Chapter 17 - Ortho Flashcards
1
Q
Erb’s Palsy
A
- also known as “waiter’s tip”
- due to traction or tear of the upper trunk, damaging the C5 and C6 roots
- caused in infants by lateral traction on the neck during delivery and in adults by trauma that bends the head away toward the opposite shoulder
- presents with weakness in the deltoid, supraspinatus, infraspinatus, and biceps brachii
- infants will present with an asymmetric Moro reflex
- unable to abduct, laterally rotate, flex, or supinate the arm, so the arm hands by their side, medially rotate, extended, and protonated)
2
Q
Klumke’s Palsy
A
- due to traction or tear of the lower trunk damaging the C8 and T1 roots
- caused in infants by upward force on the arm during delivery and in adults by trauma as if grabbing a tree branch to break one’s fall
- presents with weakness in the intrinsic muscles of the hand (lumbricals, interossei, thenar, and hypothenar)
- result is total claw hand since lumbricals normally flex MCP joints and extend DIPs and PIPs
- horner syndrome may be present if sympathetic fibers in T1 have also been damaged
3
Q
How should brachial plexus injuries be managed?
A
- improvement should be noted within 48 hours
- if it doesn’t improve within 18 months, surgery may be required
4
Q
Nursemaid’s Elbow
A
- subluxation of the radial head due to an upward force on the arm
- typically occurs in children younger than 6 years old due to the slender shape of their radial head
- presents with sudden onset of pain, which is difficult to localize, no swelling, and a refusal to use the affected arm even though normal hand function
- no radiograph is needed and a tech may accidentally reduce the subluxation in the process of positioning the patient
- reduction is by simultaneously flexing the elbow and supinating the hand
5
Q
Anterior Shoulder Dislocation
A
- the most common type of should dislocation
- it occurs with excessive external rotation, abduction, and extension of the shoulder
- treat with immobilization after closed reduction
- recurrence rate is nearly 90%
6
Q
Torticollis
A
- a tilting of the head to one side
- congenital torticollis is very common whereas acquired is very rare in pediatrics
- the congenital form is due to uterine constraint or birth trauma, which causes contracture of the sternocleidomastoid
- presents with decreased rang of motion, stiffness, and occasionally a soft tissue mass representing bleeding into the muscle if due to birth trauma
- treat with stretching exercises to relive the contracture; use helmet therapy if head asymmetry is note
- major complications are skull deformity and facial asymmetry
7
Q
Atlantoaxial Instability
A
- an unstable joint between the occiput and C1 or between C1 and C2
- most often syndromic as in Down syndrome, Klippel-Feil syndrome, or skeletal dysplasias
- the physical exam is usually normal and individuals are asymptomatic, but spinal cord injury may occur if a patient with instability sustains injury
- diagnosed with lateral flexion-extension radiographs of the cervical spine
- treated with fusion of C1 and C2 if severe
8
Q
Klippel-Feil Syndrome
A
- a failure of normal vertebral segmentation that results in relative fusion
- most commonly occurs in the cervical spine
- associated abnormalities may include congenital torticollis, GU anomalies, congenital heart disease, hearing loss, and Sprengel’s deformity
9
Q
Sprengel’s Deformity
A
a congenital anomaly of the scapula in which it is rotated laterally, leading to shoulder asymmetry and diminished shoulder motion
10
Q
Scoliosis
A
- a lateral curvature of the spine
- occurs equally in men and women, but women require intervention 8 times more often
- presents with asymmetry of the shoulder height, scapular position, and the waistline as well as a positive Adam’s forward bending test
- most cases are idiopathic, but if pain is present, it suggests there may be an underlying disorder that requires investigation
- the Cobb angle is a measure of scoliosis: draw a line along the superior aspect of the most angulated vertebrae at the top of the curvature and another along the inferior aspect of the lowest most angulated vertebrae; the angle of intersection is the Cobb angle
- scoliosis progresses only during growth or if the spinal curvature is greater than 50 degrees, which is the basis for treatment guidelines
- before and during the growth spurt: if there is 10-20 degrees, assess progression in 4-6 months, five degrees is significant; for 20-40 degrees, bracing is indicated; for more than 40 degrees, surgery is indicated
- after growth has concluded, surgery is considered if scoliosis is more than 50 degrees
- primary complications are respiratory or cardiovascular compromise, which may occur with more than 60 degrees scoliosis
11
Q
Describe how scoliosis is managed.
