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ED fellowship paeds > MSK > Flashcards

MSK Flashcards

1
Q

Discuss clavicle fractures

A

Frequently broken in children
Mid shaft account for 85% of all breaks.
Complications are rare but due to proximity to the great vessels and brachial plexus a thourough neurovascular exam should be performed. Posterior sternocalvicular displacement can cause damage to the trachea, oesophagus and subcliavian vessels.

Do not require reduction.
Ortho consult for open fractures, associated neurovascular compromise or for fractures assoicated with more than 100% displacement of the fracture fragment with skin tenting.
Distal fractures displaced more than 2 cm or comminuted should be referred to ortho

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2
Q

Discuss salter harris fracture classification

A

Type 1 Slipped, fracture plane passes all the way through the growth plate not involving bone, does not occur if the plate is fused
-good prognosis

Type 2 above
-most common 75%
fracture passes across the growth plate and up through the metaphysis
-good prognosis

type 3 lower

  • 7-10%
  • fracture plane passes some distance along the growth plate and down through the epiphysis
  • poor prognosis as the proliferative and reserve zones are interrupted

type 4 through
10%
fracture plane passes directly through the metaphysis, growth plate and down though the epiphysis
-poor prognosis as the proliferative and reserve zones are interuppted

type 5 - rammed or ruined
uncommon <1%
crushing type injury does not displace the plate but damages it by direct compression
worst prognosis

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3
Q

Discuss supracondylar fractures

A

Most common elbow fracture in children younger than 8 until this age the tensile strength of the ligaments and joint capsule is greater than the bone itself.

Classified by mechanism extension and flexion. Extension type account for 95% of injury – distal fragments are displaced posteriorly

Flexion type distal injury is displaced anteriorly

Neurovascular exam should be prompted if suspected due to the risk of compartment syndrome. Unrecognized vascular compromise can lead to Volkmann’s ischemic contracture
Neurovascular compromise complicated 11.3% of displaced supracondylar fractures - the AIN branc of the median and the radil nerve are at risk

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4
Q

Discuss Gartland classification

A

Type 1 non displaced
-treated with immobilisation and repeat xr in aa week

Type 2 displaced with posterior cortex intact
- CRPP

Type 3: Displaced often in 2-3 planes - nil cortical contact

  • CRPP
  • further classified into A (posteromedial rotation) and B (posterolateral rotation)
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5
Q

Discuss x-ray finding in supracondyular fracture

A

1) anterior humeral line should intersect the medial 3rd of the capitellum
3) Baumans angle - formed by a line drwan parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis
- normal angle is 70-75 degress, deviation of >5-10 degress indicats coronal plane deformity
- difficult to use under three years of age
4) fat pads
- anterior fat pad is normal unless bulging or in the shape of a ships sail
- posterior fat pad should never be seen

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6
Q

Discuss ossification centers of the elbow

A

Critoe
Capitellum - 1 year ossification, 12 year fusion
Radial head- 4 years ossification, 15 years fusion
Medial epicondyle- 6 years ossification, 17 years fusion
Trochlea- 8 years ossification - 12 years fusion
Olecranon - 10 years ossification - 15 years fusion
Lateral epicondyle 12 years ossification 15 years fusion

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7
Q

Discuss pulled elbow

A

Radial head subluxation is common
Typically occurs when axial traction is placed on an extended and pronated arm as when a child is swung or pulled by the arms

Occurs in children from a few months old to 5 years years peaks between 2-3 years

Children present with acute onset of pain to the arm - affected arm is typuically held against the body with the elbow slightly flexed and the arm pronated

Clinical diagnosis and radiography is not needed unless suspicion of greater underlying injury

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8
Q

Discuss reduction of pulled elbow

A

Flexion supination technique
- affected elbow is gripped with the emergency clinicians thumb over the radial head, the clinician then flexes and supinates the patients arm. As the radial head relocates the clinician feels a click

