegia, Guillain-Barre,
Mobius syndrome, congenital ptosis
Management – anticholinesterase therapy
Complications – growth retardation from
steroids, cholinergic crises
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72
Discussion Questions
1.
2.
3.
4.
Are there different concerns about a new complaint of headache in
a 3-year-old versus a 13-year-old? What are the similarities and
differences in obtaining history, physical assessment, and
differential diagnosis?
A 5-year-old has a tonic-clonic seizure and a temperature of 104°F
(40°C). How would your management vary if this child were 3
months old? 8 years old?
A 10-year-old has a chief complaint of weakness. What are the key
physical assessment points? What are the differential diagnoses?
A 17-year-old football player received a severe head injury when in
a motor vehicle accident in early May. He required hospitalization
and was unconscious for 30 hours. He had one seizure the week
following his injury. You see him 1 month after his discharge. What
sort of examination (including all the elements) are you going to
do? What do you tell him about his returning to play on the varsity
football team in late August? What sort of prediction can you make
about his recovery? What sort of follow-up do you recommend?
Copyright © 2017 Elsevier Inc. All Rights Reserved.
73
Chapter 35
Genitourinary Disorders
Copyright © 2017 Elsevier Inc. All Rights Reserved.
Standards of Care


Prevention screening for asymptomatic
bacteremia/chronic kidney disease not
recommended at any age
Blood pressure screening beginning at 3 years
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2
Anatomy and Physiology



Two kidneys, two ureters, bladder, urethra
Kidneys filter, clear, reabsorb, secrete
substances essential for metabolism
Glomerular filtration/renal blood flow increase at
birth; stabilize at 1-2 years
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3
Pathophysiology and Defense
Mechanisms



Problems occur at any point from kidneys to
urethral meatus
Disorders include: infection, inflammation,
congenital malformation/condition, abnormalities
acquired from injury, infection, malfunction
Urinary tract normally sterile – mucosal lining
and urinary pH inhibit bacterial
growth/adherence; urine flow flushes out
bacteria
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4
Assessment of the
Genitourinary System

History
➢
➢
➢
➢
➢


Symptoms, fever
Abdominal/flank pain
Voiding pattern, color/odor/frequency of urine,
dysuria, urgency
Diarrhea or chronic constipation
Sexual activity or abuse
Family history
Past history of UTI, other disorders
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5
Assessment of the
Genitourinary System

Physical examination
➢
Growth, weight gain
➢ Blood pressure
➢ Edema, pallor, hydration
➢ Ear position/formation
➢ Abdominal masses, tenderness
➢ Costovertebral tenderness
➢ External genitalia abnormalities
➢ Unusual facial features
Copyright © 2017 Elsevier Inc. All Rights Reserved.
6
Assessment of the
Genitourinary System

Diagnostic studies – as indicated
Physical characteristics – color, clarity, odor, specific
gravity, osmolality
➢ Chemical characteristics – leukocyte esterase, nitrites
indicate WBCs/bacteria
➢ Microscopic examination of urine – RBCs, WBCs,
bacteria, casts, crystals,
➢ Gram stain – to identify organisms
➢ Urine culture/sensitivities
➢ 24-hour urine collection – calcium excretion, calciumcreatinine ration, quantification of protein
➢
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7
Assessment of the
Genitourinary System

Diagnostic studies (Cont.)
Blood work – BUN, creatinine, electrolytes,
procalcitonin
➢ Ultrasonography – noninvasive structural information
➢ Voiding urosonography for VUR
➢ Dimercaptosuccinic acid (DMSA) – acute
pyelonephritis
➢ Voiding cystourethrogram – limited to febrile UTIs
after abnormal ultrasound or DMSA scan, or with
second UTI
➢
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8
Assessment of the
Genitourinary System

Management strategies
➢
➢
➢
Education and counseling
Medication, diet, activity
Referral – urologist, nephrologist, surgeon
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9
GENITOURINARY TRACT
DISORDERS
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10
Urinary Tract Infection and
Pyelonephritis

Three types of UTI in children
➢
➢
➢
Asymptomatic bacteriuria – bacteria/no symptoms
Cystitis – lower tract symptoms (bladder)
Pyelonephritis – most severe; involves kidneys; can
cause irreversible renal damage
• Fever, irritability, vomiting in infant
• Fever, bacteriuria, vomiting, flank pain in children
• Complicated UTI – fever, toxicity, dehydration or any UTI in
child under 3-6 months
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11
Urinary Tract Infection and
Pyelonephritis

