Module 4 - trauma

Question 1

Salter-Harris Type 1

Answer 1

Fracture through the zone of hypertrophic cell of the physis with no fracture of the surrounding bone

Question 2

Salter-Harris Type II

Answer 2

The most common type of growth plate fracture. Metaphyseal fragment is present on the compression side of the fracture.

Question 3

Salter-Harris Type III

Answer 3

Involves physeal separation with fracture through the epiphysis into the joint

Question 4

Salter-Harris Type IV

Answer 4

Fracture involves the metaphysis, physis, and epiphysis

Question 5

Salter-Harris Type V

Answer 5

Rare fracture. Involves a compression or crushing injury to the physis

Question 6

Pes Planus - history

Answer 6

• normal for neonates and toddlers due to fat pad in arch; resolves by 3 years old
  - flexible flat feet into adolescence usually associated with familial ligamentous laxity
  - painless, asymptomatic, noticed with weight bearing
  - abnormal wear on the inner sole of shoes

Question 7

Pes Planus - clinical manifestations

Answer 7

• normal longitudinal arch in a non-weight bearing position but disappears when standing
  - hindfoot goes into valgus, midfoot sags upon standing
  - ligamentous laxity is common, ROM is normal

Question 8

Pes Planus - managment

Answer 8

• refer to podiatrist if have symptomatic feet and rigid flatfoot
  - “Superfeet”, a removable arch may be recommended for painful, flexible flat foot
  - passive stretching for tight achilles tendon
  - arch supports relieve pain but do not “grow” an arch

Question 9

Metatarsus Adductus - Hisotry

Answer 9

• forefoot is supinated and adducted most commonly caused by intrauterine molding
• 50% cases are bilateral
• becomes more serious if foot becomes non-flexible with heel valgus
• may be familial

Question 10

Metatarsus Adductus - PE

Answer 10

• forefoot adducted with normal midfoot and hindfoot
• lateral side of foot is convex, prominent 5th metatarsal base, occasional spreading of toes with widened space between first and second toe
• forefoot has an increased >15 angle OR resists stretching; (should be able to draw a line from middle of heel and normally would pass between the second and third toes); abnormal MA angle photo to left
• Flexible vs. Rigid MA: flexible can be adducted while grasping the heel with one hand and adducting the forefoot with the other hand past midline
• conduct careful hip examination to r/o developmental dysplasia of hips

Question 11

Metatarsus Adductus - DX

Answer 11

X-rays not routinely performed unless toddlers or children reveal residual deformities, then AP and lateral weight bearing radiographs are indicated

Question 12

Metatarsus Adductus - management

Answer 12

based on rigidity
-flexible MA: foot can be stretched by parents with each diaper change by holding the hindfoot and stretch the midfoot to over correct the deformity; repeat 5 times for 5 seconds with blanching of the soft tissue
-overcorrected splint or reverse shoe for feet corrected to neutral position for 4-6 weeks
-may need serial plaster casts if no improvement with stretching exercises or correcting shoes
-surgery at 4-6 years of age if conservative treatment is unsuccessful
(on the practice quiz) To determine whether the foot is flexible or rigid, the heel isd grasped with one hand while the forefoot is abducted with the other.

Question 13

Talipes equinovarus congenita (clubfoot) - history

Answer 13

• foot cannot be manually corrected to neutral position with heel down at birth
• idiopathic, hereditary, neurogenic, associated with syndromes
• 50% cases bilateral, most common in males

Question 14

Clubfoot - PE

Answer 14

• inflexibility of sole of foot; forefoot convex with forefoot adduction
• three elements: 1)ankle is in equinus (pointed toe position), 2)inverted sole due to hindfoot varus or inversion deformity of heel, 3)forefoot has MA angle
• 90 degree rotation of forefoot

Question 15

Clubfoot - Dx

Answer 15

• AP/lateral radiographs recommended with foot being held at maximal corrected position
• ”parallelism” between lines drawn through axis of talus and calcaneus on lateral x-ray= hindfoot varus
• NOT required in infants to diagnosis anomaly

Question 16

Clubfoot - Management

Answer 16

• diagnosis, refer to orthopedist (usually shortly after birth); joints are most flexible in the first hours and days of life
• taping and strapping, manipulation, and serial casting
• ”Ponseti method” involves weekly cast changes 5-10 times
• 90% require percutaneous tenotomy of heel cord followed by long leg cast with oot in maximal abduction and dorsiflexion→ full-time 3 month bracing program→ nightly bracing for 3-5 years
• older children left untreated require osteotomies and soft tissue surgery may be required
• longterm stiffness is a concern but pain is uncommon
• symptoms may appear during adulthood

Question 17

Genu Varum & Genu Valgum distinguishing normal from abnormal.