A
before and during growth spurts:
- if there is 10-20 degrees scoliosis, follow up in 4-6 months to assess for progression; more than 5 degrees is considered significant
- for 20-40 degrees, bracing is indicated
- for more than 40 degrees, surgery is indicated
after growth has concluded:
- surgery is indicated if scoliosis is more than 50 degrees
12
Q
Kyphosis
A
- an anterior-posterior curvature of the thoracic spine, resulting in a hunched back
- most cases are “flexible” meaning they can voluntarily correct the rounded area
- Scheuermann’s kyphosis is a stiff kyphosis and develops in previously normal adolescents
13
Q
Back Strain
A
- muscular soreness from overuse or bad body mechanics
- the most common cause of back pain in children
- presents with diffuse muscular pain without neurologic deficits
- treatment includes rest and analgesics
14
Q
Spondylolysis
A
- a stress fracture in the pars interarticularis secondary to repetitive hyperextension of the spin
- typically involves the lumber region, especially L5
- presents with localized pain, which worsens with hyperextension
- may be missed by plain films, so use a bone scan or single photon emission computed tomographic scan
- treat with rest and analgesics
- may be complicated by spondylolisthesis
15
Q
Spondylolisthesis
A
- a subluxation in which the body of the vertebra involved in a spondylolysis slips anteriorly
- it may impinge on a nerve root, causing symptoms
- diagnosis is with imaging
- treat with rest and analgesics; surgery is indicated for nerve impingement, persistent pain, or progression of the subluxation
16
Q
Diskitis
A
- an infection or inflammation of the intervertebral disk
- may be caused by S. aureus, trauma, or rheumatic disease
- typically begins with signs and symptoms of a URI or mild trauma, which is followed by back pain and tenderness over the involved disk; fever may be present; children often refuse to flex the spine and young children may refuse to ambulate
- should be treated with bed rest and use of anti staphylococcal antibiotics
17
Q
Herniated Intervertebral Disk
A
- less common and due to a different mechanism than in adults
- pediatric cases are caused by repetitive activity and rarely by trauma
- the lumbar region is most commonly affected
- should be treated with bed rest; surgery is indicated only for persistent symptoms or abnormal neurologic findings
18
Q
Developmental Dysplasia of the Hip
A
- the acetabulum is abnormally float, leading to the easy dislocation of the head of the femur
- risk factors are female sex, first born, breech position, daily history, and oligohydramnios; most cases involve the left hip or are bilateral
- may be normal at birth but develop months later
- Barlow maneuver, ortolani maneuver, and Galeazzi sign are all positive
- diagnosed with ultrasound in those younger than 6 months because the femoral heads have not ossified before that; radiographs can be used after that
- a Pavlik harness can be used to hold the femur agains the acetabulum and stimulate formation of the normal cup shape; surgery may be required if the diagnosis is made beyond 6 weeks of life, there is bilateral disease, the hips are not reducible on physical exam, or the Pavlik harness fails
- may be complicated by avascular necrosis of the femoral head, limb length discrepancy, painful abnormal gait, or osteoarthritis
19
Q
What are the Barlow maneuver, Ortolani maneuver, and Galeazzi sign?
