Ortho Flashcards
1
Q
What Rotational Changes occur? (6)
A
Foot progression angle, Hip rotation, Thigh/Foot Axis, Metatarsus adductus, Calcaneouvalgus, Knee Alignment
2
Q
Torsional Conditions: Evaluation - history? (2) Exam? (5)
A
History
Progression of torsion
Preferred sleep and play positions
Examination
- Foot progression angle
- Hip rotation: Anteversion/Retroversion
- Thigh/Foot Axis: Tibial Torsion
- Metatarsus adductus
- Calcaneouvalgus
3
Q
Foot Progression Angle is? Includes? (4)
A
- Angle of where foot is facing in relation to straight line
- Includes all torsional segments
- Version of the hip
- Tibial torsion
- Forefoot position
4
Q
Angle between long axis of foot and progression of body degrees for in-toeing? Out? Normal? Mean?
A
In-toeing (-)
Out-toeing (+)
Normal: -3 to +20
Mean: +10
5
Q
Typical Progression: Foot Progression Angle?
A
Out-toeing which decreases over time
6
Q
How do you measure? Hip Rotation: Anteversion/Retroversion? What is version?
A
- Measure in prone with neutral hip extension
- “Version” is the relationship between femoral neck and shaft
7
Q
What is anteversion? (3) Retroversion? (3)
A
- Anteversion: Head of the femur is directed anteriorly
Internal rotation
In-toeing - Retroversion: Head of the femur is directed posteriorly
External rotation
Out-toeing
8
Q
Typical Progression: Hip Rotation - infants? The second resolve by? And? Total hip rotation = ? (3)
A
- Infants: Anteversion + ER contractures (appears to be out-toeing)
- ER contractures resolve by 5-6 years and anteversion becomes more apparent
- Total Hip Rotation (ER + IR)
Up to age 2: 120
Thereafter: 95-110
9
Q
Can’t in-toe 2/2? Version has to?
A
- ER contractures
- Version has to do with femoral neck alignment in relation to head
10
Q
How do you measure thigh foot axis? +/- = ?
A
- Measure of tibial torsion and angle of foot
- Long axis of foot vs. long axis of thigh
- Internal (-)
- External (+)
11
Q
Thigh Foot Axis - tx required if? What are they? (3)
A
- Treatment required if natural resolution does not happen
- Friedman Counter Strap
- Derotation Strap
- Dennis Browne Bar
12
Q
Thigh foot axis - if left untreated? (3)
A
Osteoarthritis of knee
Patellofemoral instability
Osgood Schlatters
13
Q
What is the trans malleolar axis?
A
Line along femur that bisects the malleoli
14
Q
Typical Progression: Thigh Foot Axis - infants? What happens with growth?
A
- Infants: Internal (-30 to +20)
- Spontaneous de-rotation with growth and onset of walking
15
Q
Metatarsus (forefoot) Adductus is how common? Position - forefoot? Hindfoot? DF ROM?
A
- Most common positional deformity in infants
- Forefoot: Curved medially
- Hindfoot: Slight valgus as is typical for infants
- Full dorsiflexion ROM
16
Q
Metatarsus (forefoot) Adductus tx for mild? Mod? Severe? Based on? If left untreated?
A
- Mild: resolves naturally
- Moderate: corrective shoes
- Severe: Joint manipulation and serial casting
- Based on flexibility
- If left un-treated: Increased risk of stress fractures
17
Q
Calcaneovalgus position? (2) Tx? Differential? It’s not just curvature, it’s an? Impacts?
A
- Forefoot: curved laterally
- Full or excessive dorsiflexion ROM
- Treatment: none, resolves naturally
- Differential: Vertical talus
- not just curvature, it’s an alteration of position of talus
- impacts DF ROM
18
Q
Typical Progression: Knee Alignment - newborn? 1-2 yrs? 2-4? 4-16?
A
Newborn: Peak Varum
1-2 Years: Straight
2-4 Years: Peak Valgum
4-16 years: Approaching sex-specific norm
19
Q
Rotational Profile - what do you look at for hip, tibia (2), foot? in-toeing - foot, tibia, hip?
A
Hip - version and total rotational profile
Tibia - trans malleolar axis
Thigh foot axis - incorporates position of foot
Foot - heel bisect or and what toes it’s bisecting
Foot: Metatarsus adductus
Tibia: Internal tibial torsion
Hip: Femoral anteversion
20
Q
Rotational Profile - out-toeing - foot, tibia, hip?
A
Foot: Calcaneovaltus
Tibia: External tibial torsion
Hip: Contracture of external rotators
21
Q
Developmental Dysplasia of the Hip is? Wide range of severity? (5)
A
- General “looseness” or “instability” of the hip joint
- Wide range of severity
Normal
Subluxable - in joint but can move a bit
Dislocatable - can be totally popped out
Subluxed - is kind of out of joint
Dislocated - completely out of joint
22
Q
Developmental Dysplasia of the Hip: Risk Factors - mechanical? (3) Physiologic? (2)
A
Mechanical
Small intrauterine space
Breech position
Hips on mothers sacrum
Physiologic
Estrogen and relaxin effecting the female fetus
6:1 female risk factor
23
Q
Developmental Dysplasia of the Hip: Risk Factors - environmental? (3)
A
Swaddling
Positioning
Carrying
24
Q
Developmental Dysplasia of the Hip: Evaluation (4) Imaging used?
