OITE - Pediatrics Flashcards
Distal humeral physeal separation, suspicious for what?
-Child abuse
Xray finding of distal humeral physeal seperation
- Radius ulna maintain normal relationship
- radius still lines up with capitellum
- but distal humerus metaphysis is disconnected from rad+ulna
Define sequestrum
Nidus of residual necrotic infected bone
Osteomyelitis organisms, most common?
- Staph aureus (most common)
- Kingella kingae (culture it longer in CO2 rich medium)
- GBS in neonates
- Salmonella (g-ve), in sickle cell, -H influenza (if not vx)
Involucrum?
New bone formed by elevated periosteum (in an effort to wall off infection)
How long do xrays remain normal, in context of osteomyelitis
Upto first 2 weeks (7-10 days)
What are the 2 lab markers for osteo?
- CRP peaks and normalizes earlier (track short term response)
- ESR requires 3 weeks to normalize (track long term abx tx)
Clubfoot aka ?
Congenital talipes equinovarus
Clubfoot position?
Hindfoot - equinovarus
Forefoot - supination, adductus
Midfoot - cavus
CAVE (cavus, adductus, varus, equinus) - order of ponsetti correction
When is achilles tenotomy done in ponseti method?
At 6-8 weeks
How long are Denis-Brown bars used for ?
2-4 yrs
When is tib ant transfer needed? Prevalence?
- Residual recurrent forefoot supination after 2 years
- 10 to 30%
- must have a flexible deformity, and competent tib ant
Late deformities associated with clubfoot surgery?
Undercorrection/recurrence - medial spin, intoeing
Overcorrection - flatfoot, hindfoot valgus, calcaneus gait (weak gastroc/soleus)
AVN - (talus), -Dorsal bunion (injury to peroneus longus)
What are length unstable femur fx (in school age children)?
- Comminution
- Large oblique fx pattern
How to tx length unstable femur fx.
- ORIF
- Submuscular bridge plating
- Ex fix
What fx pattern is most commonly associated with a pediatric elbow dislocation?
- Medial epicondylar fx (rate of 50%)
- Due to avulsion of flex-pronator wad
- ulnar nerve may be entrapped (within joint, after reduction)
What radiographic view will demonstrate max degree of fx displacement, if suspecting lateral condyle fx?
- Internal rotation oblique view
- MRI arthrogram can be useful
What does non-union of lat condyle fx result in?
Cubitus valgus –> and ulnar neuropathy
Where should you avoid dissection in ORIF of lat condyle fx
Posterolateral dissection should be avoided (can compromise blood supply)
Infantile Blount’s Disease?
- Progressing worsening genu varum
- Metaphyseal diaphyseal angle > 13 deg
- Onset prior to 3
Surgical tx for infantile blounts?
- Langenskiold stage 3 or more
- Failure of bracing
- Best result if prox tib fib osteotomy done before age of 4
- Plan for prophylactic fasciotomy
Distal femoral physeal injury is more common than ligamentous knee injury in peds, due to what?
Epiphyseal ligament insertions
Rate of physeal arrest in Distal femoral physeal injury?
30-50%
How to treat physeal arrest in dist fem physeal fx?
- Partial arrest - bar resection if 2cm growth remaining. (PMMA interposition to occupy space left)
- If >50% involvement, perform ipsilatearl completion of arrest
How do you ascertain degree of interosseous mold of a cast, in context of DR fx?
Look at Cast Index = (sag width / coronal width)
Want CI
Name 7 characteristic UE deformities in cerebral palsy
- Shoulder IR, Elbow flexion, Forearm pronation
- Wrist flexion, wrist ulnar deviation
- Thumb in palm
- Finger swan neck
Name 2 reasons to tx UE CP contracture
1-hygeine (antecubital fossa, wrist + hand)
2- improve function
When would you consider PSF for scoliosis of Duchenne Muscular Dystrophy
PSF for curves progressing > 25 to 30
Operate early, as it is better tolerated
Hallmarks of DMD ?
- Decreased motor skills
- Gower’s sign (proximal muscle weakness, from sit to stand)
- Calf pseudohypertrophy
- Markedly Elevated CPK
Distal humeral physeal seperation
- Posteromedial displacement of rad/ulna shafts to distal humerus
- difficult to diagnose (arthrogram), -children
Flexible flatfoot (pes planovalgus)?
- Low medial arch, valgus heel, and forefoot abduction
- NORMAL subtalar motion, no heel cord contracture
Surgical tx for flexible pes planovalgus?
- Calcaneal neck lengthening osteotomy (most common)
- Lengthen achilles tendon
- possible Medial cuneiform osteotomy
Acceptable angulation and rotation in BBFA?
10 angulation 10, rotation 30 (shaft)
Dorsal angulation 30 deg (10 yo)
Legg-Calve-Perthes Disease (coxa plana)?
Boys 4:1
Lateral pillar classification has significant prognostic value
-early fragmentation phase (best time)
-approx 6 months onset of symptoms
What is the lateral pillar classification for Legg-Calv-Perthes?
A - none
B - 50% loss of height
C - >50% loss of height
Sprengel’s deformity?
- Failure of scapular descent (high small scapula)
- Assoc with Klippel feil
- Diminished ABDUCTION is most affected function
Posteromedial tibial bowing can be associated with what other manifestation?
- assoc with calcaneovalgus foot
- often resolves spontaneously
- 2-5cm LLD at maturity
Lysosomal storage diseases, all have an increased risk for what?
