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ORTHO > COMMON PEDIATRIC ORTHO CONDITIONS > Flashcards

COMMON PEDIATRIC ORTHO CONDITIONS Flashcards

1
Q

MECHANICAL BACK PAIN

A

Most commonly what we see in the office
Usually mid or low back pain with no radiation
Associated with activity
May complain of stiffness or difficulty bending
Diagnosis of exclusion

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2
Q

BACK PAIN RED FLAGS

A 
HISTORY
⦁	Unexplained weight loss
⦁	Fevers, chills, night sweats
⦁	Night pain
⦁	History of infection 
⦁	Bladder or bowel dysfunction
⦁	Radiation into extremities
⦁	No improvement with conservative management
EXAM
⦁	Weakness
⦁	Numbness/paresthesias
⦁	Asymmetric reflexes
⦁	Clumsiness/ataxia
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3
Q

test for scoliosis

A

Adam’s test

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4
Q

ADOLESCENT IDIOPATHIC SCOLIOSIS

A
  • common
  • etiology = unknown
    ⦁ genetic? - tends to run in families
    ⦁ hormonal?
    ⦁ brain stem dysfunction?
    ⦁ platelet disorder?
  • scoliosis has NEVER been proven to cause pain
PHYSICAL EXAM FINDINGS
⦁	leg length inequality
⦁	shoulder height difference
⦁	truncal shift
⦁	waist asymmetry
⦁	Adam's test - forward bending test
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5
Q

RISSER SIGN

A

⦁ an assessment of the iliac crest, to determine how much more spinal growth is expected. This can be important for the evaluation of patients with scoliosis.

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6
Q

PHYSICAL EXAM FINDINGS FOR SCOLIOSIS

A 
PHYSICAL EXAM FINDINGS
⦁	leg length inequality
⦁	shoulder height difference
⦁	truncal shift
⦁	waist asymmetry
⦁	Adam's test - forward bending test
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7
Q

IMAGING FOR SCOLIOSIS

A
  • XRAY - see convex right thoracic curve
    • lateral = hypokyphosis & rib rotation
  • True scoliosis = curve > 10 degrees, Cobb angle

**RISSER SIGN = indirect sign using iliac apophysis to measure skeletal immaturity; no ossification of superior ileum
⦁ an assessment of the iliac crest, to determine how much more spinal growth is expected. This can be important for the evaluation of patients with scoliosis.
⦁ 1 = least mature, 5 = mature

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8
Q

TREATMENT FOR SCOLIOSIS

A

⦁ 0-25 degrees = observation
⦁ 25-50 degrees & Risser 1-3 = brace
⦁ 25-50 degrees & Risser 4-5 = observation
⦁ > 50 degrees = surgery

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9
Q

POSTURAL KYPHOSIS

A
  • gentle rounding of the back with forward bending = postural kyphosis - no tx needed
  • normal range of thoracic kyphosis = 19-45 degrees
  • vast majority = postural
    ⦁ parents complain about child’s posture
    ⦁ no pain
    ⦁ gentle rounding of back with forward bending

NO TREATMENT NECESSARY - may consider PT

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10
Q
  • sharp angled kyphosis seen on forward bending (as opposed to gentle rounding)
  • kyphosis is rigid - won’t correct with hyperextension
A

SCHEUERMANN’S KYPHOSIS

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11
Q

SCHEUERMANN’S KYPHOSIS

A
  • more common in boys
  • presents around age of puberty
  • exact cause = unknown
  • kyphosis > 45 degrees with anterior wedging across 3 consecutive vertebra on xray

sharp angled kyphosis - is rigid, and doesn’t correct with hyperextension

HX/PE
- may complain of pain about apex of kyphosis or in lower back if lumbar spine has a large compensatory curve

  • sharp angled kyphosis seen on forward bending (as opposed to gentle rounding)**
  • kyphosis is rigid - won’t correct with hyperextension*

TREATMENT
⦁ Kyphosis < 60 degrees = observation
⦁ Kyphosis 60-80 degrees = brace
⦁ kyphosis > 80 degrees = surgery