A
- Barlow: hip is dislocatable
- Ortolani: hip is reducible
- Galeazzi: an asymmetry in knee height when the hips are flexed
20
Q
Septic Arthritis
A
- a bacterial infection of the joint
- may be caused by hematogenous spread, contiguous spread, or direct inoculation
- S. aureus and Strep pyogenes are the most common organisms, although N. gonorrhoeae is a major cause in adolescents
- the hip is most commonly affected joint is the hip in young children, which is a medical emergency, and the knee in older children
- presents with fever, irritability, limp or refusal to walk, and pain with movement of the joint; erythema, swelling, and asymmetry of soft tissue folds may be present; the limb is usually held flexed, abducted, and externally rotated
- diagnosed with elevated WBC, ESR, and CRP; synovial fluid demonstrates a positive gram stain and culture as well as WBC count greater than 50K
- ultrasound may demonstrate fluid in the joint capsule
- joint aspiration is needed to avoid avascular necrosis and to diagnose the infection; IV antibiotics are added to cover gram-positives
21
Q
Transient Synovitis
A
- a self-limited, post infectious response of the hip joint, usually following a URI or diarrhea
- it is the most common cause of painful limp in toddlers
- presents with low-grade fever, lip, mild irritability, and acute or insidious onset hip pain; most hold their leg flexed, abducted, and externally rotated
- it is a diagnosis of exclusion; WBC and ESR are normal or only slightly elevated; there may be an effusion, which should be analyzed to rule out septic arthritis
- treat with NSAIDs, bed rest, and observation; the pain usually improves in 3 days with resolution in 3 weeks
22
Q
Legg-Calve-Perthes Disease
A
- idiopathic avascular necrosis of the femoral head
- most common in boys age 4-9yo; usually patients are active, thin boys who are small for age
- presents with insidious hip pain, limp, restricted hip abduction and internal rotation, and positive Trendelenburg sign
- diagnosed with radiograph
- treated by surgically position the head within the acetabulum to facilitate remolding and reossification, physical therapy, and restriction of vigorous exercise
- complete resolution within 2 years is the norm if disease develops before 9yo; osteoarthritis in adulthood is likely if disease develops after 9yo
23
Q
Slipped Capital Femoral Epiphysis
A
- displacement of the capital femoral epiphysis from the femoral neck
- most often in obese, adolescent males
- risk factors include endocrinopathies, renal failure, and radiation history; these usually present with bilateral disease
- presents with insidious onset of dull hip or referred knee pain with an altered gait and no preceding trauma, although trauma may exacerbate the pain and cause the patient to seek care
- on exam, internal rotation, flexion, and abduction of the hip are usually decreased
- diagnoses is based on radiograph
- treated by fixing the epiphysis in it’s current position to prevent further slippage; it isn’t placed back into the normal position because the force require risks avascular necrosis
- complications include avascular necrosis, chronolysis, osteoarthritis, and limb length discrepancy
24
Q
Osteomyelitis
A
- an infection of the bone most commonly acquired via hematogenous seeding
- S. aureus and S. pyogenes are the most common organisms, while Salmonella is common in sickle cell patients, and P. aeruginosa infection may occur if a child steps on a nail
- presents with fever, irritability, bone pain, erythema and swelling, and a painful limp; peak incidence is less than 1 year old and between 9-11 years old
- will find an elevated ESR, CRP, and WBC; a bone scan or MRI can detect osteomyelitis a few days after the onset of symptoms but a plain radiograph should not be used as it will appear normal until 10-14 days
- treated with antibiotics; begin with IV until the ESR declines at which time oral antibiotics can be used; surgery may be necessary if fever and swelling persist despite 48 hours of IV antibiotics
- may be complicated by contiguous spread or distant seeding causing pneumonia, chronic osteomyelitis as result of residual infection, pathologic fracture, or angular deformity/limb length discrepancy if the growth plate is involved
25
Metatarsus Adductus
- a medial curvature of the mid-foot
- occurs in children younger than 1 year of age as a result of intrauterine constraint
- the foot is C-shaped, can be straitened to varying degrees through gentle manipulation, and dorsiflexion is intact
- radiographs are not needed, it is a clinical diagnosis
- management depends on the flexibility of the foot: if it is flexible and can overcorrect with passive motion, it requires only observation; a flexible foot that corrects but does not overcorrect will benefit from stretching exercises; and a stiff foot warrants casting
26
Talipes Equinovarus (aka Clubfoot)
- a foot fixed in inversion without flexibility
- genetics are thought to play a strong role and there is an association with DDH, myelomeningocele, myotonic dystrophy, and some skeletal dysplasias
- the ankle is held in plantarflexion and inversion and is curved medially with very little range of motion at the ankle
