MSK Flashcards
What is developmental dysplasia of the hip (DDH)?
A spectrum of conditions related to the development of the hip in infants and young children.
Spectrum includes abnormalities of stability (dislocation, dislocatability and subluxation/subluxability) and abnormalities of the shape of the femoral head and acetabulum (dyspasia)
What causes DDH?
Ligamentous laxity predisposes the developing hip to mechanical forces that cause eccentric contact between the femoral head and the acetabulum
Abnormal contact results in abnormal development of the acetabulum and femoral head
What are risk factors for developmental dysplasia of the hip?
Female sex, breech position in third trimester, positive family history, swaddling with the hips in extension and abduction. (Although most patients with DDH have no risk factors aside from female sex according to UTD)
Females affected 7X more than males – due to estrogen-induced ligamentous laxity in utero
60% of patients with DDH are firstborn
Higher risk if postmature
During what age range is it important to assess the hips for DDH?
Hip examination should occur soon after birth and at every health supervision visit until approximately 9 months old and/or until the child is walking independently
*Especially important at 2 and 4 week visits
There are two maneuvers that are used for the hip assessment in the neonate? What are their names? Describe them.
Ortolani maneuver – use abduction and elevation to feel for reducibility
Barlow maneuver – use gentle adduction without downward pressure to feel for dislocatability
The sensation of reducibility or dislocatability is distinct and is felt as a jerk or a clunk
What are other findings that may be present with DDH?
Asymmetry of femur length, skin folds or gait (apparent shortening of the femur is called Galeazzi sign)
Decreased hip abduction
(these findings are less specific than the Ortolani and Barlow)
T/F: Bilateral DDH occurs in up to 10% of cases
False: Bilateral DDH occurs in 20-37% of cases.
How is the diagnosis of DDH made? Is imagining required?
The diagnosis can be made based on physical exam findings of hip instability, asymmetry (in unilateral cases) and/or limited hip abduction
Imaging can be useful if diagnosis is uncertain – usually US if in first 4 months of life
UTD recommends referral to orthopedic surgeon experienced in this diagnosis
How does the physical assessment vary between a neonate and an older child?
Infants <3 months – look for hip instability using the Ortolani and Barlow maneuvers
Infants >3 months – instability less helpful b/c the hip stabilized in the abnormal position. Look for limited abduction, apparent thigh-length discrepancy (if unilateral) and the Galeazzi (when laying down with knees bent and feet on table, one knee appears lower)
In walking children – may have a positive Trendelenburg pelvic tilt (when standing on one leg, pelvis turns down toward unaffected side) and a Trendelenburg lurch when walking
US is recommended for asymptomatic infants at 4-6 weeks age with normal physical exam if they have which risk factors?
Breech positioning at 34 weeks gestation or later
Family history of DDH
History of clinical instability on examination
Hip instability in the neonate occurs in 11.5-17% of live births. How often does this persist and lead to DDH?
Most hip instability stabilized soon after birth
60% of cases resolve by 1 week of age, 90% resolve by 2 months of age
What are the long-term effects of untreated dislocation and/or dysplasia?
Functional disability, pain and early osteoarthritis
What is the Graf score?
A classification system of the severity of the hip pathology
What is the goal of DDH treatment?
Obtain and maintain concentric reduction of the hip to provide the optimal environment for the development of the femoral head and acetabulum and reduce risk for early osteoarthritis
What does treatment for DDH consist of?
Age < 6 months: Abduction splints – Pavlik harness
(with hip dislocation or persistently dislocatable/subluxatable hips or acetabular dysplasia without dislocation (Graf type IIa or worse))
Age 6 months +: reduction under anesthesia (closed or open)
T/F: the pavlik harness treatment has a success rate of 95%
True – Pavlik harness achieves and maintains hip reduction in 95% of infants
T/F: long term follow-up is required for DDH
True – children who have been treated for DDH should be monitored with regular hip xrays until they reach skeletal maturity to evaluate hip development and complications
Where is the scaphoid bone?
The scaphoid bone is one of the carpal bones – on the thumb side of the wrist, just below the radius.
Kids of what age are able to use a numeric rating scale for pain?
8+
What is “total pain”
conceives of pain as having 4 interrelated domains: physical, psychological, social, and spiritual.
The WHO has a 2 step strategy for pain management in pediatrics. What are the STEP 1 medications for mild pain?
acetaminophen and ibuprofen
Oral if can…
In certain cases, intravenous acetaminophen or ketorolac tromethamine may be used. Adjuvants may be
added if appropriate. Acetaminophen can be given orally or rectally.
Compounded ibuprofen can be given rectally.
A child who is anxious and in pain may benefit from an adjuvant medication such as….
Benzos or haldol
A lidocaine patch may be helpful for what kind of pain in kids?
Somatic pain
What meds do we use for neuropathic pain in peds?
gabapentin or pregabalin (as per Berkowitz)
Up to date adds:
●Antidepressants (eg, SNRI, TCAs)
●Anticonvulsants (gabapentin, carbamazepine)
Step 2 in the WHO pediatric analgesic ladder involves addition of opioids for moderate to severe pain.
Are “weak opioids” such as tramadol and codeine recommended in kids?
No longer recommended.
