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Fundamentals of Pediatric Orthopedics Flashcards

1
Q
  1. Clubfoot aka?
  2. Anatomic changes 3
  3. Treatment? 2
A
  1. Talipes equinovarus
    • Talus plantar flexed
    • Heel cord tight
    • Fore foot adducted/supinated
    • Ponseti method: Casting + percutaneous heel cord lengthening
    • Serial casting and bracing
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2
Q

Developmental Dysplasia of the Hip (DDH)

  1. What is the injury?
  2. Caused by? 2
  3. Wide range of presentations? 4
A
  1. Loss of normal femoral head-acetabular relationship/stability
  2. Caused by physiological and mechanical factors
    - Ligamentous laxity, hormonal and familial factors
    - Breech position and congenital deformities
  3. Wide range of presentations:
    - Hip that is reduced but is unstable and can be dislocated
    - Dislocation that can be reduced
    - Fixed dislocation that cannot be reduced
    - Bony deformities that require surgery
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3
Q

What are the tests for congenital hip dysplasia?
2

What if you have the lack of full abduction?

A
  1. Barlow test
    Hip reduced but can be dislocated
  2. Ortolani test
    Hip is dislocated but can be reduced

Lack of full abduction – hip is out and can’t be reduced

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4
Q

TREATMENT of DDH

  1. If hip can be reduced?
  2. If hip will not stay in?
  3. When should we confirm with ultrasound? 2
  4. IF it still wont stay in what do we need to do?
A
  1. If hip can be reduced, harness or pillow first 6 months of age
  2. reduce under anesthesia, hold with spica cast
    • Confirm reduction with ultrasound after 3 weeks
    • Femoral head not visible on x-ray for 4 – 6 months
  4. Still won’t stay in, will need surgery
    - Femoral and/or acetabular osteotomy

If femoral head can be held in normal relationship with socket

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5
Q

Most common hip abduction device?

Other devices

A

PAVLIK HARNESS**
FREJKA PILLOW
BOCH HARNESS

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6
Q

Legg-Calve-Perthes Disease

  1. Most common in what population?
  2. Loss of blood supply where?
  3. Symptoms? 3
A
  1. Males 3-11 years
  2. Loss of blood supply to femoral head
    –Head can collapse and subluxation of femoral head
    present
  3. Variable hip/knee Symptoms
    -Limping
    -pain
    -Limited internal rotation and abduction of hip
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7
Q

Legg-Calve-Perthes Disease
Treatment?
2

A
  1. REDUCE PRESSURE ON FEMORAL HEAD

2. CORRECT RESULTING DEFORMITY

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8
Q

How do we accomplish the following:

  1. REDUCE PRESSURE ON FEMORAL HEAD? 4
  2. CORRECT RESULTING DEFORMITY? 1
A
    • Relative rest
    • Braces, crutches
    • Traction
    • Adductor muscle release
  2. Femoral and/or acetabular osteotomy
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9
Q
  1. Definition of scoliosis?

2. Types? 4

A
  1. Definition: Lateral curvature of the spine >10˚ by Cobb method
  2. Types:
    - Idiopathic
    - Congenital
    - Secondary
    - Neuromuscular
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10
Q

Idiopathic Scoliosis
forms? 3

80-90% of this is found in what age group?

A
  1. Lumbar
  2. Thoracic
  3. Thoracolumbar

Adolescent (10 years- end of growth) 80-90%

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11
Q
  1. Definition of Adolescent Idiopathic Scoliosis?
  2. Typically what part of the spine?

Most common type

A
  1. Lateral curvature of spine with rotation in child >11 yrs. with no obvious cause
  2. Typically right thoracic curve
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12
Q

Adolescent Idiopathic Scoliosis
screening and investigations

When do you become concerned with scoliosis?