UTI may be classified by structural or functional
abnormality
➢
Vesicoureteral reflux
➢ Obstruction
➢ Dysfunctional voiding
➢ Pregnancy


May be classified as 1st occurrence, recurrent,
chronic
Age and gender determine course of treatment
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12
Urinary Tract Infection and
Pyelonephritis




Organism most commonly E. coli
Most thought to be ascending
Most important risk factor in children is VUR
Clinical findings
➢
➢
➢
➢
➢
➢
➢
➢
Family history of VUR, recurrent UTI
Prenatally diagnosed renal abnormality
Previous infection
Circumcision
Hygiene/constipation/perianal itching/irritants
High blood pressure
Sexual activity/masturbation/abuse
Other infections – pinworms, diaper rash
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13
Urinary Tract Infection and
Pyelonephritis

Physical examination
Appearance – toxic?
➢ Vital signs
➢ Growth parameters
➢ Flank pain/costovertebral angle tenderness
➢ Suprapubic tenderness, bladder distension, fecal
impaction
➢ Genitalia – erythema, edema, irritation, discharge,
labial adhesions, uncircumcised male
➢ Neurological examination – reflexes, sacral dimpling
➢
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14
Urinary Tract Infection and
Pyelonephritis

Diagnostic studies
➢
Urine culture – positive if:
• >100,000 in clean catch
• >50,000 in catheterize/suprapubic
• >10,000 in symptomatic child
➢
UA used only to raise/lower suspicion
•
•
•
•
➢
Foul odor/cloudiness
Nitrites, leukocytes
Alkaline pH
Proteinuria, hematuria, pyuria, bacteriuria
Bacterial identification/sensitivity necessary in toxic
patients, those with pyelonephritis, recurrent UTI,
non-responsive to medication
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15
Urinary Tract Infection and
Pyelonephritis