- codeine may be a weaker analgesic than a standard dose of many NSAIDs
- has a ceiling effect
- oral bioavailability of codeine
is widely unpredictable, at 15% to 80% - codeine
is a prodrug that must be metabolized by the liver into morphine (which is highly variable in kids)
“We suggest avoiding codeine and tramadol in children <12 years because of variability in metabolism that can alter the level of active drug the child is exposed to, resulting in fatal overdoses in extreme cases”
So what opioids ARE recommended in step 2?
morphine, hydromorphone,
and oxycodone are recommended initial choices (according to Berkowitz)
UTD also states that moderate to severe pain is treated with opioids, in combo with nonopioids
How to calculate breakthrough doses of opioids?
To calculate the
as-needed dose for breakthrough pain, a general rule is that the
as-needed dose is 10% to 15% of the 24-hour total opioid dose or its
equivalent, given orally every 3 to 4 hours.
Here are some handy general pain management principles for peds according to UTD:
- Assess regularly, use self-reports of pain whenever possible.
- assess interference with daily activities (especially with chronic pain)
- include both pharm and nonpharm
- Use oral when possible to avoid painful routes of administration
- anticipate and treat side effects
- consider adjuvants
Little Suzie sprained her ankle. She’s 10 years old. Aspirin is safe to give as first line therapy…
T or F?
False! Risk of Reye’s syndrome in kids under 16
What is Reye’s syndrome?
rare but serious condition that causes swelling in the liver and brain. Reye’s syndrome can occur at any age but usually affects children and teenagers after a viral infection, most commonly the flu or chickenpox
The symptoms of Reye’s Syndrome are:
Vomiting (throwing up)
Convulsions (seizures)
Sleepiness
The most commonly used NSAID in children is?
Ibuprofen
Key safety measure you need to inform parents of when you prescribe opioids?
Lock them up to prevent accidental overdose
When opioids are changed, the dose of the calculated equivalent analgesic dose of the new drug should be lowered by ___ to ____% and increased as needed.
25-50%
This avoids overmedication, which occurs due to differences in the structure of the different opioids and their affinity for the opiate receptors
In any situation where truama is the precipitating factor (such as a fall), you must ensure you do a _____ exam to rule out potential for head injury.
Neuro
T/F Children commonly present with back pain
False
Most children do not commonly complain of severe back pain unless there has been an acute injury. Most instances are brief with non-specific findings
back pain in children under the age of ___ years old warrants immediate attention! (according to the class notes on BS)
4
Spinal anomalies? I know not…
Inadequate pain control in peds can lead to…
decreased effectiveness of analgesia later in life.
So treat pain effectively!
What are some potentially harmful physiologic effects in unmanaged pain?
Tachycardia, hypertension, increased oxygen demand/respiratory rate
Increased cortisol, adrenaline and glucagon levels
Decreased gastric and gut motility
Muscle tension, spasm, fatigue, cramping
Anxiety, fear of hospitals and medical care
T/F it’s better to use only one drug with pain management to prevent side effects
F - Combined analgesia is more effective than a single modality. This term is called “balanced analgesia” which included drugs from more than one drug class, and may be given by different routes of administration. The goal is to reduce opioid requirements and sustain minimal side effects
Which opioid has the strongest safety profile in peds?
Morphine (but further research is needed…)
Scaphoid fracture is often overlooked/misdiagnosed as..
A sprained wrist
Another name for the scaphoid is..
The hand navicular
T/F: Scaphoid fractures are the most common carpal fractures.
True
Which age group are scaphoid fractures most common in?
Age 15-30. Rare in children under 10.
Wrist injuries are common in children, why? What is usually the cause?
Skeletally immature – growing bones are more susceptible to stress than the surrounding ligaments and joint capsules
Usually caused by sports, UTD lists rugby, lacrosse and field hockey. Brenda specifically mentioned basketball (in class apparently?)
T/F: Carpal fractures account for 6% of all fractures in athletes
True – and they are likely underdiagnosed
How does a scaphoid/navicular fracture present?
Pain along radial aspect of wrist after falling on an outstretched hand
Tenderness of the anatomic snuffbox
Decreased ROM in flexion and extension
Pain with radial deviation or extension of the wrist
Positive scaphoid compression test
What the heck is a scaphoid compression test?
Performed by holding the thumb and gradually pushing in toward the scaphoid along the longitudinal axis of the thumb metacarpal – pain over the palmar scaphoid tubercle = positive
How do you diagnose a scaphoid fracture?
X-rays – best visualized with AP scaphoid view with 30 degrees of ulnar deviation
T/F: A normal wrist x-ray series rules out a scaphoid fracture
FALSE. It may not be evident on x-ray, even with correct ulnar deviation view. If clinical findings suggest fracture and x-ray is normal, splint and repeat x-ray in 10-14 days.
Bone scan or MRI can be used if needing to confirm/exclude the diagnosis sooner (ex. Elite athlete)
Treatment for scaphoid fracture
Depends on the severity
If non-displaced, can be treated with spica cast. Duration depending on specific location of fracture. Three months or more may be required.
What percentage of scaphoid fractures heal with immobilization?
90%
What are indications for surgical referral for a scaphoid fracture?
Proximal pole (proximal fifth of scaphoid)
Fracture displaced > 1mm
Delayed presentation of acute fractures (>3 weeks)
Scapholunate rupture
Carpal instability (lunate tilt on x-ray)
What is the aftercare once the fracture is healed on radiograph?
Athletes must continue to wear a protective rigid splint for 2 months
