Ortho Flashcards
1
Q
Clubfoot / Congenital talipes equinovarus
- Tx: Ponseti method 3 stages
- 1st Stretching and casting. This consists of repositioning and recasting once weekly for 6-8 weeks.
- If unsuccessful, surgery may be needed
- Long-term bracing to maintain corrected position
A
Clubfoot / Congenital talipes equinovarus
- Tx: Ponseti method 3 stages
- 1st Stretching and casting. This consists of repositioning and recasting once weekly for 6-8 weeks.
- If unsuccessful, surgery may be needed
- Long-term bracing to maintain corrected position
2
Q
Metatarsus adductus
- Usually noticed in infancy (less than ___yo)
- Tx:
- Resolves spontaneously within the 1st year, almost always by ___yr. Can try manipulative stretching several times daily, but might not hasten condition.
- Casting/splinting may be useful if persists beyond 6mo
A
Metatarsus adductus
- Usually noticed in infancy (<1yo)
- Tx:
- Resolves spontaneously within the 1st year, almost always by 3-4yr. Can try manipulative stretching several times daily, but might not hasten condition.
- Casting/splinting may be useful if persists beyond 6mo
3
Q
Internal tibial torsion
- Most common cause of intoeing age ___yo.
- Medial rotation of the tibia
- Tx:
- Reassurance. Typically resolves spontaneously by _____yo without intervention.
- Reserve surgery for severe cases causing functional or cosmetic deformity that persist past ___yo.
A
Internal tibial torsion
- Most common cause of intoeing age 1-3yo. Presents in 2nd year when child starts walking
- Medial rotation of the tibia
- Tx:
- Reassurance. Typically resolves spontaneously by 8-10yo without intervention.
- Reserve surgery for severe cases causing functional or cosmetic deformity that persist past 8yo.
4
Q
Internal femoral torsion / Femoral Anteversion
- Present in pre-school children ____yo
- Pt:
- More internal rotation
- ____ run pattern where legs “flip” outward in the swing phase
- Sit in a “___” position. Find it difficult to sit cross-legged
- Tx:
- Reassurance that is a common normal variant. Most cases resolve by ___yo.
- Surgical correction considered in rare cases when children are at or near skeletal maturity experience pain or significant gait disturbance
A
Internal femoral torsion / Femoral Anteversion
- Present in pre-school children 3-6yo
- Pt:
- More internal rotation
- “Egg beater” run pattern where legs “flip” outward in the swing phase
- Sit in a “W” position. Find it difficult to sit cross-legged
- Tx:
- Reassurance that is a common normal variant. Most cases resolve by 11yo.
- Surgical correction considered in rare cases when children are at or near skeletal maturity (>11yo) experience pain or significant gait disturbance
5
Q
Congenital Scoliosis
- Scoliosis that results from presents of 1 or more congenital vertebral malformations (CVMs)
- Ex: Hemivertebrae, butterfly vertebrae, congenital vertebral fusions
- When presents with pt with congenital scoliosis, think _____ syndrome or ____ association
- Management
- Refer to ortho.
- If signs of CNS dysfunction or midline cutaneous lesions, _____
- it s recommended that these children undergo screening with _____
A
Congenital Scoliosis
- Scoliosis that results from presents of 1 or more congenital vertebral malformations (CVMs)
- Ex: Hemivertebrae, butterfly vertebrae, congenital vertebral fusions
- When presents with pt with congenital scoliosis, think Klippel-Feil syndrome or VACTERL association
- Management
- Refer to ortho.
- If signs of CNS dysfunction or midline cutaneous lesions, spinal imaging
- Because renal abnormalities are present in 1/3 of children with CVM, it s recommended that these children undergo screening with renal US
6
Q
Idiopathic Scoliosis
- Screening: Scoliometer
- > __ (BMI 85%) or >__ (BMI <85%) degrees is considered positive and should be evaluated further with standing radiographs of spine.
- __-__ degrees warrants reexamination in months
- > __ degrees: Radiologic evaluation for Cobb angle
- > __ (BMI 85%) or >__ (BMI <85%) degrees is considered positive and should be evaluated further with standing radiographs of spine.