- typically requires casting in the first weeks of life; surgery may be necessary if there is no improvement
27
Internal Tibial Torsion
- a medial rotation of the tibia, causing the foot to point inward, caused by in utero positioning
- it is the most common cause of in-toeing in children under the age of 2; present at birth but often not noted until 1-3 years of age when child starts standing
- the foot points medially when the knee is flexed to 90 degrees while the patella faces forward; bilateral torsion is more common than unilateral
- requires only observation
28
Femoral Anteversion
- an inward angulation of the femur
- the most common cause of in-toeing in children older than 2 years of age
- the feet and patella point medially and the hips are able to internally rotate more than normal; the child often prefers to sit in a "W" position (the opposite of crossed-legged on the floor)
- requires only observation
29
Calcaneovalgus Foot
- an out-toeing in which the foot is flexible with the toes pointed outward
- plantar flexion is restricted and the foot is excessively dorsiflexed, so much so that the dorsal of the foot can often be placed into contact with the anterior leg
- caused by uterine constraint
- management incldues stretching
30
Genu Varum
- a normal variation until the age of 2 years old, which is characterized by symmetric outward bowing of the legs
- patients take on a "cowboy" stance with knees bowing laterally and the patella pointed forward
- patients have a normal gait; if weight seems to shift, this is more indicative of Blount's disease
- radiographs are necessary only if the bowing is unilateral, severe, or persists after 2 years of age
- pathologic causes could be rickets, growth plate injury, Blount's disease, or skeletal dysplasias
31
Blount's Disease (aka Tibia Vara)
- a progressive angulation at the proximal tibia
- most often seen in obese, African American boys who are early walkers since it is thought to result from overload injury to the medial tibial growth plate
- this injury causes inhibited growth only on the medial side
- presents with angulation just below the knee and a lateral thrust with gait
- a metaphysical diaphysral angle greater than 11 degrees is diagnostic
- requires bracing for 1 year if the angle is greater than 16 or the patient is 2-3 years old; surgery is required if there is no improvement, if the patient is older than 4, or if there is recurrence
- the most common complication is osteoarthritis
32
Genu Valgum
- an angulation of the knees toward the midline
- most often caused by an overcorrection of normal genu varum
- presents in those age 3-5 with separation of the ankles while standing erect with the knees together and swinging of the legs laterally with walking or running
- manage with observation and surgical intervention only if it persists beyond 10 years of age or causes pain
33
Osgood-Schlatter Disease
- an inflammation or microfracture of the tibial tuberosity caused by overuse
- it is the most common apophysitis
- usually presents in boys 10-17 years old with swelling of the tibial tuberosity, knee pain with point tenderness over the tibial tubercle, pain with extension against resistance, and pain that worsens with use
- radiographs are not necessary, it is a clinical diagnosis
- manage with rest, stretching of the quadriceps and hamstrings, and analgesics
34
Patellofemoral Syndrome
- a slight misalignment of the patella that causes pain
- most common in adolescent girls, presenting with knee pain around the patella that worsens with activity and is relieved by rest
- managed with rest, stretching, and strengthening of the medial quadriceps
35
Growing Pains
- idiopathic, bilateral leg pains that occur most in the late afternoon or evening but do not interfere with play during the day
- most often seen in those 4-12 years of age
- children often awaken at night crying in pain, but the physical exam is normal
- treat with analgesics and reassurance
36
# Define the following types of fractures:
- open
- closed
- nondisplaced
- displaced
- angulated
- overriding
- open: the skin is broken
- closed: the skin is intact
- nondisplaced: fractured ends are well approximated and in the normal position
- displaced: fractured ends that are shifted
- angulated: fractured ends that are form an angle
- overriding: fractured ends which override without cortical contact
37
Compression Fracture
- also known as a torus or buckle fracture
- occurs when the soft, bony cortex buckles under a compressive force
- usually occurs in the metaphysis
- requires splinting for 3-4 weeks
38
Greenstick Fracture
- also known as an incomplete fracture
- it occurs if only one side of the cortex is fractured
- the intact side is the site of compression injury and may be bent, whereas the fractured receives the tension and fractures
- angulation may increase even within a cast, so reduction often requires fracturing the other side of the cortex
39
# Define the following types of fracture:
- transverse
- oblique
- spiral
- comminuted
all are types of complete fractures
- transverse: horizontal across the bone
- oblique: a diagonal fracture across the bone
- spiral: an oblique fracture encircling the bone
- comminuted: composed of multiple fracture fragments
40
Long bones are divided into what three segments?