Diagnostic studies (Cont.)
➢
CBC, ESR, CRP, BUN, creatinine in children 6 years for dysuria
➢ Radiologic workup (Table 35-3) to identify structural or
functional abnormality/damage or scarring
• Renal/bladder US < 2 years with first UTI, and all children with fever, pyelonephritis, recurrent UTI • VCUG if US atypical • DMSA scan if diagnosis of pyelonephritis uncertain Copyright © 2017 Elsevier Inc. All Rights Reserved. 20 Urinary Tract Infection and Pyelonephritis  Patient and family education, prevention, and prognosis ➢ Cause, complications, treatment plan ➢ Frequent/complete voiding; increase fluids ➢ Proper hygiene/avoidance of irritants ➢ Treatment of constipation, pinworms ➢ Sexually active females – void after intercourse ➢ Decrease intake of bladder irritants ➢ Prompt medical attention for fever ➢ Cranberry juice helpful Copyright © 2017 Elsevier Inc. All Rights Reserved. 21 Vesicoureteral Reflux (VUR)      Regurgitation of urine from bladder into ureters and potentially to kidneys Exposure to infected urine and pyelonephritis Primary VUR – short ureter; ineffective valve Secondary VUR – bladder outlet obstruction Grading of VUR ➢ ➢ ➢ ➢ Grade I – does not reach renal pelvis Grade II – up to renal pelvis without dilation Grade III – renal pelvis; mild/moderate dilation Grade IV and V – distension of ureters/renal pelvis; hydronephrosis or reflux into intrarenal collecting system Copyright © 2017 Elsevier Inc. All Rights Reserved. 22 Vesicoureteral Reflux (VUR)  Clinical findings ➢ Positive history for previous UTI, abnormal voiding pattern/dysfunction, unexplained febrile illness, chronic constipation, UTI symptoms ➢ Diagnostic studies • Ultrasonography – may be normal • VCUG – presence of reflux • DMSA – to look for renal scarring Copyright © 2017 Elsevier Inc. All Rights Reserved. 23 Vesicoureteral Reflux (VUR)  Management ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ Prevent infection/scarring Grades I, II resolve spontaneously in 85%; grade III in 50%; grade IV in 30% – earlier in African-Americans Very few children with VUR require surgery Treat underlying comorbidities – constipation, dysfunctional voiding Prophylactic antibiotics may be used Interval urine cultures when symptomatic Repeat VCUG 12-18 months Nephrology consultation with higher-grade reflux, scarring, solitary or atrophic kidney, hypertension, evidence of abnormal kidney function Copyright © 2017 Elsevier Inc. All Rights Reserved. 24 Vesicoureteral Reflux (VUR)  Patient and family education , prevention, prognosis VUR does not cause scarring – infection does ➢ Screen all siblings 1+ hematuria, microscopic exam for RBCs • If proteinuria – refer to nephrologist ➢ Microscopic examination • Distorted RBCs – glomerular disease ➢ Urine culture ➢ 24-hour urine collection ➢ Renal US if Wilms/nephrolithiasis suspected ➢ Renal biopsy for recurrent gross hematuria Copyright © 2017 Elsevier Inc. All Rights Reserved. 30 Hematuria  Clinical findings – differential diagnosis Gross hematuria – poststreptococcal glomerulonephritis, renal disease, UTI, trauma, coagulopathy, crystalluria, nephrolithiasis, HSP, IgA nephropathy, SCD, rhabdomyosarcoma ➢ Symptomatic microscopic hematuria – H&P guide workup ➢ Asymptomatic microscopic hematuria rarely indicates significant disease ➢ Asymptomatic hematuria with proteinuria is worrisome for renal disease ➢ Consider evaluation for orthostatic proteinuria ➢ Copyright © 2017 Elsevier Inc. All Rights Reserved. 31 Hematuria  Management ➢ ➢ ➢  Progressive approach – Figure 35-5 Refer gross hematuria with no clear cause Asymptomatic hematuria requires reevaluation every 1-2 years Patient and family education, prevention, and prognosis ➢ ➢ Importance of follow-up Prognosis depends on cause Copyright © 2017 Elsevier Inc. All Rights Reserved. 32 Proteinuria      Commonly detected by dipstick May be transient, recurrent, fixed Can be symptom of disease or benign Qualitative protein by dipstick – 1+ (30 mg/dL) Quantitative protein in urine over set period 40 mg/m2 indicates nephritic disease ➢ Copyright © 2017 Elsevier Inc. All Rights Reserved. 33 Proteinuria  Four groups of proteinuria ➢ ➢ ➢ ➢  Isolated – orthostatic or persistent asymptomatic Transient/functional – exercise-induced or fever-induced Glomerular – high levels Tubular-interstitial – high levels Clinical findings – history ➢ ➢ ➢ ➢ ➢ Family history of deafness, visual problems, renal disease Recent strenuous exercise/febrile illness Polydipsia/polyuria Malaise, fatigue, pallor Symptoms of chronic renal disease (Box 35-2) Copyright © 2017 Elsevier Inc. All Rights Reserved. 34 Proteinuria  Clinical findings – physical examination ➢ ➢ ➢ ➢  Growth and development parameters Blood pressure, pulse, respiratory rate Edema, especially periorbital Abdominal examination for mass, fluid, tenderness Clinical findings – diagnostic studies ➢ ➢ ➢ ➢ ➢ ➢ UA – repeated 3X over 1-2 weeks First-morning urine sample Microscopic urine Protein-to-creatinine ration of urine 12- or 24-hour collection for creatinine Other tests if proteinuria >4 mg/m2
Copyright © 2017 Elsevier Inc. All Rights Reserved.
35
Proteinuria

Management
Dipstick is trace or 1+ – reassurance
➢ Dipstick > 1+ – evaluate for orthostatic proteinuria
➢ First morning 1+ or 2+, perform quantitative test
➢ Dipstick > 2+ – evaluate for nephritis
➢ Refer to nephrologist for persistent, unexplained
proteinuria, hematuria, other symptoms
➢

Patient and family education, prevention, and
prognosis
➢
Importance of follow-up
Copyright © 2017 Elsevier Inc. All Rights Reserved.
36
Nephrotic Syndrome






Excessive excretion of protein in urine from increased
glomerular filtration permeability
Selective (albumin only) or non-selective (most serum
proteins)
Massive proteinuria (3-4+) or protein-creatinine ratio
greater than 2-3:1
Edema formation from decreased plasma oncotic
pressure
Liver increases protein synthesis – hyperlipidemia and
lipiduria
Reduced volume stimulates ADH – increased
reabsorption of water
Copyright © 2017 Elsevier Inc. All Rights Reserved.
37
Nephrotic Syndrome


Congenital – genetic mutation/congenital
infection
Idiopathic – 90% of children
Minimal change disease (MCSN) – most common
➢ Mesangial proliferation
➢ Focal segmental glomerulosclerosis
➢ Membranous nephropathy
➢ Membranoproliferative glomerulonephritis
➢

Secondary – secondary disorders
Copyright © 2017 Elsevier Inc. All Rights Reserved.
38
Nephrotic Syndrome