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12
Q

SPONDYLOLYSIS

A
  • “collar on a scottie dog”
  • break of Pars interarticularis
  • one of the most common causes of back pain in children/adolescents
  • defects NOT present at birth
  • may be asymptomatic
  • genetic predisposition: inuit Eskimos - 50% prevalence
  • usually activity related; occurs with repetitive hyperextension - often seen in athletes
  • about 15% will progress to spondylolisthesis

Sports commonly associated with repetitive lumbar hyperextension = gymnastics, figure skating, javelin throw, weight lifting, cheer leading, football, butterfly stroke, volleyball

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13
Q

SPONDYLOLISTHESIS

A
  • the forward translation of a vertebral segment on the one beneath it
  • most common at L5/S1
  • the larger the slip = the greater the risk of progression or neurologic injury
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14
Q

spondylolisthesis is most common at which vertebrae

A

L5/S1

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15
Q

CLINICAL PRESENTATION OF SPONDYLOLYSIS & LISTHESIS

A 
⦁	May be asymptomatic
⦁	Activity related low back pain +/- buttock/posterior thigh pain
⦁	Radicular pain
⦁	Bladder and bowel dysfunction
⦁	Normal physical exam 
⦁	Hyper-lordosis
⦁	Limited flexion and extension
⦁	Pain with hyperextension
⦁	Hamstring tightness
⦁	Knee contracture
⦁	Crouch gait
⦁	Pain with straight leg raise
⦁	Palpable step off of spinous process
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16
Q

SPONDYLOLYSIS / SPONDYLOLISTHESIS IMAGING

A 
- XRAY: AP / lateral / obliques
⦁	- L5/S1
- CT
- MRI
- Bone scan

“scottie dog collar”

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17
Q

SPONDYLOLYSIS / SPONDYLOLISTHESIS TREATMENT

A
  • asymptomatic spondylolysis/ low grade spondylolisthesis = observation
  • symptomatic spondylolysis / low grade spondylolisthesis = PT / activity restriction
  • doesn’t improve with PT/activity restriction = TLSO Brace
  • failed management / progressive slip / neurologic symptoms = surgery
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18
Q

SEPTIC ARTHRITIS COMMON PATHOGENS

A

⦁ neonates = strep, and gram negatives
⦁ Infants = staph, H. flu
⦁ Children = staph, salmonella
⦁ Adolescents = staph, Neisseria gonorrhea

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19
Q

SEPTIC ARTHRITIS

A
  • Hip and knee are the most common sites
    >50% of cases occur in children less than 2 years of age
  • May have a recent history of mild trauma to the extremity
  • May have concurrent illness or infection
    Routes of inoculation:
    ⦁ Hematogenous
    ⦁ Direct from trauma or surgery
    ⦁ Extension from adjacent osteomyelitis

Signs and Symptoms
Acute onset of pain
Systemic symptoms
Limp or refusal to bear weight
Hip rests in a position of flexion, abduction, and external rotation
⦁ Position where joint capsule volume is largest
Severe pain with range of motion

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20
Q

SEPTIC ARTHRITIS LABS / IMAGING

A 
labs
⦁	CBC with diff
⦁	ESR
⦁	CRP
⦁	blood culture

IMAGING = XRAY area of concern
US - to aspirate any effusion that is visualized
⦁ positive = > 50k cells and > 75% PMNs

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21
Q

SEPTIC ARTHRITIS TREATMENT

A

KOCHER CRITERIA = order of sensitivity = Fever > CRP > ESR > refusal to bear weight > WBC

TREATMENT

  • emergent irrigation & debridement
  • IV antibiotics
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22
Q

KOCHER CRITERIA

A

For diagnosis of septic hip

most sensitive = fever

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23
Q

most common cause of hip pain in pediatric population

A

transient synovitis

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24
Q

TRANSIENT SYNOVITIS

A
  • Most common cause of hip pain in the pediatric population
  • Commonly affects children aged 3-8
  • Hip pain, limited ROM, and limp
  • Often history of antecedent viral illness**
  • Afebrile, normal labs
  • No effusion on ultrasound