- Physical exam: Visual inspection of back and Adam’s forward bending test.
- Assess scapular asymmetry, prominence of rib cage, asymmetry of hips
- Dx: Cobb angle >___ degrees
- Tx:
- Mild cases Cobb angle ___ degrees of 1st visit with curvature >___ degrees
- ___ -___ degrees: Bracing
- ___-___ degrees: Bracing or surgery
- Bracing generally ineffective for >__ degrees
- > ___ degrees: Surgery
- Mild cases Cobb angle ___ degrees of 1st visit with curvature >___ degrees
A
Idiopathic Scoliosis
- Screening: Scoliometer
- > 5 (BMI 85%) or >7 (BMI <85%) degrees is considered positive and should be evaluated further with standing radiographs of spine.
- 5-9 degrees warrants reexamination in months
- > 10 degrees: Radiologic evaluation for Cobb angle
- > 5 (BMI 85%) or >7 (BMI <85%) degrees is considered positive and should be evaluated further with standing radiographs of spine.
- Physical exam: Visual inspection of back and Adam’s forward bending test.
- Assess scapular asymmetry, prominence of rib cage, asymmetry of hips
- Dx: Cobb angle >10 degrees
- Tx:
- Mild cases Cobb angle <20: serial radiographs every 6 months
- Progression of curvature >25 degrees of 1st visit with curvature >30 degrees
- 30 -39 degrees: Bracing
- 40-49 degrees: Bracing or surgery
- Bracing generally ineffective for >45 degrees
- > 50 degrees: Surgery
7
Q
Kyphosis
- Postural kyphosis:
- Up to _____ degrees of thoracic kyphosis using Cobb angle measurement on lateral radiographs is considered normal
- Tx: Reassurance. Bracing, PT, NSAIDs. For severe cases (>80 degrees), surgery is often indicated
A
Kyphosis
- Postural kyphosis:
- Up to 45 degrees of thoracic kyphosis using Cobb angle measurement on lateral radiographs is considered normal
- Tx: Reassurance. Bracing, PT, NSAIDs. For severe cases (>80 degrees), surgery is often indicated
8
Q
Scheuermann disease
- Kyphosis caused by >=\_\_\_ degree anterior wedging of >=\_\_\_\_ consecutive thoracic vertebrae
- Tx:
- Initial management is conservative: avoiding pain triggers, NSAIDS, exercises to increase strength and flexibility
- Curves >\_\_\_ degrees in skeletally immature may be improved with bracing, and curves >\_\_\_ degrees that are uncontrolled by bracing sometimes require surgery.
A
Scheuermann disease
- Kyphosis caused by >5 degree anterior wedging of >3 consecutive thoracic vertebrae
- Tx:
- Initial management is conservative: avoiding pain triggers, NSAIDS, exercises to increase strength and flexibility
- Curves >60 degrees in skeletally immature may be improved with bracing, and curves >80 degrees that are uncontrolled by bracing sometimes require surgery.
9
Q
Pectus Excavatum
- Depression of midsternum
- Pt: By itself, rarely causes respiratory or cardiac problems through some complain of exercise intolerance
Pectus Carinatum (Pigeon chest/breast)
- Anterior protrusion of the sternum with lateral depression of the costal cartilages.
- Pt: Rarely symptomatic
A
Pectus Excavatum
- Depression of midsternum
- Pt: By itself, rarely causes respiratory or cardiac problems through some complain of exercise intolerance
Pectus Carinatum (Pigeon chest/breast)
- Anterior protrusion of the sternum with lateral depression of the costal cartilages.
- Pt: Rarely symptomatic
10
Q
Asphyxiating Thoracic Dystrophy (____ Syndrome)
- Inheritance?____
- Pt: _____, ___, ______ disease
- Tx: Standard approach is to provide long-term ventilation, if needed, early in life. Those less severely affected may only need ventilator support with respiratory infections.