Carpal tunnel syndrome
Vertical talus other names ?
Talipes equinovalgus
Congenital convex pes valgus
-p/w rocker bottom feet
Xray findings on lateral plantar flexion view, for vertical talus?
- Talus not in line with metatarsals
- Navicular dorsally dislocated
What is the genetic cause of dwarfism characterized by hitch-hikers thumb, cauliflower ears, and severe clubfeet?
Diastrophic dysplasia (ARecessive, twisted dwarf) -Sulfate transport protein
Marfan’s is an AD disorder with defective gene encoding?
Fibrillin
Most common cause of peroneal spastic flatfoot?
- Calcaneonavicular coalition
- commonly presents as recurrent ankle sprains
Tarsal coalition surgical tx?
50% joint involvement – Arthrodesis
Initial tx of spastic flat foot?
Casting
In Monteggia fx, want to close reduce and immobilize how?
- Hyperflexion (110 deg) and supination
- relaxes biceps and TIGHTENS IOM
When would you order an endocrine workup for SCFE
If child less than 10 years old
Pin bilateral if there is endocrine etiology
SCFE has a fx through what zone?
Hypertrophic zone
What position is the neck displaced in SCFE?
Neck displaced anteriorly
Neck externally rotated
What measure is used to determine radiographic severity of the epiphyseal slip, in order to guide treatment?
Southwick Severity Angle (epiphyseal-shaft angle difference)
Mild 50
Which 2 lines are used to divide hip into 4 quadrants, in DDH?
Hilgenreiner and Perkins
head is above H, and lateral to P
When does proximal femur ossific nucleus appear on xray?
6 months of age
Neurofibromatosis is associated with all of the following what?
Cafe au lait spots (smooth borders)
Hemihypertrophy
Scoliosis
Pseudoarthrosis (anterolateral bowing)
What lesion is hallmark and pathognmemonic for neurofibromatosis?
Plexiform neurofibromas
What is the most common skeletal dysplasia?
Achondroplasia
FGFR-3
Features of Dwarfism?
Rhizomelic limb shortening
Frontal bossing
Spinal stenosis
Champagne pelvis
Osteogenesis imperfecta associated with residue substitution?
Glycine substitution in procollagen molecule
Charcot Marie Tooth Disease, aka?
Peroneal muscular atrophy
Charcot Marie Tooth Disease, is AD. What are its features?
Cavus feet
Hammer toes
Motor deficits (tib ant, peron brevis, intrinsics foot and hand)
Myelodysplasia (myelomeningocele, spina bifida). What is the most common level involved? Results most often in what dislocation?
L3/L4
Hip dislocations (tx if L4 or L5 level)
–L3 levels and higher have poor results with recon maneuvers
Osteopetrosis?
- AR
- Failure of osteoclast to remodel (carbonic anhydrase dysfuncn)
- High mortality rate (tx with bone marrow transplant)
Arithmetic method about LE growth?
Prox femur 3mm / yr
Distal femux 10mm / yr
Prox tibia 6mm / yr
Distal tibia 5mm / yr
According to arithmetic method, when is growth cessation in boys and girls?
Boys 16 yo
Girls 14 yo
Accessory navicular first line tx?
- Non op
- Excision after 6 mo of non-op attempts
In tibial tubercle fx, injury to what artery most likely causes compartment syndrome?
Anterior tibial recurrent artery
What is cavocarus foot?
- Elevation of medial arch from relative forefoot equinus
- Spasticity of contracted plantar fascia + weak Tib Ant
In in toe-ing, what are the 4 measurements for rotational profile?
- FPA (foot progression angle)
- Hip rotation (for femoral anteversion)
- Thigh foot angle and transmalleolar axis (tibial torsion
- Heel bisector (measure for metatarsus adductus)
Another name for Toddler’s fracture of the tibia?
CAST - childhood accidental spiral tibial fx
Best predictors of septic hip, in order, are what?
- Fever > 101.3
- CRP >2.0 -ESR > 40
- Inability to bear weight
- WBC > 12,000
Which joints have an intra-articular metaphysis (and are therefore more at risk for osteomyelitis)?
hip, shoulder, elbow, ankle
Most common cause of septic arthritis in adolesecents?
N. gonorrhea
Prognosis for spont recovery for involved arm after obstetrical brachial plexopathy? After Horner’s?
90% will resolve
Horner’s
Erb’s palsy?
C5-6
Klumpkes palsy?
C8-T1
When is early surgery in obstetric brachial plexopathy indicated?
Early sgx - complete flail arm or Horners
Later sgx - Tendon transfer or osteotomy
How do you treat radial neck fx.
less than 30 deg angulation - immobilize
>30 deg angulation - Closed reduction
>30-60 – open reduction
Bone growth in humerus ratio?
80/20 prox/distal
Order of appearance of elbow growth centres?
CRITOE
1 -3 - 5 - 7 - 9 -11
Order of closure of elbow growth centres?
CTE -R-O-I
12,12,12 - 15-15-17
Ortho manifestation of sickle cell disease?
- Osteomyelitis, septic arthritis
- Dactylitis (acute hand and foot swelling)
- Osteonecrosis, bone infracts
- Growth retardation
What injuries and fx pattern are suspicious for child abuse?
- Corner fx
- Fx in non-walker (long bone)
- multiple fx in various stages of healing
- bruises of different ages
