Ortho Flashcards
torticollis in infancy
wry (twisted) neck deformity
contracture of the sternocleidomastoid (forms an intramuscular fibroma)
torticollis is caused in newborns by
uterine malposition (breech delivery) birth trauma
DDx of torticollis in older CH
neurogenic/CNS mass inflammatory (local head & neck infxns) traumatic ocular strabismus hysterical & psychiatric
Dx of torticollis often requires?
simple radiographs
consider CT of brain to uncover neurogenic causes
tx of torticollis
ROM exercises
occasionally surgically released
scoliosis is?
lateral curvature of the spine
often assoc. w/ rotation
idiopathic in 80% of cases
historical factors suggesting a pathologic cause
pain
left thoracic curves are more often associated w/ spinal pathology (syrinx or tumor)
stifness
midline skin lesion
screening exam for scoliosis should be performed when?
< 12 yrs
standing erect (plumb line) and toe-touch
leg length comparison (screeens for compensatory scoliosis)
radiographs for scoliosis indicated for?
5 degrees or more
higher risk of progression
DDx of pathologic scoliosis
secondary congenital neuromuscular constitutional traumatic neoplastic
secondary scoliosis
muscle spasm
leg length discrepancy
congenital scoliosis
d/o of spinal development
often w/ bone, renal, urogenital or neural abnormalities
neuromuscular scoliosis
cerebral palsy
polio
muscular dystrophy
spinal muscular atrophy
constitutional scoliosis
metabolic d/o’s
athritides
scoliosis curve severity
0-15 degrees 15-25 25-45 45+ 60+
mgnt of scoliosis
unlikely to progress monitor regularly bracing vs. operative operative intervention may cause pulmonary compromise
CH & walking general info
infants bend their hips, knees & ankles more than adults to improve balance
their ft are externally rotated & widely spread
they walk at a faster cadence but a slower velocity b/c of shorter stride length
on avg, infants begin to crawl when
9 months
on avg kids begin to walk w/ assistance at
12-14 months
on avg. kids begin to walk independently when
15 months
on avg kids begin to run when?
@ 18 months
ch develop a nml adult gait pattern around what age?
3 yo
genu varum
tibial bowing
nml up to 6 mon-2yrs
genu valgum
knock knees
nml at ages 3-8 yrs
concerning features of a limp
nocturnal pain/limp
pain at rest
systemic findings: fever, wt loss, lymphadenopathy, HSM
pain out of proportion to exam findings
PE for limping
general exam, inspect bilaterally attention to contusions, erythema, edema, rashes & temp of affected area ROM of affected & adjacent joints neurovascular status & strength gait: do your best
plain radiographs
fx, effusion, lytic lesions, osteoid osteoma
knee pain may be reflection of hip patho
in CH that lacks obvious focus of pain
limited in acute osteomylelits
why are plain radiographs limited in acute osteomyelitis?
appears on x-ray up to 1 wk after onset of pain
ULS for limping
effusion- esp. for hips
developmental dysplasia of hip
bone scan for limping
useful for eval of acute osteomyelitis & suble fx’s
MRI for limping
mores specific for osteomyelitis & neoplasm
labs for infxn & limping
CBC blood cx ESR CRP consider Lyme titers
labs for muscle tenderness & limping
CK
renal fx if CK elevated
return to exam to ensure no necrotizing fasciitis
joint aspiration & limping
include Gram stain, cx, cell count, glucose & protein of fluid
DDx of limping- causes localized to the limb
strain, sprain, contusion fx limp length inequality transient (toxic) synovitis septic arthritis osteomyelitis developmental dysplasia of hip (DDH) slipped capital femoral epiphysis (SCFE) Legg-Calve-Perthes dz (LCPD) Osgood-Schlatter patellofemoral syndrome osteoid osteoma neoplasm of bone, joint of soft tissue
DDx for limping trivial causes
hair tourniquets (may NOT be trivial) blisters nail trauma ill-fitting shoes subcutaneous FBs plantar warts
DDx for limping & systemic causes of arthritis
Henoch-Schoenlein purpura (HSP) rheumatologic dz Kawasaki dz serum sickness Lyme dz IBD gonorrhea & meningococcemia neoplasm
DDx limping and abdominal pathology
appendicitis
psoas muscle abscess
DDx limping and pelvic pathology
PID or abscess
ovarian torsion/cysts
DDx limping & genitourinary pathology
testicular torsion/ epididymitis
urolithiasis
inguinal hernia
DDx limping & back pathology
muscle strain
discitis, herniated disc
spondylysis/spondyloslisthesis
DDx limping & neurologic pathology
tumor: spinal/cerebral/cerebellar/retroperitoneal
stroke
A 0-2 yr old comes into the office with hip pain. What’s on your DDx?