A
Asphyxiating Thoracic Dystrophy (Jeune Syndrome)
- AR
- Pt: Short ribs, small rib cage, renal disease
- Tx: Standard approach is to provide long-term ventilation, if needed, early in life. Those less severely affected may only need ventilator support with respiratory infections.
11
Q
Developmental Dysplasia of Hip
- Screening: Screen until walking normally (~2yo)
- For less than __ mo: ___
- For ___mo: ____
- Dx:
- less than __mo: ___
- ___mo: ___
- Tx: Refer to Ortho
- less than __mo: ____
- __mo: ____
A
Developmental Dysplasia of Hip
- Screening: Screen until walking normally (~2yo)
- For <3 mo (8-10 weeks): Barlow and Ortolani.
- For >8-10 weeks: Galeazzi test
- Dx:
- <6mo: Hip US at 4-6 weeks of life (closer to 6 weeks)
- > 6mo: XR frog leg of hip
- Tx: Refer to Ortho
- <6mo: Pavlick’s Harness for approx 3 mo
- 6mo-2yo: Spica splint to attempt closed reduction. If these procedures are unsuccessful, surgery is indicated
12
Q
Leg length discrepancy
- Path:
- Fractures of the femur have the highest risk of overgrowth
- Overgrowth syndromes
- Idiopathic
- Management
- Discrepancies <2-2.5cm: Small shoe lifts
- Discrepancies 2-5cm: Candidate for epiphysiodesis
- For larger discrepancies, more complicated surgeries
A
Leg length discrepancy
- Path:
- Fractures of the femur have the highest risk of overgrowth
- Overgrowth syndromes
- Idiopathic
- Management
- Discrepancies <2-2.5cm: Small shoe lifts
- Discrepancies 2-5cm: Candidate for epiphysiodesis
- For larger discrepancies, more complicated surgeries
13
Q
Unilateral Coxa Vara
- When angle between neck and shaft of femur is less than ___
- Pt:
- Trendelenburg limp: Abnormal but painless gait pattern
- Limb length discrepancy, prominent greater trochanter, limitation of abduction and internal rotation of the hip
A
Unilateral Coxa Vara
- When angle between neck and shaft of femur is <110-120
- Pt:
- Trendelenburg limp: Abnormal but painless gait pattern
- Limb length discrepancy, prominent greater trochanter, limitation of abduction and internal rotation of the hip
14
Q
Coxa Valga
- Femoral neck shaft angle is >___ degrees
- Pt:
- Leg lengthening (rather than shortening) of the affected limb, which leads to circumduction and limited ROM in _____
A
Coxa Valga
- Femoral neck shaft angle is >139 degrees
- Pt:
- Leg lengthening (rather than shortening) of the affected limb, which leads to circumduction and limited ROM in adduction (other than abduction)
15
Q
Transient Synovitis
- Joint aspiration is the reference standard in differentiating toxic synovitis from septic arthritis. - Tx: - After ruling out a disorder requiring specific tx and intervention, NSAIDs and relative rest are mainstays of tx. Full recovery within 1-4 weeks
A
Transient Synovitis
- Joint aspiration is the reference standard in differentiating toxic synovitis from septic arthritis. - Tx: - After ruling out a disorder requiring specific tx and intervention, NSAIDs and relative rest are mainstays of tx. Full recovery within 1-4 weeks
16
Q
Septic (Pyogenic) Arthritis
- Dx: Joint aspiration is the best test for confirming the diagnosis
Kocher criteria to distinguish septic joint from transient synovitis
1) ____
2)____
3) ____
4) ____
CRP >___ (not part of the original Kocher criteria)
1= 3% probability of septic arthritis, 2= 40%, 3= 93%, 4= 99%
Rec: draw CBC, ESR, and CRP in all pts with clinical concern for septic arthritis or transient synovitis
A
Septic (Pyogenic) Arthritis
- Dx: Joint aspiration is the best test for confirming the diagnosis
Kocher criteria to distinguish septic joint from transient synovitis
1) Refusal to bear weight
2) Fever, Temp >38.5/101.3
3) ESR >40
4) WBC>12,000
CRP >25 (not part of the original Kocher criteria)
1= 3% probability of septic arthritis, 2= 40%, 3= 93%, 4= 99%
Rec: draw CBC, ESR, and CRP in all pts with clinical concern for septic arthritis or transient synovitis
17
Q
Legg Calve Perthes Disease
- ______ of the femoral head
- Ddx: Secondary to an underlying disease - corticosteroid use, sickle cell disease
- Pt:
- Hip pain and a limp (90% unilateral). Pain is insidious and worsens with activity
- Providers should consider the potential for interarticular hip pathology in any pt presenting with a limp and painful, restricted hip ROM. There should be a low threshold for obtaining radiographs in these pts, which should include an AP view of the pelvis and a “frog leg” lateral view of the hip. It is important to remember that hip pathology may present as knee pain, and the hip should always be examined in pts presenting with knee pain.