TREATMENT

  • Observation and NSAID’s
  • Most improve within 24-48 hours
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25
Q

LEGG-CALVE -PERTHES DISEASE

A
  • Idiopathic osteonecrosis of the proximal femur
  • Self limited course
  • Resolves in 2-5 years

Affects:

  • Boys > girls
  • Age 4-8
  • Etiology - unclear
Reported associations:
⦁	Behavioral disorders
⦁	Lower socioeconomic status
⦁	Urban locations
⦁	Cigarette smoke exposure
⦁	Caucasians
⦁	Coagulopathy

child is hyperactive, small for his age, and has loss of abduction and internal rotation

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26
Q

SIGNS/SYMPTOMS OF PERTHES DISEASE

A

SIGNS/SYMPTOMS

  • painless limp - worse with activity; improves with rest
  • may have pain in hip/groin/thigh/knee
  • hip stiffness

XRAY = AP & frog leg lateral - irregulatory of femoral head ossification
crescent sign at femoral head (advanced)

PROGNOSTIC FACTORS
⦁ Age < 6 does better
⦁ Height of the lateral pillar during fragmentation stage
⦁ Sphericity of the femoral head/ congruency of the hip joint at skeletal maturity

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27
Q

PERTHES TREATMENT

A
  • main objective = keep femoral head in acetabulum - promotes sphericity development of both the femoral head and the acetabulum
  • goal = maintain/restore range of motion of the hip
    ⦁ mainstay = PT
    ⦁ casting
    ⦁ surgery for severe cases
  • but self limiting…does resolve on its own, just don’t want any complications to occur
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28
Q

most common orthopedic disorder in newborn

A

DDH

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29
Q

risk factors for DDH

A 
⦁	Female 
⦁	First born
⦁	Breech (feet first)
⦁	Family history
⦁	“Packaging deformities”
	- Torticollis
	- Metatarsus adductus
	- Congenital knee dislocation
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30
Q

Barlow & ortolani = only reliable from ages

A

0-3

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31
Q

TESTS FOR DDH (0-3 months)

A

⦁ Barlow - adduction & depression of flexed femur = dislocated a dislocatable femoral head
⦁ Ortolani - abduction and elevation of flexed femur - reduces a dislocated femoral head
⦁ Galeazzi sign - limb length discrepancy - due to unilateral dilocated hip

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32
Q

Galeazzi sign

A

DDH

limb length discrepancy - due to unilateral hip dislocation

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33
Q

KLISIC SIGN

A

DDH

place 3rd finger over greater trochanter and 2nd finger on anterior superior iliac spine; a line between the 2 fingers should point at umbilicus

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34
Q

DDH (3 months - 1 year)

A

⦁ limited hip abduction

⦁ KLISIC SIGN = place 3rd finger over greater trochanter and 2nd finger on anterior superior iliac spine; a line between the 2 fingers should point at umbilicus

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35
Q

SIGNS/SYMPTOMS OF DDH (> 1 YEAR)

A

⦁ pelvic obliquity
⦁ waddling or trendelenburg gait
⦁ excessive lumbar lordosis in bilateral dislocations
⦁ toe walking on affected side

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36
Q

WHEN TO ULTRASOUND FOR DDH

A
  • not recommended to do US of all newborns
  • positive Barlow / Ortolani = referral to orthopedic surgeon
  • soft signs = f/u in 2 weeks - repeat exam; if positive in 2 weeks = refer to ortho surgeon
  • triple diapering NOT recommended
  • if physical exam negative at 2 week f/u = f/u at well-baby exam
  • well baby exam = 2-4 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months
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37
Q

DDH TREATMENT

A
  • 1st line tx = Pavlik harness
  • if pavlik harness fails in 1st 3 weeks = hip abduction orthotics
  • closed reduction & spica casting at 6-18 months
  • open reduction +/- pelvic or femoral osteotomy at > 18 months
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38
Q

SNAPPING HIP (COXA SALTANS)

