OITE Review Flashcards
MRI indications scoli (5)
L thoracic curve Pain Neuro sx - asym abdominal reflex, hyper-reflexia Rapid progression Apical kyphosis
What factor is most predictive of predicting AIS progression?
Age = skeletal maturity
Risser sign
What is the most correlative XR finding for AIS progression?
Tanner whitehouse = hand XR
Bracing rules for AIS
<25 = nothing
<40 + skeletally mature = watch
Immature < 40 = brace (reduce risk surg 50% if bracing done at least 12hrs per day, compliance is MOST important factor for det prog to surgery)
If very skeletally immature and must fusion spine, do you do post or ant approach?
Ant to prevent crank shaft phenom
Delayed infx bugs (2) for AIS vs acute
P.acnes & S.epi (NOT aureus!!!)
Acute = aureus
Curve & age for infantile idiopathic scoli
LEFT thoracic
Age = <3yo
What is the measurement for infantile IS?
RVAD > 20 = high risk progression
Treat infantile IS
Body cast
RVAD>35 - MRI +/- growing rod (less effective the longer is in)
Don’t fuse b/c get alveolar aka pulm insuff
Which type of scoli is highest risk of neural axis involvement
Juvenile = 3-10yo
Think arnold chiari malform
What deform is the worst outcome for congenital scoli
Failure formation vs segmentation vs mixed Worst prog = 1. Uni lat var \+ CL hemi vert 100% risk progression GET MRI****
Which spine deform has highest risk neurologic compromise from surgery?
Congenital kyphosis
DMD inheritence
XL recessive - more common BOYS
- High creatine kinase
- Gower’s sign
What is a pars stress frx called? Most sensitive test?
Spondy-lo-lysis
SPECT = single proton…. = most sensitive
What level is most common spondy in kids?
L5-S1
- HAMSTRING tightness on exam
What is the most important determinant of pain and non-union for spondy (how they’ll do once they get it)
Slip angle >45 deg
VS PI - dets if you will get a spondy at all
How measure pelvic incidence
total of sacral slope + pelvic tilt
What is Scheurmann’s kyphosis
Idiopathic kyphosis - usual brace
Normal kyphosis in T spine 20-50deg
What is Klippel Feil
= abnormal cervical segmentation (AA fusion)
Sprengel’s deform on right - scapula is up with limited ROM
Deafness (the other one that isn’t paget)
Webbed neck
Trt = conservative, NO CONTACT SPORTS
AA instability
Down’s
JRA
Treat if >5mm EXCEPT Downs > 10mm b/c lig lax at baseline
What is the most common level for pseudo sublux
C2/3 - don’t have to do anything about it
Association w/ C1/2 rotary sublux
Think after retrophayngeal infx/URI
SCM spasm on SAME SIDE as chin (aka actue torticollis)
Association for sacral agenesis
Maternal diabetes
What disease has palpable SCM mass - treat and what to r/o
Cong muscular torticollis
PT + stretching
R/o DDH
RF DDH
Breech
Female (left side most common)
First born
Packaging disorders associated with DDH
Torticollis - SCM away from chin
Metatarsus adductus
When does O&B not helpful - what test do you use
6mo
Galeazzi test - does one leg look shorter than other when knees flexed
2 US findings for DDH
Alpha angle > 60 = normal Less means the tab is SHALLOW = bad (in adults alpha bigger is bad) Beta angle > 55 Image - White line = ilium - Muscle is LATERAL
When can you get XR for DDH
> 4mo - FH starts to ossify
What is normal AI and CEA
AI < 25 = normal
CEA < 25 = ABnormal
What are 4 things that might prevent hip reduction
Inverted labrum vs limbus
Lig teres
IP tendon
How treat stable vs unstable sublux hip?
Stable = watch Unstable = Pavlik
How treat dislocated or dislocate-able hip?
Non-reduce -> OR
Reduce -> Pavlik
Palvik - ant vs post strap roles & 2 comp of Pavlik
Ant strap - stop flexion (less than 90)
Too much - fem nerve palsy
Post strap - stop aBduction
Other comp = AVN (post sup retinacular art)
What is Pavlik disease?