Hyperpronation technique

  • childs affected elbow is held with the emrgency clinicaicns thumb over the radial head and the forearm is hyperpronated
  • pronation is typically less painful and is the technique of choice
  • sucess rates are 85% for supination and 95% for pronation
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9
Q

Discuss toddlers fracture

A

Oblique nondisplaced fractures of the distal tibia caused by low engery torsional forces applied to the porous bone of infants

Peak incidence is between 9 and 36 months can occur as old as 6 years

Mechanism can be as mild as the child twisting a leg. The child will limp or refuse to weight bear

AP and lateral XR may show spiral or oblique fracture.
Long leg cast with the knee flexed for approximately 3 weeks

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10
Q

Discuss Developmental dysplasia of the hip

A

Denotes a wide range of physical and imaging conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations.

Risk factors include

  • breech presentation
  • female gender
  • family history
  • Oligohydraminios, primiparity, high birth weight, postmaturity and infant swaddling

Usually unilateral in 80% of cases

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11
Q

Discuss clinical features of DDH

A

May be diagnosed at birth or despite frequent and appropriate physical examination may not be discovered until later in live.

Physical fidning include

  • discrepancy in leg length
  • skinfold
  • ROM assymetrry
  • abnormal finding on the barlow provocative test and Ortolani reduction maneuver.

Skin fold assymetry may be noted in the groin, below the buttock and along the thigs. Not pathognomonic for DDH as 30% of normal children can have abnormal skin folds it is sensitive and the diagnosis of DDH is unlikley without asymettrical skin folds

With the onset of walking gait asymmetry or asymmetrical intoeing or out toeing is a clue to the presence of DDH

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12
Q

Discuss ix of DDH

A

Radiographs of infant hips are extremly difficult to interpret before the femoral head ossifies at 3-6 months of age

In infants with unstable but nondislocated hips xr shows the hpips in a normal position.
Before ossification a better diagnostic test is ultrasound

Once ossification has occured displacement of shentons line is indicative of DDH

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13
Q

Discuss management of DDH

A

Best when begun early- patients with untreated abnormalities of the hips that persist beyond the newborn period are at risk of OA, pain, abnormal gait, leg length discrepancy and decreased agility

neonates with dislocated hips at births should be referred to a paediatric orthopedist. with loose but non dislocateable hips referral can be delayed 2-4 weeks

The goal of treatment is concentric reduction and stabilization of the hip and resolution of dysplastic features of the bone and cartilage. The two most important complications are failure to achieve these goals and asceptic necrosis of the femoral head. In the first 6 months of life the use of the pavlik harness is the mainstay of treatment.

If DDh is diagnosed after 6 months of age the use of a hip spica cast or fixed orthosis is often requried, most children older than 18 months require surgical reconstruction

Beyonf age of 6 years in bilateral cases and 8-10 years in unilateral repair is not attempted due to the risk of asceptic necrosis

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14
Q

Discuss DDX of hip pain in children

A

Infection

  • septic arthritis
  • osteomyelitis
  • psoas abcess
  • appendicitis
  • discitis

inflammatory

  • transient synovitis
  • systemic rehumatolgic disease
  • rheumatic fever

Trauma

  • hip or pelvic fractures
  • overuse injuries

Neoplasm

  • leukemia
  • osteogenic or Ewings sarcoma
  • metastatic disease

Haem

  • haemophila
  • sickle cell

Orthopeadic

  • Perthes and secondary avasuclar necrosis
  • slipped capital femoral epiphysis
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15
Q

Discuss transient synovitis

A

One of the most common causes of hip pain in childhood

  • occurs in up to 3% of children
  • self limiting condition caused by nonpyogenic inflammatory response of the synovium

It can occur in infants, adolcents and adults with a peak incidence between 3-9 years of age
Boys more common than girls with a slight predilection to the right, bilateral is rare occuring in only 5% pof cases

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16
Q

Discuss clinical features of transient synovitis

A

Commonly report pain in the hip or groin but pain can also refer to the knee ( femoral nerve) medial thigh (obturator nerve) or buttock (sciatic nerve

May walk with a hip or refuse to walk

leg held in flexion with slight abduction and external rotation.