- diaphysis
- metaphysis
- epiphysis
41
Physeal Fracture
a fracture involving the growth plate, which has not yet calcified and is vulnerable in children and which is classified according to the Salter-Harris system:
- grade I: within the physis
- grade II: in the physis and above into the metaphysis
- grade III: in the physis and below into the epiphysis
- grade IV: through the metaphysis, physis, and epiphysis
- grade V: a crushing of the physis
42
Clavicular Fracture
- most often caused by falling onto the shoulder or by birth trauma and most often involve the middle and lateral aspects
- infants may be asymptomatic but present with an asymmetric Moro reflex or pseudoparalysis; crepitus may be felt over the fracture
- children typically hold the affected limb with the opposite hand, have their head tilted toward the affected side, and have point tenderness and deformity over the fracture
- diagnosed with plain radiographs
- managed with sling for 4-6 weeks although neonates often require no treatment at all
- may be complicated by a brachial plexus injury
43
Supracondylar Fractures
- occur when a child falls on an outstretched arm or elbow
- present with point tenderness, swelling, and deformity of the elbow
- may be an emergency if the fracture is displaced or angulated because of the risk for neruovascular injury and compartment syndrome
- would most often damage the radian or median nerves or the brachial artery
- be sure to assess pulse, sensation, and movement of the fingers to asses this risk for compartment syndrome as pain with passive extension of the fingers would be indicative
- radiographs may demonstrate a triangular fat pad shadow posterior to the humerus
- if this sort of fracture is suspected, however, never passively move the arm as this increases the risk for neurovascular injury
- cast nondisplaced fractures but displaced or angulated fractures require surgical reduction and pinning
- may be complicated by cubits varus, a decreased or absent carrying angle as a result of poor position of the distal fragment
44
Compartment Syndrome of the Arm
- occurs when the pressure within the anterior fascial compartment is greater than 30-45 mmHg
- leads to ischemic injury and Volkmann's contracture, a flexion deformity of the fingers and wrist
- a sensitive indication is pain with passive extension of the fingers
- late signs are the five P's: pallor, pulselessness, paralysis, pain, and paresthesias
45
What is a collet fracture?
a forearm fracture of the distal radius
46
What is a monteggia fracture?
a forearm fracture of the proximal ulna with dislocation of the radial head
47
What is a Galeazzi fracture?
a fracture of the radius with distal radioulnar joint dislocation
48
How are forearm fractures managed?
open or closed reduction followed by splinting, which is replaced with a cast 4-7 days later, once the swelling has resolved; should heal within 6-8 weeks
49
Femur Fracture
- presents with erythema, swelling, deformities, and point tenderness
- get AP and lateral radiographs that include the joint above and below the injury because the mechanical force needed to fracture the femur may have caused other injuries
- managed with casting for 8 weeks; some femur fractures require traction for callus formation before casting
50
Toddler's Fracture
- a spiral fracture of the tibia in which the tibia remains intact
- may occur after very mild or no identified trauma
- most often seen in those 9 months to 3 years of age when a child trips or falls while running
- child will refuse to bear weight but is willing to crawl; there is erythema, swelling, and mild point tenderness
- requires a long leg cast for 3-4 weeks
51
Name six fracture types consistent with child abuse.
- metaphase fractures
- posterior or first rib fractures
- multiple fractures at various stages of healing
- complex skull fractures
- scapular, sternal, or vertebral spinous process fractures
- those for which the given mechanism does not fit the history or developmental abilities of the child