Post acetabular wear - why check every week via US
Who can’t you use Pavlik?
NM kids - Pavlik works on your muscles to keep hip in place
What do you do for kids with DDH who are walking
Surg: open reduction // osteotomy
What are the 6 pelvic osteotomies for DDH
Salter Pemberton Triple Dega - CP young kid Shelf - salvage Chiari - salvage
What do you if a young kid fails Pavlik?
Give 3 wks
Abduction brace
If that fails, closed reduction casting + hip arthrogram to check reduction
What is Legg Calve Perthes
Idiopathic AVN
4-8yo boys
Associated with ADHD, protein C and S def, and thrombophilia
What is the classification for LCP
Pillar - LATERAL physis
>50% of the femoral head = BAD -> probs needs surg
Young and lower Pillar classification = better outcomes
Who gets SCFE
Fat boy with knee pain
What zone is SCFE affect vs atypical SCFE
Hypertrophic zone (same as SH frx) Atypical = primary spongiosa
What is a stable SCFE
Anything the kid was walking on no matter how bad the XR looks
How do you fix SCFE surgically?
IN SITU - dont reduce anything
Screw fixation
Unstable = HIGH risk AVN
What is atypical SCFE
<10yo Do an endocrine work up - won't be fat - Hypo thyroid - Renal osteodystrophy THESE are the kids you prophylactically do the other size
Where is your screw start point for SCFE?
Center through the physeal line
>5 threads through the physis
Start point not directly lateral - might need to start slightly anterior
If screw head is medial to the inter troch line can get labral tears
Who do you do bilateral SCFE screws on?
Endocrine abnormalities
Tri-rad cart open aka v young
LE physis grown
3 9 6 5
What are the rules for distal femur vs prox tibial for limb length discrep
Distal femur: 0.9cm/yr
Prox tibia: 0.6 cm/yr
Girls grow until 14 // boys 16
Treat limb length discrp
<2cm = shoe lift
2.5cm - 4 = epiphysiodesis
4+ cm - lengthening
Volkman law
Tension accelerates growth
14 yo boy, complete growth arrest at distal femoral physis - what is the predicted leg length discrp
2yrs left to grow x .9cm = 2cm
What association x2/ treat op vs non-op for congenital knee dislocation
Larsen syndrome
And ipsi hip dislocation - have to treat knee first b/c can’t put a Pavlik on dislocated knee
Trt: close reduction and splinting in FLEXION
IF can’t get 30 deg flexion after 3mo casting -> surg
What does O vs B positive test mean?
Ortolani + = reducible
Barlow + = dislocatable
Gene for long femoral deficiency
SHH - longitudinal growth
Mutation for pseudoachondroplasia
COMP (collagen)- AD - normal faces, cervical instability
Mutation for diastrophic dysplasia
Sulfate transport protein, AR, “cauliflower ears, club foot + achondroplasia”, kyphoscoli - urgent treatment for kyphosis b/c high rates neurologic involvement
What is multiple epiphyseal dysplasia presentation
Bilateral Perthes (NEVER bilat w/ Perthes) -> next step skeletal survey to r/o MED
Presentation for Poland syndrome
Symbrachydactyly
UniL chest wall hypoplasia
Alpert syndrome mutation and presentation
AD - FGFR2
Complex syndactyly - its either this or Poland
What is the mutation and chromosome and region of cartilage for achon
AD - FGFR3
Chr 4
Proliferative zone
Most common cause rickets in US
hypophos X-linked R
What are the labs for rickets + treatment
Normal Ca, low PO4, high alk phos
Treat with vit D and phos
Common presentations of OI
Olecranon frx
Basilar invagination
Treat med + surg for OI
IV pamidronate (bisphos - x osteoclasts)
Osteotomies w/ IM implants (not plating)
Scoli - FUSE them
Mutation and chromosome for osteopetrosis
Chr 11 AR - no carbonic anhydrase - bad osteoclasts