Passive movement may be pain free with a slightly decreased range of motion with extreme internal rotation or abduction

17
Q

Discuss IX of transient synovitis

A

Diagnosis of exclusion
Bloods (FBC, ESR, CRP)
XR

Kocher criteria to differentiate from septic arthritis
1) fever
2) inability to weight bear
3) raised ESR >40
4) Raised WBC > 12
Variable sensitivity and specificity increased when all 4 are present

XR may be normal or nonspecific - finding suggestive of transient synovitis include
- medial joint space widening
- accentuated pericapsuolar shadow
-Waldenstrom sign - lateral displacement of the femoral epiphysis
All of these finding can be present in PERTHEs and if present require MRI to exclude

Patient with severe symptoms 
-absent ROM
-ill appearing 
-inability to weight bear 
-high fever 
-marked raised ESR or CRP 
should undergo joint aspiration

Most cases of transient synovitis can be managed at home
NSAIDS
Excellent prognosis

18
Q

Discuss septic arthritis in children

A

70% of cases occur in children younger than 4 years of age with peak between 6-24months

Risk factors include

  • Trauma
  • immunodeficiency
  • hemophilia
  • haemoglobinopathy
  • recurrent haemarthroses
  • diabetes
  • IVDU
  • RA

lower extremities involved in 75% of cases
Most commonly spread via haematogenous route, can be direct inoculation spread from adjacent tissue

19
Q

Discuss common bacterial causes by age and appropriate antibiotics for septic arthritis

A 
> 3 months 
-staph aurea (MSSA and MRSA) 
-Group B srep (agalactiae) 
-Gram -ve bacilli 
-N gonorrheae
Cefotaxime 50 mg/kg BD + vanc if needed for MRSA or severe 
3months - 3years 
- S-aureus 
-kingella Kingae
-GAS
-strep pneumo 
-HIB
Fluclox + ceftriaxone 
>3 years 
-staph 
-GAS
-S pneumo 
-N gonorrhoea (sexually active adolescents) 
Fluclox + ceftriaxone
20
Q

Discuss IX of septic arthritis

A

Bloods ( cultures, ESR, CRP, FBC)
XR +- MRI +- US ( effusion, osteomylitis)
Joint aspirate

21
Q

Discuss indication for surgical drainage and washout

A

Involvement of the hip joint
large amounts of puss
loculated fluid
recurrence of joint fluid after 4-5 aspirations
lack of clinical improvement with 72 hours of appropriate IVABs

22
Q

Discuss synovial fluid and diagnosis

A

Normal
-clear, yellow
- <200 WBC
<10 PMN

Juvenile rheumatoid arthritis

  • turbid
  • 25-50000 WBC
  • 50-75% PMN
Septic 
Turbid, white grey
10000-250000 WBC
>75% PMN
-low glucose high lactate
23
Q

Discuss Perthes Disease

A

Idiopathic avascular necrosis of the proximal femoral head

Usually occurs between the ages of 3-12 years of age with a peak between 5-7 years of age. Has been reported in teenagers and in children less than 2 years

Boys are more affected than girls
20% are bilateral 10% are familial

24
Q

Discuss clinical features of perthes

A

Insidious and stuttering onset of limp
Pain tends to be localised to the groin or referred to the anteriormedial aspect of the thigh, worse with movement and relieved with rest

There is limited hip ROM particularly abduction and internal rotation

Trendelenburgs sign

In advanced disease with femoral head collapse - a limb length discrepancy can be identified

25
Q

Discuss IX fo perthes

A

Labs to exclude other causes of hip pain

Diagnosed and staged with AP frog leg lateral radiographs

  • radiolucent V shaped osteoporotic defect in the lateral epiphysis
  • speckled calcification lateral to the capital epiphysis
  • diffuse metaphyseal reaction
  • lateral capital femoral epiphysis subluxation

MRI can provide earlier and comprehensive information regarding extent of necrosis