Chronic – periods of remission/relapse
Steroid responsiveness best prognostic indicator
(95% of children)
Steroid resistant – no response
Steroid partial responders/steroid dependent
Primary mechanism likely immunologic
30% to 60% have atopic disease; 3% have
family history
Copyright © 2017 Elsevier Inc. All Rights Reserved.
39
Nephrotic Syndrome

Clinical findings – history
➢
➢
➢
➢
➢

History of allergy
Edema is cardinal feature, especially periorbital
Low urine production
GI symptoms
Respiratory difficulties – secondary to edema
Clinical findings – physical examination
➢
➢
➢
➢
➢
Edema in tissues of low resistance/dependent
Anorexia, irritability, fatigue
Muscle wasting, malnourishment, growth failure
Hypertension
Chronically ill-appearing
Copyright © 2017 Elsevier Inc. All Rights Reserved.
40
Nephrotic Syndrome

Clinical findings – diagnostic studies
➢
➢
➢
➢
➢
➢

UA and microscopic
Quantitative urine protein
CBC, electrolytes, BUN, creatinine, calcium, albumin,
total protein, LFT, lipids, C3/C4, ANA
Consideration of VDRL
Karyotype if neonatal/infant
If criteria for MCNA not met, referral for biopsy
Clinical findings – differential diagnosis
➢
Starvation, liver disease, protein-losing enteropathy,
GN
Copyright © 2017 Elsevier Inc. All Rights Reserved.
41
Nephrotic Syndrome

Management
➢
Control edema/await remission
➢ Consultation with nephrologist
➢ Hospitalization for severe symptoms
➢ Prednisone 2 mg/kg/day – remission indicated by
diuresis
➢ Noncorticosteroid medication prescribed by
nephrologist if steroid resistant/dependent
➢ No limitation on activity; salt restriction during active
period
Copyright © 2017 Elsevier Inc. All Rights Reserved.
42
Nephrotic Syndrome

Management (Cont.)
➢
➢
➢
➢


Diuretics/albumin replacement in acute phase
Daily home testing
Routine immunizations except during
immunosuppression
Prompt treatment of infection
Complications – susceptible to infections, hyperor hypotension, thromboembolism
Patient and family education, prevention and
prognosis
➢
Continued, regular care
Copyright © 2017 Elsevier Inc. All Rights Reserved.
43
Nephritis and Glomerulonephritis

Nephritis – noninfectious, inflammatory response of
kidneys
➢
➢





Variable hypertension, edema, proteinuria, hematuria
Acute, intermittent, chronic
Primary glomerulonephritis (GN) – glomerular
impairment
Secondary glomerulonephritis – renal involvement
secondary to systemic disease
GN – inflammation in glomeruli
Interstitial nephritis – inflammation interstitium
Poststreptococcal glomerulonephritis – classic form
Copyright © 2017 Elsevier Inc. All Rights Reserved.
44
Nephritis and Glomerulonephritis

Intermittent gross hematuria/proteinuria
syndromes
➢
IgA nephropathy/Berger disease
➢ Alport syndrome – hereditary
➢ Benign recurrent

Chronic nephritis
➢

Pyelonephritis
➢

Membranoproliferative GN
Inflammation of renal parenchyma
PSGN – most common form in childhood
Copyright © 2017 Elsevier Inc. All Rights Reserved.
45
Nephritis and Glomerulonephritis

Clinical findings – history
➢
➢
➢
➢
➢

Streptococcal skin or pharyngeal infection in past 2-3 weeks
Abrupt onset gross hematuria
Decreased urine output
Lethargy, anorexia, N/V, chills, fever, backache
Medications
Clinical findings – physical examination
➢
➢
➢
➢
➢
➢
➢
Transient hypertension
Edema
Circulatory congestion
Ear malformations
Flank pain/abdominal pain
Costovertebral angle tenderness
Rashes/arthralgias
Copyright © 2017 Elsevier Inc. All Rights Reserved.
46
Nephritis and Glomerulonephritis

Clinical findings – diagnostic studies
➢
UA with microscopic
➢ Serum C3 or C4; total protein, albumin
➢ CBC, ESR, ASO, streptozyme test, DNA titer
➢ Electrolytes, BUN, creatinine, cholesterol

Differential diagnosis
➢
Acute nephritis as part of systemic diseases,
reactions to drugs
Copyright © 2017 Elsevier Inc. All Rights Reserved.
47
Nephritis and Glomerulonephritis