NF mutation and presentation
Chr 17 (17 letters in NF) - neurofibromin Smooth cafe au lait Ant lat bowing Tibia pseud-arthrosis Neuro sx - malignant neuro sheath tumors
Rough cafe au lait
McCune Alright
Cafe au lait - fibrous dysplasia - precocious puberty
Marfans mutation, presentation
Ch 15 - fibrilin - AD Superior lens dislocation TGF-beta -> heart and lungs Dural ectasia -> need to fuse not brace Hip stuff
How is the ADI to fuse a Down’s kid
> 10 (higher than normal b/c baseline lig lax)
Kid w/ multiple joint dislocations - disease + mutation
Larsens - filamin B mutations
Cervical kyphosis
What is a Sprengel’s deformity
Scapula doesn’t descend - don’t confuse with scoli
Don’t nee to treat
KF disease
What must you do for total radius gone but have a thumb
MUST do CBC peripheral smear and cardiac work up - kid could die
What is CI to centralizing the ulna for radial def conditions
No elbow flexion - without this no point in centralizing
Diseases if missing a thumb and key question
Key question - CMC stable? unstable - amp the thumb, move the index finger over and make it into a thumb Holt Oram - cardiac US Fanconi - chromosomal breakage analysis TAR - CBC and peripheral blood smear
What is a Madelung deformity
Volar-ulnar issues cause distal radius malformation
Tear drop of the radius on lateral XR
SHOX gene mutations
Do you need to do anything about a prox rad-ulnar synostosis?
Nope
How treat thumb duplication
Keep ulnar thumb for UCL
1-3: fuse the digit
Poor prognosis for brachial plexus
No biceps after 6mo
- More ulnar to biceps, median to brachialis
Horner’s
Pregang - no sympa, no rhomboids, C spine muscular weak, positive histamine test
What is the risk of SH 2 vs SH 3/4
SH 2 - physeal bar, look on MRI
SH 3/4 - growth arrest
Kids both bone
Short arm cast!!!!
Unless you have a supracondylar - fix at the same time
When do you un-reduce a supracondylar
Lose perfusion in the hand
When does ROM return to normal for supracondylars
6mo after - no formal PT needed
What is the 2 biggest problems with lat condyle frx
Inadequate reduction of periosteum -> loss ROM
Do NOT to post-lat approach b/c AVN -> cubitus valgus -> tardy ulnar nerve palsy (later in life post-lat rotatory instab)
What degrees do you need to fix a ped radial head and neck frx
> 6mo
Which kids who have a Chance frx what is the other injury you need to look for
Intra-ab (seat belt sign)
Open or closed for peds hip fractures?
OPEN b/c MUST get anatomic reduction
Rules for SPICA
Do not apply short leg first then rest - higher risk compartment syndrome
Avoid 90-90 - femoral n palsy
Cast wedging - if your femur fracture falls into varus, this will put them into valgus
How treat femoral shaft fractures by age
0-6mo Palvik
6mo-5yrs Spica
>5yo stable - flexible nail (>85% canal filled)
>5yo unstable - plate
>5yo + >100lbs = rigid nail - MUST do GT start very lateral (MFCA becomes dom BS after 4yo, before was lig teres)
What is trapped that is fucking with your tibial eminence reduction
Ant horn med men
What deformity is worst and seen in peds tibia fractures
Valgus - prox metaphysis b/c med growth plate grows faster than lateral - self correcting
What is a Tillaux frx
AITFL avulsion
SH 3 of distal tibia
MUST get CT
ORIF >2mm displaced
What is a triplane frx
SH 4 frx - SER
Tillaus + physis + metaphysis
AP looks like SH3
Lat looks like SH 2
Treat transient synovitis
Hx viral illness with normal ESR/CRP
Trt NSAIDS -> doesn’t improve MRI
What is the involucrum vs sequestrum
NEW bone vs DEAD bone (debride this)
What are the RF for DVT after osteomyelitis
MRSA
CRP >6
>8yo