Answer 17

If the varus angle is greater than 15 degrees in infants, does not begin to decrease in the second year, is asymmetric, is associated with short stature, or is rapidly progressing, the condition is considered pathologic - refer to a pediatric orthopedic specialist

Question 18

Legg-Calve-Perthes Disease - definition

Answer 18

The basic underlying cause is insufficient blood supply to femoral head, articular cartilage hypertrophies, epiphyseal marrow becomes necrotic. Area revascularizes, new bone. Can take 18 to 24 months, subchondral area can fracture. Affects children 4 to 8 years old

Question 19

Legg-Calve-Perthes Disease - presentation

Answer 19

Can be an acute or chronic onset with or without a hx of trauma to hip

• The most common presenting sign is an intermittent limp (abductor lurch), especially after exertion, with mild or intermittent pain.
• The most frequent complaint is persistent pain in the groin, anterior hip region, or laterally around the greater trochanter. Antalgic gait with limited hip movement
• Pain may be referred to the medial aspect of the ipsilateral knee or to the anterior thigh
• Limited range of motion
• trendelenburg gait resulting from pain in the gluteus medius
• muscle spasm
• atrophy of gluteus, quadriceps, and hamstring
• decreased abduction, internal rotation, and extension of the hip
• pain on rolling the leg internally

Question 20

Legg-Calve-Perthes Disease - management

Answer 20

Referral to an orthopedist,
In females, tends to be more serious; bed rest, traction, then PT; bracing and surgery may be needed; bilateral involvement does occur
(on practice quiz)
Routine AP pelvis and frog-leg lateral views are used to confirm the diagnosis, stage the disease, and follow disease progression and response to treatment. Radiographic findings can include smaller epiphyses, increased epiphyseal density, a subchondral fracture line, lateralization of the femoral head, and other features. Changes in the epiphyseal margin are discernable

Question 21

Transient Synovitis of the Hip - presentation/management

Answer 21

Limited hip motion with complaint of pain. Often febrile and history or recent URI. Occurs in children 3 to 8 year old range
- Affects 3-8 years of age
- Pain
- Mild to moderate fever, mild irritability; resolves within 1 week
- Limited hip motion; ESR <25 mm/h
- Inflammatory reaction; unknown etiology; often URI (50%) prior
(on practice quiz) Anteroposterior and frog-leg radiographs of the hip are usually normal.
Management - rest

Question 22

Osgood-Schlatter Disease

Answer 22

Caused by microtrauma in the deep fibers of the patellar tendon at its insertion on the tibial tuberosity. Usually seen in the adolescent years after a rapid growth spurt.
The diagnosis is usually based on history and physical examination. The quadriceps femoris muscles insert on a relatively small area of the tibial tuberosity. Naturally high tension exists at the insertion site. In children, additional stress is placed on the cartilaginous site as a result of vigorous physical activity, leading to traumatic changes at insertion. It occurs more frequently in boys than girls, with a male-to-female ratio of 3:1

Question 23

Slipped Capital Femoral Epiphysis (SCAFE)

Answer 23

A Salter-Harris type I fracture through the proximal femoral physis. Stress around the hip causes a shear force to be applied at the growth plate. Although trauma may play a role in the fracture, there is an intrinsic weakness in the physeal cartilage. The fracture occurs at the hypertrophic zone of the physeal cartilage. Stress on the hip causes the epiphysis to displace posteriorly and inferiorly to the metaphysis. Because the blood supply to the epiphysis crosses the weakened area, the epiphysis is at risk for avascular necrosis.Limited abduction and extension. Limping and pain in the groin or diffusely over the knee or anterior thigh. Typically occurs just after the onset of puberty in overweight boys.