A
  1. Adam’s forward bend test
  2. Radiographic examination
  3. MRI

25 degrees

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13
Q 
Adolescent Idiopathic Scoliosis
screening and investigations
1. Adam’s forward bend test- what does it look like?
2. Radiographic examination- what kind?
3. MRI - Useful for what? 3
A
  1. Diving position
  2. AP & lat full length
    of spine while standing
  3. Useful if
    -neurological deficits,
    -neck stiffness or
    -headache
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14
Q
  1. What is kyphosis?
  2. Usually seen in what gender?
  3. How does it correct?
  4. What is Scheuermann’s disease?
  5. PP?
    - Usually seen in who?
    - How is it corrected?
A
  1. Increased thoracic curvature in the saggital plane -Postural
  2. Usually seen in girls
    • Gentler, more pliable curve
  3. Corrects with time/bracing
  4. Osteochondrosis of the spine
  5. Ring apophyses do not develop normally, resulting in wedged vertebra
    • Usually seen in boys
    • Sharper, more rigid curve
    • May need surgical correction
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15
Q

Gower’s Sign: indicates what?

A

weakness of the proximal muscles, namely those of the lower limbs. The sign describes a patient that has to use their hands and arms to “walk” up their own body from a squatting position due to lack of hip and thigh muscle strength.

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16
Q

Muscular Dystrophy
Diagnosis? 2

Treatment? 3

A
  1. Diagnosis:
    - Biopsy
    - Electromyography (EMG)
  2. Treatment:
    - PT/OT
    - Bracing
    - Surgery (Scoliosis)
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17
Q

Normal Musculoskeletal Variants

5

A
  1. Metatarsus Adductus
  2. Axial Rotation
  3. Idiopathic Toe Walking
  4. Pes Cavus (Flat Foot)
  5. Angular Variations
    - Genu Varus (Bow Legged)
    - Genu Valgus (Knock-knees)
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18
Q

Most common congenital

foot deformity

A

Metatarsus Adductus

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19
Q 
1. Metatarsus Adductus
is what?
2. More common in what gender?
3. Right or left?
4. Most likely cause?
5. treatment?
A
  1. Excessive amount of adduction of the metatarsals relative to the long axis of the foot
  2. Female>Male
  3. Left>Right
  4. Most likely cause: intrauterine restriction
  5. 85-90% resolve spontaneously by 1 yr. old
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20
Q

Metatarsus Adductus
management
3

A
  1. Flexible Metatarsus Adductus:
  2. Flexible MA beyond 8 mo old:
  3. Extreme adduction of great toe
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21
Q

Describe the following treatments for Metatarsus Adductus:
1. Flexible Metatarsus Adductus?

  1. Flexible MA beyond 8 mo old? 2
  2. Extreme adduction of great toe?
A
  1. stretching 5X at each diaper change
    • referral for biweekly casting
    • Correction usually achieved in 3-4 casts
  3. surgical release of abductor hallucis done between 6-18 months of age
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22
Q

Axial Rotation
Deescribe the three types of toe in rotation?
Describe the four types of toe out rotation?

A

Toe-in

  1. Internal Femoral Torsion (Too much hip anteversion)
  2. Internal Tibial Torsion (most common cause)
  3. Metatarsus Adductus

Toe-out

  1. External Femoral Torsion (Too much hip retroversion)
  2. External Rotation Contracture
  3. External Tibial Torsion
  4. Flat Foot
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23
Q

What do the following result from:

  1. Internal Femoral Torsion (Too much hip anteversion)?
  2. Internal Tibial Torsion (most common cause)?
  3. External Femoral Torsion (Too much hip retroversion)?
A
  1. –Results from “W” sitting
  2. –Results from intrauterine positioning
  3. –Results from intrauterine positioning
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24
Q

Treatment for axial rotation:

  1. Infant?
  2. Toddler? 3
  3. Surgery? 3
A
  1. Infant
    Good sleeping positions (back or side)
  2. Toddler
    - Good sitting habits (avoid sitting in positions with exaggerated lower limb deformation)
    - Nocturnal bar (Dennis Browne Bar) for internal tibial torsion present after 18 months.
    - Weekly corrective casting for 4-5 weeks if no better by age 4
  3. Surgery
    - Failure to correct spontaneously with growth
    - Gross asymmetric deformity
    - Symptomatic evolving congenital or neuromuscular conditions.
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25
Q
  1. Idiopathic toe walking
    May have what characteristics?
  2. Typically seen in what ages?
  3. Often associated with what?
A
  1. May have good ankle range of motion or more fixed contractures
  2. Typically seen in children less than 4 yrs old
  3. Often associated with subtle neurological abnormalities such as speech and language delay
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26
Q