Management – PSGN
➢
Supportive with spontaneous resolution
➢ Hospitalization if severe oliguria, hypertension
➢ Antibiotics for positive cultures
➢ Resolution begins with diuresis
➢ Gross hematuria persists 1-2 weeks; urine abnormal
up to 6-12 weeks; microscopic hematuria up to 2
years
Copyright © 2017 Elsevier Inc. All Rights Reserved.
48
Nephritis and Glomerulonephritis

Management – other
➢
➢
➢
➢
➢


Acute nephritis – possible hospitalization
IgA nephropathy – annual follow up – BP/UA
Benign familial/hereditary – audiometry/review family history
Benign recurrent – UA/renal function every 1-2 years
Chronic nephritis – team approach
Complications – prolonged oliguria/renal failure,
hypertensive encephalopathy, CHF, irreversible renal
parenchyma damage
Patient and family education, prevention, prognosis
➢
PSGN – excellent outcome; IgA nephropathy – poor
Copyright © 2017 Elsevier Inc. All Rights Reserved.
49
Renal Tubular Acidosis


Dysfunction of renal tubule transport capability – low
serum carbon dioxide
Type I – defect in distal tubule
➢

Type II – proximal/bicarbonate-wasting RTA
➢



Hypokalemia, hyperchloremia, CO2 < 16, urine pH > 5.5
Hypokalemia, hyperchloremia, CO2 < 16, urine pH < 5.5 Type III – subtype of type I/premature infants Type IV – hyperkalemic RTA Fanconi syndrome – complex form of pRTA Copyright © 2017 Elsevier Inc. All Rights Reserved. 50 Renal Tubular Acidosis    Occurs in children evaluated for growth failure Caused by defect in ability of distal tubule to excrete hydrogen Clinical findings – history ➢ Failure to gain weight ➢ Polyuria/polydipsia ➢ Muscle weakness ➢ Irritability before/satiation after eating ➢ Preference for liquids Copyright © 2017 Elsevier Inc. All Rights Reserved. 51 Renal Tubular Acidosis  Clinical findings – physical examination ➢ ➢  Clinical findings – diagnostic studies ➢ ➢  Arrested growth curve after first year Normal physical exam/development Serum electrolytes, renal function tests 24-hour creatinine clearance, renal US if above findings abnormal Differential diagnosis – primary vs secondary RTA Copyright © 2017 Elsevier Inc. All Rights Reserved. 52 Renal Tubular Acidosis  Management ➢ ➢ ➢ ➢ ➢   Correction of acidosis/maintaining bicarb Oral alkalizing medications Response to medication helps confirm type Maximizing caloric intake Meticulous follow-up; referral if not growing well Complications – rare Patient and family education, prevention, prognosis ➢ ➢ Continued, regular care Isolated pRTA responds quickly with catch-up growth Copyright © 2017 Elsevier Inc. All Rights Reserved. 53 Nephrolithiasis and Urolithiasis     Urinary stones anywhere in urinary tract Prevalence varies by region (southeast US) Metabolic factors (hypercalciuria), structural anomalies, infections increase risk Clinical findings – history ➢ ➢ ➢ ➢  Family history, including arthritis, gout, renal stones/fragments in urine Diet high in protein, Na, Ca, oxalate Colic in infancy UTI in preschooler Clinical findings – history ➢ Abdominal, flank, pelvic pain Copyright © 2017 Elsevier Inc. All Rights Reserved. 54 Nephrolithiasis and Urolithiasis  Clinical findings – diagnostic studies ➢ ➢ ➢ ➢   Differential diagnosis – other causes of flank pain Management ➢ ➢ ➢  UA – gross/microscopic hematuria 24-hour urinary calcium excretion Abdominal radiography, US, CT Stone composition analysis Increased fluid intake – 2 L of urine/day Stone removal Dietary/urology referral Patient and family education, prevention, prognosis ➢ Referral to nephrologist /potential for end-stage renal disease Copyright © 2017 Elsevier Inc. All Rights Reserved. 55 Wilms Tumor       Most common genitourinary tract malignancy Stage I – limited to kidney; may be excised Stage II – extends beyond kidney; may be excised Stage III – postsurgical residual extension in abdomen Stage IV – hematogenous metastasis; lung Stage V – bilateral kidney involvement Copyright © 2017 Elsevier Inc. All Rights Reserved. 56 Wilms Tumor   Most occur ages 2-5 years Associated congenital anomalies: ➢ Cryptorchidism, hypospadias, duplication of collecting system ➢ Ambiguous genitalia, hemihypertrophy, aniridia ➢ Cardiac abnormalities ➢ Beckwith-Wiedemann, Denys-Drash, Perlman  Clinical findings – history ➢ ➢ Palpable mass; increased abdominal size Pain with rapid growth/hemorrhage Copyright © 2017 Elsevier Inc. All Rights Reserved. 57 Wilms Tumor  Clinical findings – physical findings ➢ ➢  Firm, smooth abdominal or flank mass; does not cross midline Left varicocele if spermatic vein obstructed Clinical findings – diagnostic studies ➢ ➢ ➢ ➢ Chest/abdominal radiography to differentiate neuroblastoma Abdominal US to differentiate solid/cystic mass UA, CBC, reticulocyte, liver/renal function CT of chest, abdomen, pelvis by oncology team Copyright © 2017 Elsevier Inc. All Rights Reserved. 58 Wilms Tumor   Differential diagnosis – neuroblastoma, multicystic kidney, hydronephrosis, renal cysts Management ➢ ➢   Diagnostic workup is urgent/referral to oncology Surgery to remove affected kidney; chemo/radiation therapy if needed Complications – lungs/liver most common metastatic sites Patient and family education, prevention, prognosis ➢ ➢ Determined by histology, age, stage Kidney protectors for sports Copyright © 2017 Elsevier Inc. All Rights Reserved. 