Question 24

SCAFE - Dx

Answer 24

AP pelvis, frog-leg lateral, and true lateral views of the pelvis are obtained. Radiographic findings include flattening of the epiphyseal prominence, widening or irregularity of the growth plate, and narrowing of the area if the epiphysis has slipped posteriorly (Fig 43.11). Radiographically, the slippage is measured using the Southwick method and can be classified as mild (<33% slippage of the epiphysis or less than a 30-degree slip angle), moderate (30% to 50% slippage of the epiphysis or 30- to 50-degree slip angle), or severe (>50% slippage of the epiphysis or >50-degree slip angle).

Question 25

Galeazzi Maneuver

Answer 25

ignals conditions that cause leg length discrepancies. Includes flexing the hips and knees while the infant or child lies supine, placing the soles of the feet on the table near the buttocks, and then looking at the knee heights for equality. Positive if knee heights are unequal.
Not reliable in children with dislocatable but not dislocated hips or in children with bilateral dislocation

Question 26

Hip abduction test - abnormal

Answer 26

Supine child with hips flexed 90 degrees and fully abducted. Suspect hip disease in any patient who lacks more than 35 to 45 degrees of abduction.

Question 27

Trendelenburg Sign

Answer 27

Used to identify conditions that cause weakness of the hip abductors
Have child stand and raise one leg off the ground
Normally muscles around a stable hip are strong enough to maintain a level pelvis if one is raised
Positive test = pelvis (iliac crest) drops on the side of the raised leg = weak hip abductor muscles on the side that is bearing the weight
May or may not be painful as it involves muscle weakness around the hip joint
Bilateral dislocated hips = wide-based trendelenburg limp is noted

Question 28

Burns - superficial

Answer 28

Scarring is unlikely, with healing expected in 3 to 7 days.

Question 29

Burns -Superficial partial-thickness

Answer 29

This type of burn usually heals without scarring in 7 to 14 days.

Question 30

Burns - deep partial thickness

Answer 30

It may take up to 3 weeks to heal with scarring likely.

Question 31

Burns - full thickness

Answer 31

Surgical intervention and skin grafting are usually required.

Question 32

Contusions - indicator to refer

Answer 32

hildren with contusions that restrict movement or sensation and those affecting the quadriceps muscle may include compartment syndrome. These children should be referred to orthopedic specialists immediately so that the compartment pressure does not result in irreplaceable damage.

Question 33

Lacerations - management

Answer 33

Decision to close → “golden period” to close within 6 hours, but low risk for infection can be closed with 12-24h

Question 34

lacerations - sutures

Answer 34

good for uncomplicated lacs to truck, scalp, arms and legs

Question 35

lacerations - staples

Answer 35

scalp, trunk and extremities (NOT hands or feet), closes faster and less risk of infection but not as cosmetically appealing

Question 36

lacerations - steri strips

Answer 36

superficial wounds

Question 37

lacerations - adhesive

Answer 37

simple lacs, clean edges, applied on TOP of skin while edges approximated. Don’t use over a joint, sloughs off in 7-10 days (on practice quiz) hold wound edges together and apply on top of skin

Question 38

abrasions - management

Answer 38

Cleansing the wound by scrubbing with soap or an antibacterial cleanser using a wet gauze or soft surgical nail brush. Povidone-iodine, alcohol, & hydrogen peroxide should NOT be used on open wounds. A secondary infection could occur if not properly cleaned.
(on the practice quiz) irrigate gently with normal saline
Small abrasions can be left open to air or may require a small bandage. Larger abrasions heal quicker if kept moist
Cover large abrasions and abrasions of the hands, feet, and areas overlying joints with a sterile non adherent dressing. Antibiotic ointment may be applied especially to elbows or knees to prevent cracking or reopening of woundInstruct the caregiver to wash the abrasion at least every day and reapply the dressing and antibiotic ointments until a protective dry scab forms.
Provide instructions regarding s/sx of infection
Tetanus prophylaxis should be administered if the wound is significant or if the child has not received a tetanus immunization in the past 5 years.