3) Pediatric Radiology and Osteochondroses Flashcards
1
Q
Podopediatric radiology considerations
A
- Ossification
- Alignment
- Osteochondroses / apophysitis
- Misc. physeal / epiphyseal abnormalities
2
Q
Newborn primary ossification centers
A
- 2 nd and 3 rd mets.: 9 th week IU
- 4 th and 5 th mets.: 10 th week IU
- 1 st metatarsal: 12 th week IU
- Calcaneus: 3 mo. IU
- Talus: 6 mo. IU
- Cuboid: -/+ birth
3
Q
Primary centers of ossification time of appearance
A
- Lateral cuneiform: 1 st year
- Medial cuneiform: 2 nd year
- Intermediate cuneiform: 3 rd year
(pneumonic 3-1-2) - Navicular: 2 – 4 years
- Sesamoids: 8 – 14 years
4
Q
Secondary ossification centers appearance
A
- Calcaneus: 6-8 yrs.
- Metatarsals: 6 mo. – 3 yrs.
- Phalanges: 1 – 2 yrs.
5
Q
Secondary ossification centers time of closure
A
- Calcaneus: 8 – 12 years
- Metatarsals / phalanges: 12 – 16 years
- Tibia / fibula: 16 – 21 years
6
Q
Biomechanical influences (Wolf’s Law, navicular)
A
- Wolf’s law: Bone is a dynamic tissue which responds (increases / decreases) to the forces to which it is subjected
- Navicular: excessive pronation may influence development
7
Q
Radiographic alignment angles
A
- Metatarsus adductus angle (AP)
- Calcaneal inclination angle (Lat)
- Talar declination angle (Lat)
- Talo – calcaneal (Kite’s) angle (AP)
8
Q
Metatarsus adductus angle
A
- 30 degrees at birth
- 20 degrees at onset of ambulation
- 5 - 15 degrees by age 4 years
- If it hasn’t reduced to 20 by the time they begin walking –> met adductus foot –> casting to reduce
9
Q
Calcaneal inclination angle
A
- 10 – 15 degrees at birth
- 15 – 25 degrees by age 6 years
10
Q
Talar declination angle
A
- 15 – 25 degrees at birth
- 10 – 15 degrees by age 6 years
11
Q
Talo-calcaneal angle (Kite’s angle)
A
- 30 – 50 degrees at birth
- 15 – 35 degrees by 4 years
12
Q
Avascular necrosis
A
- A circulatory abnormality involving a growth center
13
Q
Osteochondroses etiologies
A
- Trauma
- Infection
- Congenital
- Endocrine (hypothyroidism)
- Atavistic
14
Q
Atavistic – never normal from the beginning, probably some kind of bone dysplasia or something there
Trauma usually top of the list for onset
A
- Never normal from the beginning, probably some kind of bone dysplasia or something there
Trauma usually top of the list for onset
15
Q
Clinical features of osteochondroses
A
- Pain
- Edema
- Erythema
- Increased temperature
- Antalgic gait
- Age correlation
16
Q
Osteochondroses radiographic features
A
- Initial increase in density (sclerosis)
- Fragmentation
- Restitution (remodeling)
- Diminished size
17
Q
Three fractures that are among the most difficult to heal
A
- Sesamoids
- Jones
- Navicular three fractures that are among the most difficult to heal
18
Q
Osteochondroses differential diagnosis
A
- Osteomyelitis
- Cellulitis
- Neoplasm
19
Q
Legg-calves-perthes disease (coxa plana)
A
- Avascular necrosis of the femoral capital epiphysis
- Exact etiology unknown
- Males > Females
- Ages 4 – 8 years
- Increased incidence in low birth weight children
20
Q
Legg-calves-perthes disease (coxa plana) etiologies
A
- Trauma is usually the cause
- Knee pain in a child or adolescent must be considered hip pathology until proven otherwise
21
Q
Legg-calves-perthes disease clinical features
A
- Hip / groin / thigh / knee pain
- Antalgic gait
- Pain with hip rotation, esp. internal
22
Q
Coxa plana management
A
- Orthopaedic referral
- Complete NWB rest
- Casting / bracing
- Occasionally surgery
23
Q
Kohler’s disease
A
- Avascular necrosis of the navicular
- AKA Panner’s disease
- Males > females
- Unilateral > bilateral
- Ages 3 – 8 years
24
Q
Kohler’s disease clinical features
A
- Midfoot pain
- Antalgic gait
- Edema / erythema
- Excessive subtalar / midtarsal pronation
25
Kohler's disease radiographic findings
- Silver dollar navicular --> clerotic/white pigmented deformity of bone
- May need a talonavicular fusion, bone graft, etc.