A
  • caused by motion of muscles / tendons over bony prominences around the hip joint
  • often seen in athletes and dancers in their teens
  • 3 types
    ⦁ External snapping hip = Caused by iliotibial band sliding over the greater trochanter
    ⦁ Internal snapping hip = Caused by iliopsoas tendon sliding over the femoral head, prominent iliopectineal ridge, exostoses of lesser trochanter, or iliopsoas bursa
    ⦁ Intra-articular snapping hip = Caused by loose bodies in the hip or labral tears

Signs and Symptoms
⦁ May be painful or painless
⦁ Patient often able to reproduce snapping
⦁ External snapping can be seen across the room while internal snapping can he heard across the room
⦁ Clicking or locking sensation is more indicative of intra-articular pathology

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39
Q

external snapping

internal snapping

A

IT band - Ober’s test

iliopsoas

40
Q

EXTERNAL SNAPPING

A

⦁ Palpate over greater trochanter as hip is actively flexed; Applying pressure over the greater trochanter should stop the snapping

⦁ Ober’s Test

41
Q

INTERNAL SNAPPING

A

⦁ Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position

42
Q

MRI indicated with _______ snapping

A

inter-articular

43
Q

TREATMENT FOR COXA SALTANS

A

Often none needed
Activity modification for painful external or internal snapping
Physical therapy
Rarely injections for persistent painful snapping
Surgery for those that fail nonoperative measures
Even more rare

44
Q

Most common cause of in toeing from ages 1-3 years​

A

internal tibial torsion

45
Q

INTERNAL TIBIAL TORSION

A
  • Most common cause of in toeing from ages 1-3 years​
  • Majority are bilateral ​
    ⦁ If unilateral more likely on the left side​
  • Due to Intrauterine positioning​

-No investigations necessary
-No treatment required
-Favorable natural history​
-Spontaneous resolution
⦁ Usually by age ~6

46
Q

PHYSICAL EXAM OF INTERNAL TIBIAL TORSION

A
  • thigh foot axes - prone baby; knee flexed to 90 degrees
  • infants have 5 degrees internal rotation
  • adults have 10-20 degree external rotation
47
Q

most common newborn foot problem

A

metatarsus adductus

48
Q

higher rates of metatarsus adductus with:

A

⦁ Late pregnancy
⦁ First pregnancy
⦁ Twin pregnancy
⦁ Oligohydramnios

49
Q

associated conditions with metatarsus adductus

A

DDH

Torticollis

50
Q

physical exam of metatarsus adductus

A

⦁ Heel Bisector Line

= draw line through midline axis of foot; should normally run through the 2nd webspace; with metatarsus adductus = further away from big toe

51
Q

TREATMENT FOR METATARSUS ADDUCTUS

A

95% resolve spontaneously by age 4

  • actively correct = no treatment
  • passively correct = via stretching by parents
  • rigid deformities = serial casting
52
Q

most common cause of in toeing in early childhood

A

increased femoral anteversion

53
Q

INCREASED FEMORAL ANTEVERSION

A
  • Femoral torsion - angular difference between femoral neck and transcondylar axis
  • at birth = average of 40 degrees of femoral anteversion*
  • by age 8 = decreases to normal adult vales of 15 degrees
  • Most common cause of in toeing in EARLY CHILDHOOD (age 1-3 = internal tibial torsion)
  • females
  • bilateral
  • W sitter (sits with legs splayed out in W
  • egg beater runners
  • increased hip IR and decreased ER
54
Q

physical exam & TREATMENT OF FEMORAL ANTEVERSION

A

PHYSICAL EXAM

  • hip rotation while patient is prone - bend legs laterally at right angles at same time
  • thigh foot axis = normal (when prone, feet don’t internally rotate)