- Tx:
- Patients should be made ____
- Supportive care with PT and anti-inflammatory medications are the best treatment choice. Complete recovery typically takes ____.
A
Legg Calve Perthes Disease
- Avascular necrosis (osteonecrosis) of the femoral head
- Ddx: Secondary to an underlying disease - corticosteroid use, sickle cell disease
- Pt:
- Hip pain and a limp (90% unilateral). Pain is insidious and worsens with activity
- Providers should consider the potential for interarticular hip pathology in any pt presenting with a limp and painful, restricted hip ROM. There should be a low threshold for obtaining radiographs in these pts, which should include an AP view of the pelvis and a “frog leg” lateral view of the hip. It is important to remember that hip pathology may present as knee pain, and the hip should always be examined in pts presenting with knee pain.
- Tx:
- Patients should promptly be made non-weight bearing of the affected limb and instructions for activity restriction to reduce strain across the femoral head. Prompt referral to an orthopedist.
- Supportive care with PT and anti-inflammatory medications are the best treatment choice. Complete recovery typically takes 4-5 years.
18
Q
Slipped Capital Femoral Epiphysis
- Path: Posterior and inferior displacement of capital femoral epiphysis from femoral neck.
- RF: Obese child during early adolescence and near time of peak linear growth, boys, African Americans, those with endocrine dysfunction
- Associated with ____ and _____ deficiency
- Dx:
- In displaced SCFE (majority of cases): Capital femoral epiphysis slips posteriorly and medially relative to the femoral metaphysis (ice cream slipping off cone)
- A common radiographic finding is lack of extension of the epiphysis past the Kline line (a line along the superior edge of the femoral neck)
- Tx:
- Immediate nonweight bearing status, emergent ortho referral, surgical repair.
A
Slipped Capital Femoral Epiphysis
- Path: Posterior and inferior displacement of capital femoral epiphysis from femoral neck.
- RF: Obese child during early adolescence and near time of peak linear growth, boys, African Americans, those with endocrine dysfunction
- Associated with hypothyroidism and growth hormone deficiency
- Dx:
- In displaced SCFE (majority of cases): Capital femoral epiphysis slips posteriorly and medially relative to the femoral metaphysis (ice cream slipping off cone)
- A common radiographic finding is lack of extension of the epiphysis past the Kline line (a line along the superior edge of the femoral neck)
- Tx:
- Immediate nonweight bearing status, emergent ortho referral, surgical repair.
19
Q
Normal physiologic progression
- Genu varum up to ____yo followed by gene valgum at approx ____yo. By ___yo, most children return to normal physiologic vagus.
A
Normal physiologic progression
- Genu varum up to 2yo followed by gene valgum at approx 3yo. By 7yo, most children return to normal physiologic vagus.
20
Q
Blount Disease
- Pathologic ______ malformation caused by abnormal growth of the medial portion of the proximal tibial physis
- Infantile Blount
- Diagnosed <4yo
- Distinguish from physiologic varus
- Adolescent Blount: >4yo
- If exam demonstrates significant or asymmetric genu varus, radiographic exam must be performed.