59 COMMON GENITOURINARY CONDITIONS IN MALES Copyright © 2017 Elsevier Inc. All Rights Reserved. 60 Hypospadias      Urethral meatus located anywhere from proximal glans to perineum on ventral surface Chordee – ventral bowing of penis Torsion – rotation of penis to left or right Occurs in 1/250 males; 10% have undescended testicles Clinical findings – history ➢ ➢ Family history Child sits to void; has difficulty with aim Copyright © 2017 Elsevier Inc. All Rights Reserved. 61 Hypospadias  Clinical findings – physical examination ➢ ➢   Differential diagnosis – intersex abnormalities Management ➢ ➢   Dorsally hooded foreskin in newborn Visualization of meatus/urinary stream Surgical repair for functional, normal-appearing penis Do not do circumcision; refer to pediatric urologist Complications – peer taunting; erectile problems Patient and family education, prevention, prognosis ➢ Education, reassurance; workup for other anomalies Copyright © 2017 Elsevier Inc. All Rights Reserved. 62 Cryptorchidism       Undescended testes – does not reside in/cannot be manipulated into scrotum Retractile testis – can be brought into scrotum and remains there Gliding testis – brought into scrotum; returns to high position Ectopic testis – outside normal path of descent Trapped testis – dislocated after herniorrhaphy Progressive deterioration of any testis not in scrotum Copyright © 2017 Elsevier Inc. All Rights Reserved. 63 Cryptorchidism    Majority descend spontaneously by 3 months Bilateral in 10% of cases Clinical findings – history ➢ ➢ ➢ ➢ Family history undescended testes/malignancy Testes not consistently descended during baths Prematurity, hypospadias, congenital hip subluxation, low birth weight, Down syndrome, Klinefelter syndrome Congenital, endocrine, chromosomal, intersex disorders Copyright © 2017 Elsevier Inc. All Rights Reserved. 64 Cryptorchidism  Clinical findings – physical examination ➢ ➢ ➢ ➢ ➢   Cross-leg/frog-leg position; squatting/standing Scrotal rugae less developed Bilateral/unilateral absence of testicle Retractile/gliding testes Location – prescrotal, canalicular, ectopic, intraabdominal Diagnostic studies – none unless other problems Differential diagnosis – anorchism/chromosomal abnormalities Copyright © 2017 Elsevier Inc. All Rights Reserved. 65 Cryptorchidism  Management ➢ Improvement of fertility ➢ Decrease malignancy potential ➢ Minimize psychological stress ➢ Surgical intervention between 9 and 15 months ➢ Referral should occur prior to 6 months  Complications – poor testicular development, infertility, malignancy, torsion Copyright © 2017 Elsevier Inc. All Rights Reserved. 66 Cryptorchidism  Patient and family education, prevention, and prognosis ➢ Correction does not reduce malignancy risk; allows self examination ➢ Self-examination should be taught to all adolescents Copyright © 2017 Elsevier Inc. All Rights Reserved. 67 Hydrocele     Painless scrotal swelling – serous fluid in scrotum Noncommunicating – only in scrotum Communicating – processus vaginalis patent – fluid moves from abdomen to scrotum Clinical findings – history Intermittent/constant bulge in scrotum – increases with activity; decreases with rest ➢ Tense overlying skin ➢ No distress or vomiting ➢ Copyright © 2017 Elsevier Inc. All Rights Reserved. 68 Hydrocele  Clinical findings – physical examination ➢ Asymmetry or scrotal mass ➢ Testes descended ➢ Translucent on transillumination ➢ Noncommunicating – scrotal sac tense, slightly blue tinged, fluctuant, does not reduce ➢ Communicating – fluid comes and goes  Differential diagnosis – hernia, undescended or retractile testicle, inguinal lymphadenopathy Copyright © 2017 Elsevier Inc. All Rights Reserved. 69 Hydrocele  Management Noncommunicating – fluid usually absorbed spontaneously; no treatment unless very large or persists after 1 year ➢ Communicating – many resolve; referral if persists after 1 year ➢  Patient and family education, prevention, prognosis ➢ ➢ Reassure parents will resolve Alert to signs of hernia Copyright © 2017 Elsevier Inc. All Rights Reserved. 70 Spermatocele   Benign, painless mass on epididymis or testicular adnexa; older adolescents Clinical findings ➢ ➢ ➢ ➢   Swelling Painless, mobile cystic nodule No change in size with Valsalva US if large/painful Differential diagnosis – varicocele, epididymal cyst Management – no treatment unless large, painful Copyright © 2017 Elsevier Inc. All Rights Reserved. 71 Varicocele   Benign enlargement of testicular veins – feels like a “bag of worms” History ➢ ➢  Physical examination ➢  Palpate in standing position Diagnostic studies ➢ ➢  Painless swelling in left side Pain occurs with prolonged standing Ultrasonography to rule out malignancy if 4-5″   Diagnostic studies – radiographs Differential diagnosis – rickets, Blount disease, infections, tumor, internal tibial torsion Copyright © 2017 Elsevier Inc. All Rights Reserved. 53 Genu Varum  Management ➢ ➢   No treatment for physiologic genu varum Refer to orthopedist for persistent or increasing deformity – bracing is effective Complications – knee degeneration/deformity Prevention – early identification and referral Copyright © 2017 Elsevier Inc. All Rights Reserved. 54 Genu Valgum     Knock-knees Females > males; physiologic valgus until 7-8 years
Rickets, skeletal dysplasia, posttraumatic physeal arrest,
tumors, infection
History
➢
➢
➢