Idiopathic toe walking
management
If contracture is present?
4

A
  1. PT/OT (Stretching, strengthening, and gait training)
  2. Orthotics (Night and day)
  3. Serial Casting
  4. Surgical Heel Cord (Achilles) lengthening (If patient fails conservative treatment and are >4-5 years old)
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27
Q

FLAT FOOT

3

A
  1. Immature foot – normal variant (most toddlers have flat feet)
  2. Low arch heel valgus
  3. Arch starts to form around age 4
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28
Q

Flat Foot
Management
2

A
  1. No need for formal treatment
  2. Can try a wedge
    Orthotics not necessary and are costly (especially in a growing child)
29
Q

Angular Variations
1. What are the types of GENU VARUM (bow legs)?
3

A
  1. Physiologic bowing - usually corrects by age 2
  2. Metabolic bowing – vitamin D deficiency (Rickets)
  3. Blount’s disease – damage to epiphysis- may need bracing or surgery
30
Q 
Angular variations
GENU VALGUM  (knock knees)
1. How are most corrected?
2. After age 11-13 what may you need to do?
A
  1. Most correct spontaneously
    - Braces and modified shoes not effective
  2. After age 11-13 may need surgery for marked deformity
31
Q

Common Pediatric Orthopedic Injuries

6

A
  1. Slipped Capital Femoral Epiphysis (SCFE)
  2. Radial Head Dislocation (Nursemaid Elbow)
  3. Common Pediatric Fractures
  4. Osteochondrosis
  5. Patellofemoral Arthralgia (PFA)
  6. Spondylolysis
32
Q

Slipped Capital Femoral Epiphysis

  1. Most common in what ages?
  2. Gender?
  3. Increased frequency with what?
  4. What will also increase in likelihood?
A
  1. Most common from 9 yrs-end of growth
  2. More prevalent in males
  3. Increased frequency with endocrine disorders; hypothyroid, renal disease, growth and sex hormone imbalance
  4. Obesity increases likelihood (places more stress across femoral epiphysis)
33
Q

Slipped Capital Femoral Epiphysis

  1. Symptoms of unstable?
  2. Symtpoms of stable?
  3. What kind of movement is restricted?
A
  1. Unstable: sudden, severe pain with limp
  2. Stable: limp with groin pain, variable medial knee and/or anterior thigh pain
  3. Restricted internal rotation, abduction, flexion
34
Q

Slipped Capital Femoral Epiphysis

Management

A

1, X-rays: AP, frog leg lateral
2. Mild slips: subtle changes on the frog leg view only
3 . Immediate Referral– surgical pin or screw placement

35
Q

Slipped Capital Femoral Epiphysis complications?

3

A
  1. Avascular Necrosis (AVN),
  2. Chondrolysis,
    3 Osteoarthritis
36
Q
  1. What is Radial Head Dislocation
    (Nursemaid’s Elbow)? 2
  2. How will the patient act with this?
  3. PE? Imaging?
A
  1. Subluxation or dislocation injury from sudden pull of child’s arm
    - Elbow becomes locked in slight flexion with forearm pronation
  2. Patient guards elbow and refuses to use arm
  3. May be swollen and tender with palpation of radial head.
    Xrays often normal
37
Q

Radial Head Dislocation
Treatment:
2

A
  1. Gentle supination of hand while flexing elbow with thumb placing gentle pressure over radial head.
  2. May use sling for a few days as needed for comfort.
38
Q

Pediatric Fractures

4

A 
1. Growth Plate (Epiphyseal) 
Fractures
2. Supracondylar Humerus Fracture
3. Wrist/Forearm Fractures
4. Clavicle Fractures
39
Q

Pediatric Fractures

  1. What do we need to remember about child bone fractures?
  2. How do they deal with amounts of displacement and plastic deformity.
A
  1. Kids have the ability to remodel bone.
    - -This ability diminishes with age and closure of growth plates
  2. Surprisingly well
40
Q

Growth Plate (Physeal) Fractures

  1. What percent of skeletal injuries involve the physis?
  2. What can this disrupt?
  3. Injury near but not at the physis can stimulate what?
A
  1. 20%
  2. bone growth
  3. bone to grow more
41
Q

Most common fracture around the elbow in children?

60 percent of elbow fractures

A

Supracondylar Humerus Fracture

42
Q

Occurs from a fall on an outstretched hand. What mechanical factors contribute to this?

