Module 4 - ortho Flashcards
Proximal humeral epiphysiolysis
“Little League Shoulder”
Shoulder pain-gradual onset; pain increase with throwing, especially curve ball
modify activity; gradual restart, but limit intensity and frequency of throwing with retraining and muscle strengthening
seen in skeletal immature children; radiographs show widening
Varus overload of the elbow “Little League Elbow”
elbow pain with activity; locking and decrease extension of elbow; medial humeral epicondyle tenderness
rest; NSAIDS; ice; when pain-free, gradual return to activity with retraining; surgery if elbow instability
leads to osteochondral lesions and stress fractures if severe; radiographs reveal widening proximal physis; also seen in gymnasts
DDH - infant
The Barlow and Ortolani tests are used to screen for DDH in neonates; once they reach the 2nd and 3rd months of life, the soft tissue tightens and these tests become less reliable.
Ultrasound should only be obtained if there is a high index of suspicion of dysplasia based on a positive clinical examination
60%-80% of abnormal hips of newborns identified by physical exam resolve by 2-8 weeks; close observation is recommended
DDH - infants (6-18mo)
Klisic and Galeazzi tests are used to screen older infants.
Limited abduction of the affected hip and shortening of the thigh is a reliable sign; normal abduction with comfort is 70-80 degrees bilaterally; limited abduction includes those cases with less than 60 degrees of abduction or unequal abduction from one side to the other
Other findings include asymmetry of inguinal or gluteal folds and unequal leg lengths, shorter on the affected side.
DDH - not diagnosed or not treated
short leg with toe walking on the affected side
positive trendelenburg sign
marked lordosis or toe walking
painless limping or waddling gait with child leaning to the affected side
if hips are dislocated bilaterally, asymmetries are not observed; limited abduction is the primary indicator in the situation. Also, in subluxation of the hip, limited abduction again is the primary indicator; waddling gait may also be noted
DDH - diagnostics
ultrasound is superior to radiographs for evaluating cartilaginous structures and is recommended for infants after 4 weeks of age; prior to 4 weeks, high incidence of false-positives; used to assess the relationship of the femur to the acetabular development and stability of the hip
radiologic evaluation of the newborn to detect and evaluate DDH is recommended once the proximal epiphysis ossifies, usually by 4-6 months; prior to this, radiography is unreliable’ AP and lateral Lauenstein (frog-leg) position radiographs of the pelvis is indicated.
DDH - management
treatment of choice for subluxation and reducible dislocations identified in the early phase is a Pavlick harness; success rate is between 80%-90%; radiographs or ultrasound documentation can be used during treatment to verify the position of the hip; if not responding to treatment , surgical treatment may be needed. Harness is worn 24 hours a day, except for bathing, and worn full time for 3-6 weeks and then may be required only during waking hours for decreasing periods of time.
6-18 month-old infants with a dislocated hip is likely to require either closed manipulation or open reduction; preoperative traction, adductor tenotomy, and gentle reduction are especially helpful in preventing osteonecrosis of the femoral head; after closed or open reduction, a hip spica cast is applied in order to maintain the hip in more than 90 degrees flexion and avoid excessive internal or external rotation
annual or biennial follow-up including radiographs to the point of skeletal maturity is recommended to evaluate for the possibility of late asymmetric epiphyseal closure
Clavicular fracture - manifestations
Difficult delivery, high birth weight, forceps delivery, shoulder dystocia.
Older kids typically fall on an outstretched hand, or other trauma
Pain with shoulder movement
Decreased arm movement, absent moro reflex
Swelling, bony abnormality, discoloration, and/or crepitus elicited over fx site
Bony callus palpable ~10 days after injury, painless firm lump
Spasm of sternocleidomastoid muscle on affected side
Associated erb palsy
Clavicular Fx - Mangement (Neonate)
Incomplete fractures that don’t cause pain need no treatment
Immobilization of the shoulder is an option when movement results in pain (usually with a complete fracture).
Pin the sleeve of the infants arm to the front of the shirt for 1-2 weeks
Clavicular Fx - Management (older child)
Sling immobilization for comfort, 3-4 weeks
A figure-eight clavicular brace can be used if displacement results in decreased shaft length. Effectiveness is questionable.
Union requires about 4 weeks of healing; protect for 4-5 weeks.
NSAIDs or other analgesics for pain
Surgical intervention is uncommon, may be needed in:
open fractures, neurovascular compromise, multiple trauma, ribcage fractures, and greater than 100% displacement with severe skin tenting.
Return to noncontact sports in 4-6 weeks, contact sports in 8-12 weeks.
Costochondritis - definition
Inflammatory process of costochondral cartilage, causing localized tenderness and pain in anterior chest wall.
Most cases are idiopathic but can be caused by trauma like lifting heavy objects or coughing
Costochondritis - manifestations
Acute or gradual onset; typically insidious, occurring over several days or weeks
Sharp, darting, or dull; tenderness on palpation (Tietze syndrome)
Radiation from chest to upper abdomen or back
Tightness r/t muscle spasm
Exacerbated by coughing, sneezing, deep inspiration, movement of upper torso and upper extremities
Costochondritis - Diagnosis
History and physical findings are diagnostic
Chest radiography can help rule out other causes
CT scan will show swelling of costal cartilage
Constochondritis - management
NSAIDs and other mild analgesics
Avoid strenuous activity
Cough suppressants if cough is an aggravating factor
Stretching exercise and ice to area
Benign, self-limited and not related to cardiac disease