- Plain radiographs show metaphysesal breaking (most common in the infantile form) and the tibial metaphysesal-diaphyseal angle is >16 degrees.
- Tx:
- Infantile Blount: Bracing for approx 2 years. If unsuccessful or angle is >20 degrees, surgery is indicated
- Surgical intervention usually needed for adolescent form.
A
Blount Disease
- Pathologic varus malformation caused by abnormal growth of the medial portion of the proximal tibial physis
- Infantile Blount
- Diagnosed <4yo
- Distinguish from physiologic varus
- Adolescent Blount: >4yo
- If exam demonstrates significant or asymmetric genu varus, radiographic exam must be performed.
- Plain radiographs show metaphysesal breaking (most common in the infantile form) and the tibial metaphysesal-diaphyseal angle is >16 degrees.
- Tx:
- Infantile Blount: Bracing for approx 2 years. If unsuccessful or angle is >20 degrees, surgery is indicated
- Surgical intervention usually needed for adolescent form.
21
Q
Genu varum (bowlegs) - Increases as children start to walk, but typically resolves by 2yo, at which point the knee should transition to valgus alignment (genu valgum) Genu valgus (knock knee) - Physiologic knee valgus peaks at 4yo and then decreases until final alignment is reached at about 7yo
- Radiography for genu valgum is indicated for children
- > ___yo with intermalleolar distances >__cm
- Intermalleolar measurements outside 2 STDs from the mean for age.
- With other indicators described earlier that increase the risk of associated pathology.
A
Genu varum (bowlegs) - Increases as children start to walk, but typically resolves by 2yo, at which point the knee should transition to valgus alignment (genu valgum) Genu valgus (knock knee) - Physiologic knee valgus peaks at 4yo and then decreases until final alignment is reached at about 7yo
- Radiography for genu valgum is indicated for children
- > 7yo with intermalleolar distances >8cm
- Intermalleolar measurements outside 2 STDs from the mean for age.
- With other indicators described earlier that increase the risk of associated pathology.
22
Q
Growing Pains
- Benign limb pains of unknown etiology that are not due to growing
- Pt: Typically bilateral deep sharp aching pain in the muscles of the legs. Occurs usually late in the day or during the night. There is no joint involvement, and inflammation is absent.
- Beware: The other diagnosis that causes nighttime bone pain (since it is difficult for most pts to differentiate bw bone and muscle pain) is malignancy.
- Unilateral symptoms require further evaluation.
- Children who should be evaluated for other conditions such as arthritis or infection: Activity-related pain, increasing pain intensity, joint swelling, limp, or constitutional symptoms (eg fever, malaise, or a decrease in activity)
- Tx: Reassurance. Generally disappear by _____yo.
- _______ and OTC analgesics are often helpful for accelerating pain relief
A
Growing Pains
- Benign limb pains of unknown etiology that are not due to growing
- Pt: Typically bilateral deep sharp aching pain in the muscles of the legs. Occurs usually late in the day or during the night. There is no joint involvement, and inflammation is absent.
- Beware: The other diagnosis that causes nighttime bone pain (since it is difficult for most pts to differentiate bw bone and muscle pain) is malignancy.
- Unilateral symptoms require further evaluation.
- Children who should be evaluated for other conditions such as arthritis or infection: Activity-related pain, increasing pain intensity, joint swelling, limp, or constitutional symptoms (eg fever, malaise, or a decrease in activity)
- Tx: Reassurance. Generally disappear by 12-13yo.
- Massage and OTC analgesics are often helpful for accelerating pain relief
23
Q
AMPLIFIED MUSCULOSKELETAL PAIN SYNDROMES
- Syndromes that cause noninflammatory musculoskeletal pain in children.
- Syndromes include juvenile fibromyalgia, complex regional pain syndrome, localized pain without autonomic changes, and intermittent pain.
- Path: AMP episodes are the result of amplified pain signs. The 3 primary causes include injury, illness, and psychological stressors.
- Pt:
- Pain experience is real
- Can present with one affected limb but can anywhere on the body and can also be diffuse.