May be associated with what other kind of fractures? 2

A
  1. Ligamentous laxity and
  2. hyperextension of the elbow are important mechanical factors

a distal radius or forearm fractures

43
Q

Supracondylar Humerus Fracture

  1. What kind of injury is high with these?
  2. Which one specifically?
A
  1. Nerve injury incidence is high, between 7 and 16 %
    - -Median, radial, and/or ulnar nerve
  2. Anterior interosseous nerve injury is most commonly injured nerve
44
Q

Supracondylar Humerus Fracture treatment?

2

A
  1. Long arm cast for stable/non-displaced fractures

2. Percutaneous fixation with K-wires for unstable fractures.

45
Q

Wrist/Forearm Fractures

3

A
  1. Torus (buckle) fractures
  2. Greenstick fractures
  3. Complete (transverse) fractures
46
Q

Greenstick fractures are disruption of what?

A

Disruption of only one cortex

47
Q

Torus fractures:

  1. reduction needed?
  2. After how long is it ok to cast at first visit?
  3. Otherwise?
  4. What kind of cast?
  5. Followup?
  6. How do we manage after cast removal?
A
  1. No reduction needed
  2. If > 48 hours old, ok to cast at first visit
  3. Otherwise splint and cast at 5-7 days
  4. Short arm cast for 4 weeks
  5. Repeat x-rays at weeks to show evidence of healing
  6. Splint an additional 2 weeks
    after cast removal
48
Q

Greenstick Fractures

  1. Short arm cast if what?
  2. If displaced >15 degrees? 3
A
  1. non-displaced
    • Reduce and immobilize in long arm splint
    • 4 weeks in cast after swelling improves
    • 2 weeks in splint after cast is removed

(so they cant supinate and pronate)

49
Q

Complete Fractures

  1. Non-displaced treatment?
  2. Displaced treatment?
  3. How does age relate to immobilization?
  4. If x-rays are normal initially but there is tenderness over growth plate? 3
A
  1. short arm cast for 3-6 weeks
  2. reduce ASAP and cast
  3. The older the child, the longer immobilization
  4. -Immobilize for 2 weeks
    -Bring child back in 2 weeks
    to re-examine and re-xray
    -If no callus, fracture is unlikely
50
Q

Distal Radius Fractures

  1. Peak injury time correlates with what?
  2. Why?
  3. Most injuries result from what?
  4. What do we need to check on PE?
  5. What two bones do we need to look at also?
A
  1. Peak injury time correlates with peak growth time
  2. Bone is more porous
  3. Most injuries result from FOOSH
  4. Check sensation: median and ulnar nerve
    - –Nerve injury more likely to occur with significant angulation of fragment or with significant swelling
  5. Examine elbow (supracondylar) and wrist (scaphoid)
51
Q

Whats the most common pediatric fracture?

  1. Where most commonly is the fracture?
  2. Stable injuries are treated with what?
A
  1. Clavicle fractures
  2. In children, 90% in the middle third
  3. Stable injuries, treat with sling or figure of 8 splint
52
Q
  1. Osteochondrosis (Apophyseal Injury) is what?
  2. Causes? 3
  3. Common Examples?
A
  1. Pain at tendonous insertions at secondary ossification centers (Apophyses)
  2. Causes:
    - Increase in activity level
    - Increase in mass
    - Puberty

Common Examples:

  • Osgood Schlatter (patellar tendon-tibial tuberosity)
  • Sever Disease (achilles-calcaneus)
53
Q

Osgood Schlatter: General features?

5

A
  1. Inflammation where patellar tendon inserts on tibia
  2. Leaves a lump – prominent, tender tibial tubercule
  3. Clinical diagnosis
  4. X-rays may show apophysitis
  5. Majority of the time, patients outgrow it (closure of physis)
54
Q

Osgood Schlatter: Treatment?

5

A
  1. Conservative (same as PFA)
  2. Eccentric strengthening
  3. Iontophoresis/Steroid
  4. Brace/Pressure Band
  5. Excision of detached/fragmented bone fragment
55
Q

Osteochondrosis
Treatment:
1. Conservative?
2. Surgical?