26
Kohler's disease management
- NWB immobilization 6 – 8 weeks
| - Orthosis later
27
Frieberg's disease (infarction)
- Avascular necrosis of a metatarsal head
- Second metatarsal most common
- Females > males; ages 13 – 20 years most common
- Can be unilateral, bilateral or simultaneous multiple met. head involvement
28
Frieberg's infarction clinical features
- Pain
- Edema
- Erythema
- MTPJ crepitation
29
Frieberg's infarction management
- NWB immobilization
- Orthosis / metatarsal head accommodation
- Rocker bar
- Surgery
30
Freiberg's infarction surgical management
- Resection
- Implant
- Fusion
- Chondroplasty
31
Other osteochondroses
- Treve’s (Ilfeld’s) disease: hallucial sesamoids
- Buschke’s disease: cuneiform
- Diaz (Mouchet’s) disease: talus
- Haglund’s disease: Os tibialis externum
- Thicmann’s disease: phalanges
32
Apophysitis
- An epiphysis under traction
| - Inflammatory disease
33
Osgood-Schlatter's disease
- Inflammation of the proximal tibial tubercle (apophysitis / tendonitis)
- Overuse anterior knee pain
- Males > females
- Ages 11 – 15 years
- Unilateral > bilateral
34
Osgood-Schlatter's disease clinical features
- Pain with palpation of proximal tibial tubercle
- Edema
- Tight quadriceps / hamstrings
- Growth spurt
- Prominence of tubercle
35
Osgood-Schlatter's disease management
- Rest
- Ice
- Stretching
36
Sever's disease
- Calcaneal apophysitis
- Most common pediatric overuse injury
- Males > females
- Ages 7 – 13 years
- Soccer cleats are most notorious ! (baseball #2)
37
Sever's disease clinical features
- Posterior (postero-plantar) heel pain
- Equinus
- External angle of gait
- Active child
38
Sever's disease management
- Rest
- Ice massage
- Heel lift
- Achilles stretching
- Orthosis if indicated
- Casting (3-4 weeks)
39
Islen's disease
- Apophysitis of the fifth metatarsal base
- Overuse lateral foot pain
- Males > females
- Ages 11- 14 years (“Bar Mitzvah bone”)
40
Islen's disease clinical features
- Pain along styloid process
- Edema
- Overuse
- Rearfoot varus
- Tight, stiff shoes
41
Islen's disease management
- Rest
- Ice massage
- Avoid stiff shoes
- Orthoses if indicated
42
Os vesilinium
- Accessory ossicle at fifth metatarsal base
- Incidence: 0.1 – 1 %
- Probably represents an ununited apophysis
- Become symptomatic via trauma
43
Os vesilinium treatment
- ORIF if Peroneus brevis involvement
| - Excision
44
Miscellaneous
- Slipped capital femoral epiphysis
| - Osteochondrosis deformans tibiales (Blount’s disease)
45
Slipped capital femoral epiphysis
- Displacement of the femoral capital epiphysis
- Exact etiology unknown
- Males > females
- Ages 11 – 16 years
- L > R; 25 % bilateral
- Obese juvenile / adolescent
46
Slipped capital femoral epiphysis clinical features
- Hip / thigh / groin / knee pain
- Pain with hip rotation (esp. internal)
- Antalgic gait
- Whitman’s sign: hip rotates externally when flexed
47
Slipped capital femoral epiphysis (SCFE)
- Pre-slip: widening
| - Minimal slip: displacement < 1 cm
48
Slipped capital femoral epiphysis management
- Immediate NWB
- Traction / splinting
- ORIF
49
Blount's disease
- Arrest of the medial proximal tibial growth plate
- Exact etiology unknown. Abnormal pressure with ligamentous laxity ?
- Obese children who are early walkers
- Usually B / L
- Infantile and adolescent forms
- Males > females
50
Blount's disease clinical features
- Prolonged (> 2-3 years) genu varum
- Late onset genu varum (8 – 13 years)
- Not generally painful
51
Blount's disease treatments
- High top shoes
- Orthoses / braces
- Epiphysiodesis/tibial osteotomy