There are four radiographic classification stages of perthes disease

26
Q

Discuss management of Perthes

A

Diagnosed Perthes should have orthopod consult
Goals are to improved ROM, prevent deformity, limit growth disturbance and prevent degenerative joint disease

The cornerstone of treatment is containment of the femoral head in the acetabulum to equalise pressure on the head and mold it to the acetabulum – can be achieved surgically or nonopertativley - cast for non op

Despite adequate treatment most patient will develop OA in there 30-40

27
Q

Discussed slipped capital femoral epiphysis

A

Invovles posterior and inferior splippage of the proximal femoral epiphysis on the metaphysis

Increased rates are seen in

1) Race (high prevelance in african, hispanic and pacific islanders
2) males
3) underlying medical condition ( more frequent with endocrinopathies, renal, osteodystrophy and radiation therapy)

Peak incidence is during the adolescent growth spurt 12-16 in boyrs and 10-14 in girls
The age at diagnosis is decreasing with increasing rates of obesity

SCFE is bilateral in up to 80% of cases

Although associated with the above most cases are idiopathic in the setting of an obese adolcent

Classification is based on stability, in stable SCFE ambulation is possible in unstable it is not - 90% of cases are stable and children often present with weeks of pains localised to hip thigh groin or knees

28
Q

Discuss IX of SCFE

A

AP and lateral radiographs of both hips - with stable slippage frog legs should be obtained

With early SCFE the initial slippage is posterior so the AP view is normal in appearance or shows a widening of the physis - slip is better seen on lateral x0rays
on AP films signs of slippage include Kleins line and the blanch sign of Steele

Kleins line is a line drawn along the superior margin of the femoral neck with a normal hip the line intersects with or falls within the epiphysis in a slip it does not

MRI can be used to determine slip

29
Q

Discuss management and complications of SCFE

A

Non weight bearing with orthopod review
most require surgey to stabilise

The most worrisome short term complciations of SCFE are avasuclar necrosis and chrondolysis - other complications include nonunion premature closure of the epiphyseal plate and degenerative changes.

30
Q

Discuss Osgood Schlatter syndrome

A

Traumatic induced apophyseal injury to the tibial tubercle.
It is most common in boys between 10 -15 years of age and girls between 8-13 yeas of age
Bilateral in 30%

Presents with tenderness pain and swelling at the site of the patellar tendon on the tibial tubercle. Tubercle may be prominent and the qaurdiceps tight

pain is worse with activities that cause the quadriceps to contact and stress the tubercle such as running and jumping.

Extension of the knee again resistance causes pain

XR may be normal or show enlarged fragmented and irregular tibial tuberosity with or without overlying bony ossicle. These finding are non specific and are not diagnositc of their own.
US may reveal pretibial swelling, fragmentation of the ossification center, insertional thickening of the patella tendon and or excessive fluid collection.

Treatment includes RICE, NSAIDS, the use of a patella strap mayu help relieve symptsom
After acute inflammation has settled treatment focuses on strengthening and stretching of the quadricpes muscles

31
Q

Describe a TIllaux fracture

A

Salter harris 3 fracture the the anterolateral aspect of the distal tibial epiphysis - intra-articular
Occurs in older children and adolescents when the medial aspect of the distal tibial growth pate has started to fuse

Usually is the result of an abuduction-external rotation mechanisms

32
Q

Define greenstick and torus fracture

A

GREENSTICK: Incompolete fracture of long bones most commonly seen in children <10 involving only one cortical surface. Usually mid diaphyseal. USually associated with angulation

TORUS: Incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. Result from trabecular compression due to an axial loading force. Torus fractures strictly speaking refer to circumferential buckle fractures.

33
Q

Describe plastic deformity

A

Bowing without disruption of the cortex

Usually require orthopedic review for manipulation

33
Q

Describe plastic deformity

A

Bowing without disruption of the cortex

Usually require orthopedic review for manipulation

ED fellowship paeds (15 decks)

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