TREATMENT

  • rarely requires any intervention
  • extreme cases = best treated with ostotomies of the femur
55
Q

pediatric causes of in-toeing

A
  • internal tibial torsion
  • metatarsus adductus
  • increased femoral anteversion
56
Q

most common etiology for non-idiopathic SCFE

A

HYPOTHYROIDISM

elevated TSH

57
Q

associated conditions with SCFE

A

⦁ hypothyroidism = most common etiology for non-idiopathic SCFE - elevated TSH
⦁ renal osteodystrophy (elevated BUN and Cr)
⦁ growth hormone deficiency
⦁ panhypopituitarism
⦁ down syndrome

58
Q

indications for an endocrine workup in SCFE

A

⦁ age < 10

⦁ weight < 50%ile

59
Q

STABLE vs UNSTABLE SCFE

A

STABLE = able to bear weight with or without crutches = minimal risk of osteonecrosis

UNSTABLE = unable to ambulate, even with crutches. high risk of osteonecrosis

60
Q

classification of SCFE (acute vs chronic vs acute on chronic)

A

Acute = symptoms < 3 weeks

Chronic = symptoms > 3 weeks

Acute on Chronic = acute exacerbation of long-standing symptoms

61
Q

SIGNS/SYMPTOMS OF SCFE

A

⦁ Groin / thigh / KNEE pain
⦁ Antalgic, waddling, or Trendelenburg gait
⦁ Externally rotated foot progression angle
⦁ Decreased hip ROM
⦁ Thigh atrophy
⦁ Obligatory external rotation with passive flexion of hip

62
Q

KLEIN’S LINE

A

SCFE

63
Q

SCFE TREATMENT

A

non-weight bearing with crutches

urgent surgery (increased risk of AVN)

64
Q

OSGOOD SCHLATTER’S DISEASE

A 
Pain involving anterior knee
Pain with kneeling
Enlarged tibial tubercle
Tender over tibial tubercle
Pain on resisted knee extension
65
Q

imaging of Osgood schlatters

A

Lateral of knee

Irregularity and fragmentation of the tibial tubercle

66
Q

Osgood schlatters treatment

A

NICER

67
Q

FLEXIBLE FLATFEET

A

Decrease in medial longitudinal arch with valgus alignment of hindfoot

The most common foot problem seen in the pediatric orthopedic clinic

Almost all infants have flatfeet with an arch developing by age 10

Patients/parents may complain of abnormal appearing feet, nonspecific pain, or abnormal shoe wear

Often a family history of flatfeet

68
Q

too many toes sign

A

flexible flatfeet

can see an arch when they stand on their toes, or when the evert their foot

69
Q

with flexible flatfoot = important to check

A

achilles contracture

70
Q

MEARY’S ANGLE

A

flexible flatfeet

talus bent forward

71
Q

TREATMENT FOR FLEXIBLE FLATFEET

A

Nothing has been shown to help develop an arch in a child

Observation

Over the counter or custom orthotics may provide some relief

Stretching programs for those with tight Achilles tendons

Surgery rarely indicated

72
Q

TARSAL COALITION

A

Abnormal fusion of 2 or more bones in the midfoot or hindfoot

Can be osseous, cartilaginous, or fibrous

50% of cases are bilateral

Calcaneonavicular and talocalcaneal coalitions are the most common

Calcaneonavicular coalitions present around age 8-12

Talocalcaneal coalitions present around age 12-15

Coalitions are believed to become symptomatic upon ossification or maturation of a fibrous coalition to a cartilaginous or osseous coalition

73
Q

recurrent ankle sprains

A

tarsal coalition

74
Q

TARSAL COALITION symptoms

A

Symptomatic rigid flatfeet
Pain made worse with activity and improves with rest
Recurrent ankle sprains
Calf pain secondary to peroneal spasticity
Limited subtalar motion
Heel cord contractures

imaging = xray

75
Q

“anteater sign”

A

calcaneonavicular coalition = best seen in oblique view

responds better to non-surgical treatment than talocalcaneal coalition

76
Q

C sign

A

talocalcaneal coalition = best seen in lateral view

77
Q

TARSAL COALITION TREATMENT

A

Activity modification
NSAID’s
Shoe inserts
Immobilization in cast or boot for severe cases

Calcaneonavicular coalitions respond better to nonsurgical treatment than talocalcaneal coalitions