DDH (developmental dysplasia of hip)
septic arthritis
A 3-5 yr old comes into the office w/ hip pain. What is on your DDx?
transient synovitis
A 4-7 yr old comes into the office w/ hip pain. What is your DDx?
Legg-Calve-Perthes
A 10-15 yr old comes into office w/ hip pain. DDx?
SCFE
A 0-2 yr old w/ knee pain. DDx?
septic arthritis
A 10-15 yr old w/ knee pain. DDx?
subluxing patella chondromalacia
Osgood Schlatter
Tibia pain in 0-2 yr old. DDx?
toddler fx
tibia pain in 3-5 yr old. DDx?
“growing pains”
tibia pain in 10-15 yr old. DDx?
stress fx
spine pain in a 3-5 yr old. DDx?
discitis
spine pain in 10-15 yr old. DDx?
spondylolisthesis
0-5 yr old with any limb pain. DDx?
JRA
Leukemia
Cerebral Palsy
Osteomyelitis
4-7 yr old with any limb pain. DDx?
osteomyelitis
10-15 yr old with any limb pain. DDx?
bone tumor
osteomyelitis
what is the MCC of limp in children?
trauma
greenstick fxs reflect the unique ability of kids’ bones to ?
bend
MC mechanism in toddler’s fractures
twisting or tripping
what is more common? soft tissue or bone injury
soft tissue injury
MC ID’d fx in preschool children (ages 9mo to 3 yrs) presenting w/ a limp
toddler’s fx
what is a toddler’s fx
nondisplaced spiral or oblique fx of lower third of tibial shaft
the MC presentation of toddler’s fx
child refuses to bear wt on affected leg
hx of minimal or no trauma
what do you find on PE in toddler’s fx
possibly warmth & pain w/ palpation
usually no swelling
pain w/ gentle torsion of the foot
pathophys of toddler’s fx
sudden twisting of tibia
fx more obvious 10-14 days after injury (callus formation)
generally heals w/ subperiosteal new bone formation running entire length of tibia (indicates fx more extensive & likely extends up the shaft through middle & proximal 1/3)
tx of toddler’s fx
long leg cast immobilization
what is developmental dysplasia of the hip
displacement of th efemoral head from its nml position in the acetabulum- affects nml development of both
dislocation in DDH
femoral head completely outside of the acetabulum
subluxable in DDH
femoral head can be displaced outside of acetabulum
dysplasia in DDH
radiographic abnormality
in DDH children often walk on what?
affected side’s toes to compensate for short limb
risk factors in DDH
female gender breech malposition FH of DDH limited fetal mobility clinical evidence of joint instability significant persistent hip asymmetry
hx in DDH
prenatal hx (breech, gestation, birthweight) MS abnormalities FH of DDH ethnic background postnatal risk factors
examination of DDH
screen on every well child visit
0-4 mo check hip instability via Ortolani maneuver, Barlow maneuver
4 mo leg length/abduction-Galeazzi sign
12 mo+- trendelenburg’s sign
imaging of DDH
plain films- incrase inusefulness beyond 4 months of age; widened pelvic floor; decreased femoral head coverage; femoral ossific nucleus
ULS- requires static & dynamic images, trained
Dx DDH
reg. well child visit screening- follow clics for 1st 2 wks, refer clunks (subluxation, dislocation on exam)
work up- ULS < 5 months, plain films > 4months
tx of DDH < 6 mo old
Pavlik harness- prevent hip extension & abduction
tx of DDH > 6 mo old
open or closed reduction
what is Legg-Calve-Perthes dz
avascular necrosis of proximal femoral head
Legg-Calve-Perthes dz is predominately?
unilateral
both hips are involved in less than 10% of cases
hips are involved successively, not simultaneously
Legg-Calve-Perthes dz may have insidious onset or may occur after?
