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
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
3
Q
test for scoliosis
A
Adam’s test
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
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.
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
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
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
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
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
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
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
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
14
Q
spondylolisthesis is most common at which vertebrae
A
L5/S1
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
16
Q
SPONDYLOLYSIS / SPONDYLOLISTHESIS IMAGING
A
- XRAY: AP / lateral / obliques ⦁ - L5/S1 - CT - MRI - Bone scan
“scottie dog collar”
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
18
Q
SEPTIC ARTHRITIS COMMON PATHOGENS
A
⦁ neonates = strep, and gram negatives
⦁ Infants = staph, H. flu
⦁ Children = staph, salmonella
⦁ Adolescents = staph, Neisseria gonorrhea
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
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
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
22
Q
KOCHER CRITERIA
A
For diagnosis of septic hip
most sensitive = fever
23
Q
most common cause of hip pain in pediatric population
A
transient synovitis
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
25
LEGG-CALVE -PERTHES DISEASE
- 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
26
SIGNS/SYMPTOMS OF PERTHES DISEASE
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
27
PERTHES TREATMENT
- 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
28
most common orthopedic disorder in newborn
DDH
29
risk factors for DDH
```
⦁ Female
⦁ First born
⦁ Breech (feet first)
⦁ Family history
⦁ “Packaging deformities”
- Torticollis
- Metatarsus adductus
- Congenital knee dislocation
```
30
Barlow & ortolani = only reliable from ages
0-3
31
TESTS FOR DDH (0-3 months)
⦁ 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
32
Galeazzi sign
DDH
limb length discrepancy - due to unilateral hip dislocation
33
KLISIC SIGN
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
34
DDH (3 months - 1 year)
⦁ 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
35
SIGNS/SYMPTOMS OF DDH (> 1 YEAR)
⦁ pelvic obliquity
⦁ waddling or trendelenburg gait
⦁ excessive lumbar lordosis in bilateral dislocations
⦁ toe walking on affected side
36
WHEN TO ULTRASOUND FOR DDH
- 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
37
DDH TREATMENT
- 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
38
SNAPPING HIP (COXA SALTANS)
- 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
39
external snapping
internal snapping
IT band - Ober's test
iliopsoas
40
EXTERNAL SNAPPING
⦁ Palpate over greater trochanter as hip is actively flexed; Applying pressure over the greater trochanter should stop the snapping
⦁ Ober's Test
41
INTERNAL SNAPPING
⦁ Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position
42
MRI indicated with _______ snapping
inter-articular
43
TREATMENT FOR COXA SALTANS
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
Most common cause of in toeing from ages 1-3 years
internal tibial torsion
45
INTERNAL TIBIAL TORSION
- 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
PHYSICAL EXAM OF INTERNAL TIBIAL TORSION
- thigh foot axes - prone baby; knee flexed to 90 degrees
- infants have 5 degrees internal rotation
- adults have 10-20 degree external rotation
47
most common newborn foot problem
metatarsus adductus
48
higher rates of metatarsus adductus with:
⦁ Late pregnancy
⦁ First pregnancy
⦁ Twin pregnancy
⦁ Oligohydramnios
49
associated conditions with metatarsus adductus
DDH
| Torticollis
50
physical exam of metatarsus adductus
⦁ 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
TREATMENT FOR METATARSUS ADDUCTUS
95% resolve spontaneously by age 4
- actively correct = no treatment
- passively correct = via stretching by parents
- rigid deformities = serial casting
52
most common cause of in toeing in early childhood
increased femoral anteversion
53
INCREASED FEMORAL ANTEVERSION
- 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
physical exam & TREATMENT OF FEMORAL ANTEVERSION
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
pediatric causes of in-toeing
- internal tibial torsion
- metatarsus adductus
- increased femoral anteversion
56
most common etiology for non-idiopathic SCFE
HYPOTHYROIDISM
elevated TSH
57
associated conditions with SCFE
⦁ hypothyroidism = most common etiology for non-idiopathic SCFE - elevated TSH
⦁ renal osteodystrophy (elevated BUN and Cr)
⦁ growth hormone deficiency
⦁ panhypopituitarism
⦁ down syndrome
58
indications for an endocrine workup in SCFE
⦁ age < 10
| ⦁ weight < 50%ile
59
STABLE vs UNSTABLE SCFE
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
classification of SCFE (acute vs chronic vs acute on chronic)
Acute = symptoms < 3 weeks
Chronic = symptoms > 3 weeks
Acute on Chronic = acute exacerbation of long-standing symptoms
61
SIGNS/SYMPTOMS OF SCFE
⦁ 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
KLEIN'S LINE
SCFE
63
SCFE TREATMENT
non-weight bearing with crutches
urgent surgery (increased risk of AVN)
64
OSGOOD SCHLATTER'S DISEASE
```
Pain involving anterior knee
Pain with kneeling
Enlarged tibial tubercle
Tender over tibial tubercle
Pain on resisted knee extension
```
65
imaging of Osgood schlatters
Lateral of knee
Irregularity and fragmentation of the tibial tubercle
66
Osgood schlatters treatment
NICER
67
FLEXIBLE FLATFEET
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
too many toes sign
flexible flatfeet
can see an arch when they stand on their toes, or when the evert their foot
69
with flexible flatfoot = important to check
achilles contracture
70
MEARY'S ANGLE
flexible flatfeet
talus bent forward
71
TREATMENT FOR FLEXIBLE FLATFEET
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
TARSAL COALITION
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
recurrent ankle sprains
tarsal coalition
74
TARSAL COALITION symptoms
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
"anteater sign"
calcaneonavicular coalition = best seen in oblique view
responds better to non-surgical treatment than talocalcaneal coalition
76
C sign
talocalcaneal coalition = best seen in lateral view
77
TARSAL COALITION TREATMENT
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
SEVER'S DISEASE
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
SIGNS/SYMPTOMS OF SEVER'S DISEASE
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
sever's disease treatment
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
PEDIATRIC FRACTURES
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
PLASTIC DEFORMATION FRACTURES IN CHILDREN
Microscopic mechanical failure of bone
Radiographs reveal angulation without an obvious fracture line
83
GREENSTICK FRACTURE
Occurs with greater force than plastic deformation
Results in failure (fracture) on one side of the bone but plastic deformation on the other
84
TORUS / BUCKLE FRACTURE
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
PHYSIS
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
SALTER HARRIS TYPE I
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
most common salter harris
type II
88
TYPE II SALTER HARRIS
Fracture line passes through a portion of the growth plate and exits through a segment of the METAPHYSIS
89
TYPE III SALTER HARRIS
Fracture line passes through the physis and exits into the epiphysis
Intra-articular fracture
90
TYPE IV SALTER HARRIS
Fracture line crosses all zones
Metaphysis, physis, and epiphysis
Intra-articular fracture
91
TYPE V SALTER HARRIS
Crush injury to the physis
Rare
92
SALTER HARRIS intra-articular fractures
types 3 & 4
93
COMPLICATIONS OF PEDIATRIC FRACTURES
- growth arrest
-
94
GROWTH ARREST COMPLICATION WITH FRACTURES
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
NURSEMAID'S ELBOW
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
SIGNS/SYMPTOMS NURSEMAID'S ELBOW
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
TREATMENT OF NURSEMAID'S ELBOW
closed reduction
Supination +/- flexion OR
Hyper-pronation