A
  1. Conservative
    Rest, NSAIDs, Ice, PT, -
    -Casting/Boot (Sever’s Disease)
  2. Surgical
    Indicated for avulsion of apophysis >1 cm
56
Q

PATELLO-FEMORAL ARTHRALGIA (PFA) is also called what?

A

AKA Chondromalacia Patellae – more common in girls, 4:1

57
Q
  1. PATELLO-FEMORAL ARTHRALGIA (PFA) means what?
  2. What is the PP?
  3. Where is the pain?
A
  1. Means sore kneecap - common, frustrating but not serious
  2. Inflammation of articular surface of the patella
  3. Vague, diffuse anterior discomfort
58
Q
  1. PATELLO-FEMORAL ARTHRALGIA (PFA) Clinical Diagnosis – is an injury of what?
  2. Pain where? 3
  3. Other features? 4
A
  1. overuse more than acute injury
    • Anterior knee discomfort,
    • pain with stairs,
    • can’t sit with bent knee
    • Increased Q angle,
    • tender undersurface of the patella
    • Tight hamstrings,
    • weak quadriceps
59
Q

PFA-TREATMENT

  1. Responds to good management? 3
  2. Conservative? 4
  3. Surgical- rarely needed?
A

Responds to good management

  1. Exercise programs
  2. Setting realistic goals (be patient)
  3. May need to involve parents

Conservative

  1. Relative Rest
  2. Physical therapy (Quadriceps strengthening)
  3. Ice and NSAID’s
  4. Patellar stabilization brace (If associated instability)

Surgical – rarely indicated
1. Where underlying anatomy is abnormal may need lateral release and/or tibial tubercule osteotomy

60
Q 
1. SPONDYLOLYSIS
 is what?
2. Caused by?
3. How does pain progress?
4. May progress to what?
5. Dx? 3
6. Rx? 3
A
  1. Stress fracture of pars
  2. Repetitive hyperextension of back
    - -Gymnastics, football, wrestling, rowing
  3. Progressive low back pain with activity
  4. May progress to slip (spondylolisthesis)
  5. Dx:
    - X-ray,
    - CT, or
    - bone scan
  6. Rx:
    - rest,
    - brace
    - rare cases, fusion
61
Q
  1. What is Acute septic arthritis?
  2. Has close association with what in kids?
  3. Most common joint? 2
  4. Most common organism?
A
  1. Pyogenic bacteria invade a synovial joint
  2. Pediatric incidence has close association with osteomyelitis
  3. Most common joint: hip and elbow
  4. Most common organism: Staph Aureus

Emergency

62
Q

Acute septic arthritis
infants
Manfests how?
7

A
    • May develop with few clinical manifestations
    • Tenderness
    • Increased warmth over joint in question
    • “pseudoparalysis”
    • Painful restriction
    • Fever and WBC misleadingly slight
    • Purulent exudate particularly Staph
63
Q

Acute septic arthritis
older children
6

A
  1. Severe pain
    - Pain with passive motion.
  2. Protective muscle spasm
  3. Marked tenderness
  4. Fever
  5. Elevated WBC
  6. Elevated ESR/CRP
64
Q

Acute septic arthritis
Evaluation
4

A
  1. C&S blood, urine
  2. X-ray
  3. Ultrasound
  4. Immediate needle aspiration
65
Q
  1. For acute spetic arthritis what would we use the US for?
  2. Immediate needle aspiration
    4
  3. Often cause by what?
  4. Joint fluid will be what color?
A
  1. –Very useful for guiding injection (especially in the hip joints)
    Immediate needle aspiration
    • Inspection of aspirate (cloudy)
    • Culture & Sensitivity
    • Gram stain
    • Crystals
  3. Often caused by hematogenous spread.
  4. Joint fluid is usually clear with a yellow tint.
66
Q

Acute septic arthritis
Management?

2

A
  1. Refer Immediately for surgical washout (I&D)

2. Empiric IV Abx.

67
Q

Acute septic arthritis medical therapy?

2

A
  1. 3RD generation cephalosporin and penicillinase resistant synthetic penicillin
  2. MRSA should be covered with either clindamycin or vancomycin.
68
Q
  1. What is an Open Fractures

2. Management?

A
  1. Fracture with overlying skin compromise
    - -May be subtle
  2. Requires IMMEDIATE REFERRAL to orthopedics
    - -Must be washed out within 24 hours.

Pediatrics (18 decks)

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