hip injury
coagulation or endocrine abnormalities may also contribute to cause
pathophysiology of Legg-Calve-Perthes dz
- rapid growth relative to blood supply development of secondary ossification centers in epiphysis
- causes interruption of adequate blood flow & results in avascular necrosis (necrosis, removal of necrotic tissue, & replacement w/ new bone)
- bone replacement may result in nml bone
frequency of Legg-Calve-Perthes dz
4/100,00
usually bet 4-10 yr old (mean age 7 yo)
boys>girls 4:1
white children affected more
sx’s of Legg-Calve-Perthes dz
antalgic limp, pain typically mild
pain often gradual onset, intermittent & referred to thigh or knee
pain usually worsens w/ activity
exam of Legg-Calve-Perthes dz
loss of medial rotation
loss of abduction
acute radiographic signs in Legg-Calve-Perthes dz
- small femoral epiphysis (96%)
- sclerosis of femoral head w/ sequestration & collapse (82%)
- widening of joint space d/t thickening of cartilage, failure of epiphyseal growth, the presence of joint fluid, or joint laxity (60%)
- fx line between avascular center of the femoral head & the subchondral bone
what does a bone scan show in LCP dz
reduced uptake
what does an MRI show in LCP dz
marrow necrosis
irregularity of the femoral head
loss of signal from affected side
non-operative mgnt of LCP dz
prevent deformity & osteoarthritis
- restoration/maint of ROM
- prevention of subluxation
- attainment of a spherical femoral head at healing
- bed rest & NSAIDs
- abduction bracing until lateral portion of femoral head has regenerated (12-18 mo)
- surgery for sever dz
Slipped Capital Femoral Epiphysis (SCFE)
structural failure of the upper femoral physis that allows displacement of the femoral head on the neck
- frequently misdiagnosed
- early tx leads to better outcome but there are freq. delays in dx
what is the MC hip abnormality presenting in school age or adolescence (age 7-15)?
slipped capital femoral epiphysis
what is a primary cause of osteoarthritis?
SCFE
what is the key predisposing factor in SCFE?
obesity
almost exclusive incidence of SCFE during adolescent growth spurt suggest?
hormonal role
pathophysiology of SCFE
Salter-Harris type 1fx thru proximal femoral physis
- physeal cartilage weak
- hip stress–>shear force at growth plate–>epiphysis to move posteriorly & medially
- blood supply tenuous & frequently lost after fx
manipulation of SCFE frequently results in what?
osteonecrosis & chondrolysis d/t tenuous blood supply
frequency of SCFE
m>f >AA typically occurs after onset of puberty freq. in overwt, skeletally immature boys slippage is bilateral in 20-37%
sx’s of SCFE
hip & knee pain
insidious onset
antalgic limp
out-toeing (to avoid internal rotation)
signs of SCFE
- thigh may be shortened, externally rotated, and abducted
- internal rotation & abduction limited by pain
- tenderness on palpation of hip w/ discomfort often referred to hip, groin, or thigh
early radiologic findings in SCFE
widening of growth plate & osteopenia of the involved femoral head & neck
late radiologic findings of SCFE
displacement of the femoral neck relative to the femoral head
“ice cream scoop falling off the cone”
acute signs of SCFE
widened physis
lateral frog leg readiograph- demonstrates slippage earliest, slippage begins w/ posterior displacement & prgresses w/ medial rotation
line of Klein
line drawn along lateral aspect of femoral neck on AP view
line should intersect a portion of femoral head
tx of SCFE
fixation: using a screw
osteotomy-attempts to change head alignment may predispose to avascular necrosis
goal- avoid chondrolysis, AVN, degenerative arthritis
what is a common cause of knee pain in active adolescents?
osgood-schlatter dz
how do you dx osgood-schlatter dz
characteristic localized pain at tibial tuberosity
*radiographs not needed for dx, but do confirm clinical suspicion & exclude other causes of knee pain
pathophysiology of Osgood-Schlatter dz
most cases caused by micro trauma in deep fibers of patellar tendon at insertion on tibial tuberosity (avulsion mya be present)
usually d/t quadriceps femoris
s/sx of Osgood-Schlatter dz
pain heat tenderness soft-tissue edema at tibial tuberosity thickening & indistinct margins of patellar tendon
cartilaginous tibial tuberosity in Osgood-Schlatter dz
no initial change
after 3-4 wks, fragmented ossification visible w/in tendon
ossified tibial tuberosity in Osgood-Schlatter Dz
linear or nodular avulsed bony fragments
bony defect at donor site
tx for Osgood-Schlatter Dz
conservative
- NSAIDs
- application of ice
- avoid stress on knee caused by quads loading
- possible brief period of inactivity
- stretching of quads & hamstrings to reduce stress on tubercle
- usually self-limited & resolves w/ skeletal maturity
osteoid osteoma
benign skeletal tumor
osteoid osteoma presents as?
severe pain, worse at night & with activity
osteoid osteoma dramatically improves w/ what?
NSAIDs
what will you see on x-ray in osteoid osteoma?
radiolucent nidus 2-3 mm diameter w/ large, dense reactive bone growth
CT can confirm
osteochondroma
benign focal neoplasm
non-painful swelling, may be irritated by athletic activity
osteosarcoma
malignant focal neoplasm
typically painful
common at metaphysis of long bone
“sunburst” pattern on x-ray
Ewing’s sarcoma
malignant focal neoplasm
typically painful
name some systemic neoplasms
leukemias & lymphomas
metastases from other sites
pain from leukemia is often described as?
a deep, boring pain that awakens a child from sleep
*up to 25% of pts w/ leukemia present w/ limp, bone pain or refusal to walk as a primary complaint