Progression of deformity
Risk factors
Joint pain/stiff gait
Physical examination
➢
➢
➢
Bilateral tibial-femoral angle 4-5 inches
Copyright © 2017 Elsevier Inc. All Rights Reserved.
55
Genu Valgum



Diagnostic studies – none unless pathology
Differential diagnosis – rule out pathology
Management
➢

Surgical for persistent deformity
Prevention – same as for genu varum
Copyright © 2017 Elsevier Inc. All Rights Reserved.
56
Osgood-Schlatter Disease



Microtrauma in patellar tendon at insertion on tibial
tuberosity
Diagnosis based on history/physical exam
History
➢
➢

Physical examination
➢
➢

Recent physical activity; track, soccer, football
Increased pain with activity; exacerbated with running, jumping,
squatting, stairs
May reproduce pain by extending knee against resistance,
stressing quadriceps, squatting
Focal swelling, heat, point tenderness
Diagnostic studies – based on history/exam
Copyright © 2017 Elsevier Inc. All Rights Reserved.
57
Osgood-Schlatter Disease

Management
➢
➢
➢
➢
➢
➢


Self-limiting; symptom management
Avoid activities that cause pain
Ice or cold therapy for inflammation
Quadriceps-stretching exercises when acute symptoms subside
NSAIDs have questionable benefit
Neoprene sleeve to stabilize patella/strap
Complications – persistent pain
Prevention – early management to decrease length of
disability
Copyright © 2017 Elsevier Inc. All Rights Reserved.
58
Tibial Torsion




Twisting of long bone along axis
Rotation outside range of normal version
Congenital, developmental, acquired
Physical examination
➢
➢


Observe gait for in-toeing
Thigh-foot angle to assess tibial rotation
Diagnostic studies – radiographs not necessary
Differential diagnosis – genu varum, femoral
torsion, adducted great toe
Copyright © 2017 Elsevier Inc. All Rights Reserved.
59
Tibial Torsion

Management
➢
➢
➢

Observation/monitoring of tibial version
Refer to orthopedist if significant
Special shoes ineffective
Complications – significant functional problems if
severe
Copyright © 2017 Elsevier Inc. All Rights Reserved.
60
Popliteal Cysts