A
AMPLIFIED MUSCULOSKELETAL PAIN SYNDROMES
- Syndromes that cause noninflammatory musculoskeletal pain in children.
- Syndromes include juvenile fibromyalgia, complex regional pain syndrome, localized pain without autonomic changes, and intermittent pain.
- Path: AMP episodes are the result of amplified pain signs. The 3 primary causes include injury, illness, and psychological stressors.
- Pt:
- Pain experience is real
- Can present with one affected limb but can anywhere on the body and can also be diffuse.
24
Q
Juvenile Fibromyalgia
- Hypersensitivity syndrome. ___ body areas of pain for at least ___ months
- Pt:
- Diffuse musculoskeletal pain with many points on tenderness on exam.
- Do NOT have evidence of articular swelling, loss of motion, or muscle weakness if these are present, look for another diagnosis
- Dx: Clinical
- Tx: OTC pain medications. Amitriptyline or cyclobenzaprine. Psychosocial intervention. No narcotics.
A
Juvenile Fibromyalgia
- Hypersensitivity syndrome. 3 body areas of pain for at least 3 months
- Pt:
- Diffuse musculoskeletal pain with many points on tenderness on exam.
- Do NOT have evidence of articular swelling, loss of motion, or muscle weakness if these are present, look for another diagnosis
- Dx: Clinical
- Tx: OTC pain medications. Amitriptyline or cyclobenzaprine. Psychosocial intervention. No narcotics.
25
Q
Complex regional pain syndrome (CRPS)
- Pt:
- Allodynia (pain aggravated by light touch) or hyperalgesia.
- Have localized autonomic dysfunction with edema, coolness or excess warmth, mottling, and/or sweatiness.
- Rule out _____ disorders
- Tx:
- PT/OT
- School absenteeism can be a big problem in pts with AMP syndromes. Be sure to ask about attendance
A
Complex regional pain syndrome (CRPS)
- Pt:
- Allodynia (pain aggravated by light touch) or hyperalgesia.
- Have localized autonomic dysfunction with edema, coolness or excess warmth, mottling, and/or sweatiness.
- Because fatigue and pain can be seen in some pts with an autoimmune disorder, such as SLE, Sjogren, and JIA, be sure to check appropriate laboratory tests (CBC, ESR, RF, ANA, anti-SSA and anti-SSB, CPK, thyroid function tests) to rule out these conditions.
- Tx:
- PT/OT
- School absenteeism can be a big problem in pts with AMP syndromes. Be sure to ask about attendance
26
Q
NON-NEOPLASTIC BONE LESIONS Nonossifying fibroma (NOF) - Pt: Small well defined radiolucent cortical lesion with surrounding rim of sclerosis.
- Management
- Small NOFs ________
- Nonossifying firms ____ carry a risk of pathologic fracture and should be followed every 6-12mo with radiographs
A
NON-NEOPLASTIC BONE LESIONS Nonossifying fibroma (NOF) - Pt: Small well defined radiolucent cortical lesion with surrounding rim of sclerosis.
- Management
- Small NOFs resolve spontaneously and do not require follow-up, reassurance for no tx
- Nonossifying firms >50% of bone’s diameter carry a risk of pathologic fracture and should be followed every 6-12mo with radiographs
27
Q
NON-NEOPLASTIC BONE LESIONS
Unicameral ‘simple’ bone cysts (UBCs)
- Fluid-filled cysts surrounded by a thin rim of bone
- Tx:
- Observation with serial plain films and, for larger lesions (>50% of the bone), ______
- Children with UBCs ______, should be referred to an ortho surgeon for tx.
A
NON-NEOPLASTIC BONE LESIONS
Unicameral ‘simple’ bone cysts (UBCs)
- Fluid-filled cysts surrounded by a thin rim of bone
- Tx:
- Observation with serial plain films and, for larger lesions (>50% of the bone), activity restriction to prevent fracture
- Children with UBCs in location where a fracture is likely to lead to surgery, such as the femoral neck, should be referred to an ortho surgeon for tx.