Surgery is indicated when a patient fails nonoperative management

Resection of the coalition and interposition of fat, tendon, muscle, or bone wax

78
Q

SEVER’S DISEASE

A

Common cause of heel pain in growing children
Especially in athletes participating in running and jumping sports

Overuse injury of the calcaneal apophysis

Presents just before or during peak growth spurt

79
Q

SIGNS/SYMPTOMS OF SEVER’S DISEASE

A

Pain in the area of the posterior calcaneus
Pain made worse with activity
Stretching a tight Achilles tendon exacerbates the pain
May see warmth, erythema, or swelling

Positive squeeze test
Pain with squeezing of the calcaneus with medial-lateral compression

80
Q

sever’s disease treatment

A

achilles tendon getting stretched too much

Activity modification
Achilles tendon stretches
Ice
Heel cups
NSAID’s
Short leg cast immobilization for severe, persistent pain
81
Q

PEDIATRIC FRACTURES

A

Children’s bone is less mineralized, more porous, and has more vascular channels compared to adults

This results in a more elastic bone

Less strength and response to bending forces

Able to absorb more energy before failure

82
Q

PLASTIC DEFORMATION FRACTURES IN CHILDREN

A

Microscopic mechanical failure of bone

Radiographs reveal angulation without an obvious fracture line

83
Q

GREENSTICK FRACTURE

A

Occurs with greater force than plastic deformation

Results in failure (fracture) on one side of the bone but plastic deformation on the other

84
Q

TORUS / BUCKLE FRACTURE

A

Occur in the metaphyseal of bones which is composed of cancellous (soft) bone and thin cortical (hard) bone
The thin cortical bone fails in compression buckling outwards
The periosteum remains intact

85
Q

PHYSIS

A

Located between the cartilaginous epiphysis and the newly generated bone in the metaphysis

Responsible for longitudinal bone growth

Within the growth plate chondrocytes undergo differentiation

Progress through the resting, proliferative, prehypertrophic, and hypertrophic stages

Fractures most commonly occur through the hypertrophic zone

86
Q

SALTER HARRIS TYPE I

A

Fracture traverses entire growth plate (physis)

Diagnosis is difficult as radiographs are usually normal

Patient is point tender over the physis with localized swelling

87
Q

most common salter harris

A

type II

88
Q

TYPE II SALTER HARRIS

A

Fracture line passes through a portion of the growth plate and exits through a segment of the METAPHYSIS

89
Q

TYPE III SALTER HARRIS

A

Fracture line passes through the physis and exits into the epiphysis

Intra-articular fracture

90
Q

TYPE IV SALTER HARRIS

A

Fracture line crosses all zones
Metaphysis, physis, and epiphysis

Intra-articular fracture

91
Q

TYPE V SALTER HARRIS

A

Crush injury to the physis

Rare

92
Q

SALTER HARRIS intra-articular fractures

A

types 3 & 4

93
Q

COMPLICATIONS OF PEDIATRIC FRACTURES

A
  • growth arrest

-

94
Q

GROWTH ARREST COMPLICATION WITH FRACTURES

A

Fracture involving the growth plate resulting in permanent injury

Can involve all of the growth plate or only a portion

Complete arrests lead to shortening of a bone

Partial arrests lead to angular deformity

95
Q

NURSEMAID’S ELBOW

A

Common injury in early childhood
Children age 1-4

Subluxation of the radial head

Due to sudden longitudinal traction applied to the hand

Radial head escapes under the annular ligament

Annular ligament becomes interposed between the radial head and capitellum (elbow)

96
Q

SIGNS/SYMPTOMS NURSEMAID’S ELBOW

A

Child will refuse to use the affected limb

Elbow is held in slight flexion with the forearm pronated

Will have pain and tenderness to the lateral elbow

Supination is reduced

CLINICAL DIAGNOSIS

Radiographs are not routinely needed

97
Q

TREATMENT OF NURSEMAID’S ELBOW

A

closed reduction

Supination +/- flexion OR
Hyper-pronation

ORTHO (15 decks)

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