Baker cysts – egress of fluid in knee joint
Clinical findings – swelling behind the knee
Diagnostic studies – US to distinguish fluid-filled
cyst from solid tumor
Differential diagnosis – lipoma, xanthoma,
vascular tumor, fibrosarcoma
Management – observation; ice/NSAIDs;
surgical incision if severe
Copyright © 2017 Elsevier Inc. All Rights Reserved.
61
Pes Planus





Flatfoot – physiologic or flexible; resolves by 2-3 years of
age
Flexible flatfoot persisting into adolescence usually
associated with familial ligamentous laxity
May be associated with Marfan, Down syndrome
History – onset with weight bearing; painless and
asymptomatic
Physical examination
➢
➢
➢
➢
Longitudinal arch disappears when standing
Hindfoot into valgus; midfoot sag is evident
Generalized ligamentous laxity
Range of motion normal in flexible flatfoot
Copyright © 2017 Elsevier Inc. All Rights Reserved.
62
Pes Planus


Differential diagnosis – congenital vertical; talus
Management
➢
Refer to orthopedist if symptomatic
➢ Removable, longitudinal arch support
➢ Passive stretching if Achilles tendon tight


Complications – variation of normal unless pain
or rigidity
Patient education – shoes do not fix problem
Copyright © 2017 Elsevier Inc. All Rights Reserved.
63
Metatarsus Adductus





Adduction of forefoot in relation to hindfoot
Metatarsus varus if forefoot is also supinated
Intrauterine molding in most cases
History – family history
Physical examination
➢
Forefoot adducted; midfoot/hindfoot normal
➢ Lateral border has convex shape
➢ Grasp heel and abduct forefoot to see if flexible

Diagnostic studies – radiographs not routine
Copyright © 2017 Elsevier Inc. All Rights Reserved.
64
Metatarsus Adductus


Differential diagnosis – vertical talus clubfoot
Management
Flexible foot – teach parents to stretch with each
diaper change
➢ Non-flexible foot – refer to orthopedist – may need
serial casting
➢

Complications – early intervention may prevent
more intensive therapy
Copyright © 2017 Elsevier Inc. All Rights Reserved.
65
Talipes Equinovarus

Clubfoot – three elements:
➢
➢
➢




Ankle is in equinus – foot in pointed-toe position
Sole of foot is inverted from hindfoot varus
Forefoot has convex shape
Cannot be manually corrected to neutral position
Idiopathic (hereditary), neurogenic, or
associated with syndromes
History – present at birth
Physical examination – as described above
Copyright © 2017 Elsevier Inc. All Rights Reserved.
66
Talipes Equinovarus


Diagnostic studies – AP and lateral radiographs
Management
➢
➢

Refer to orthopedist as soon as possible
Serial casting or surgery and casting
Complications – may become more distorted
with growth
Copyright © 2017 Elsevier Inc. All Rights Reserved.
67
In-Toeing and Out-Toeing



Degree of rotation and source of deformity must
be assessed
History – onset, progression, limitations,
treatments, family history
Physical examination
➢
➢

Observe gain
Examine for femoral anteversion, internal or external
tibial torsion, MA or other deformity
Management – based on diagnosis
Copyright © 2017 Elsevier Inc. All Rights Reserved.
68
Toe Walking




Persistent toe walking is frequently associated with
neurologic problems – CP
Unilateral may be associated with short leg
History – onset, severity, neurologic history, use of
walker or jumper
Physical examination
➢
➢
➢
➢

Look at shoe wear
Assess for tight heel cords
Conduct neurologic assessment
Measure leg length/hips
Management – depending on etiology
Copyright © 2017 Elsevier Inc. All Rights Reserved.
69
Ganglions of the Hands





Hard, fixed masses on wrists, flexor aspects of
fingers
Rarely symptomatic; usually regress
spontaneously
Rest/splinting
Refer for needle aspiration or surgical excision if
needed
Steroid injections not advised
Copyright © 2017 Elsevier Inc. All Rights Reserved.
70
Leg Aches of Childhood

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“Growing pains”
Nonarticular – in shins, calves, thighs, popliteal fossa
Almost always bilateral
Late in day or is nocturnal, lasting minutes to hours with
no pain in morning
Must differentiate between these and more serious
causes
History
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Time of day; duration of pain
Location of pain
No limp/disability; no fevers or swelling
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71
Leg Aches of Childhood
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Physical examination
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Have child stand on tiptoes and heels
➢ Measure leg lengths
➢ Evaluation range of motion, limp
➢ Assess for swelling, erythema, tenderness
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Diagnostic studies – none
Management – rea…
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