A
- Hip ROM: Limited abduction
- Asymmetry of thigh folds
- Apparent shortening of femur/uneven knees (“Galeazzi Sign”)
- Hip “clicks” are usually insignificant
- Imaging (ultrasound) bc of radiation; bones are made out of cartilage, don’t show up on xray
25
Developmental Dysplasia of the Hip: Evaluation techniques? (2) Describe each. These signs disappear when?
- Barlow: Dislocates over the posterior rim; IR and pressure
- Ortolani: reduces dislocation: ER and flexion
- These signs disappear by 2 months, limited abduction is the only sign after that
26
Developmental Dysplasia of the Hip: Intervention goal? Infants (12 mos? Without intervention? (4)
- Goal: Relocate and preserve joint shape
Infants (12 months: Surgical intervention
- Without Intervention
Hip replacement
AVN
Femoral nerve palsy
Erosion of the acetabular rim
27
Legg Calve Perthes Disease (LCPD) is? Caused by? (2) Most common presentation? Resolves how? What kids do best? Most common presentation?
- AVN of the ossific nucleus of the femoral head – medial circumflex artery
- Unknown cause
- 2nd hand smoke??
Small, active children
5-10 years old
Learning disabilities
More common in males
- Spontaneous resolution over 1-3 years
- Children
28
LCPD exam findings? (5) Tx? (3)
```
Limp
Trandelenburg gait
Limited abduction, internal rotation
X-Ray: Subchondral fracture, femoral head collapse, coxa magnum (head doesn't grow in the confines of the acetabulum)
Pain: Groin, medial thigh, medial knee
```
Treatment: WIDE RANGE – observation, casting, derotational osteotomy
29
Slipped Capital Femoral Ephiphysis (SCFE) types? (3) Risk factors? (3)
Types
Acute: Significant trauma
Acute on Chronic: Chronic slip, trauma makes it worse
Chronic: Most common type
- Risk factors:
Obesity
African american
Males
30
SCFE exam? (4) Intervention? (2) Primary responsibility is? Should monitor?
```
Examination
Pain: Groin, medial thigh, medial knee
Hip held in ER
Hip moves passively into ER with hip flexion
50% of cases are bilateral
```
Intervention:
Pinning surgery ( head to neck approximation)
Non weight bearing
- should monitor other side
- NWB crutch walking
31
Blount's disease aka? What is it? Differential from? (3)
- Infantile Tibial Vara
- Compression at the medial knee causes suppression of growth that gets worse, not better, over time
- Differential from typical genu varum, rickets, Vitamin D deficiency
32
Blount’s Disease: Infantile Tibial Vara: Evaluation? (4) Intervention? (2)
Thickening of medial tibial cortex
Breaking of medial metaphysis
Lateral thrust of knee in stance
Overweight, early walkers
Intervention
HKAFO 23 hours per day
Surgery
33
Leg Length Discrepancies - what's considered normal? Causes? (3) Impairments? (3)
-
34
Leg Length Discrepancies: Evaluation & quantification? (5)
- Level pelvis with blocks under foot, measure blocks
- Tape measure
- ASIS to: medial malleolus, lateral mallelous, heel pad
- Umbilicus to heel pad
- Radiologic measurements - scannogram
35
Leg length intervention? (4)
Conservative: Shoe lift
Surgical: Mosely graph predicts growth, can help time
Stop growth in the longer leg by damaging the growth plate
Lengthen the shorter leg
36
Lengthening the Shorter Leg- Factors to consider? (2)
Soft tissue mobility
| Stability of joints above and below
37
Physeal Distraction – the Illizarov Method (4) Stop what?
- Can also correct rotational deformities
- 1mm per day, ¼ mm 4 times per day
- Active participation in PT while device is in place
- Pain can be significant, extended
- Stopping Growth in the Longer Leg
38
“Club Foot” Talipes Equinovarus: Examination - what kind of muscles? Position of ankle? Forefoot? Hindfoot? Calcaneous? Talar head? Cause? (3)
```
- Hypoplastic muscles
Position
- Ankle: Plantarflexion
- Forefoot: Adduction + Pronation (Medially curved)
- Hindfoot: Varus
- Calcaneous: Small
- Talar Head: Small and flattened
- Cause – largely unclear
- Positional
- Associated with other disorders
```
39
“Club Foot” Talipes Equinovarus: Intervention? (4) Goal? (3)
- Ponseti Method:
- Serial Casting in 70 degrees abd forefoot
- Talonavicular joint reduction
- Percutaneous Achilles tendon lengthening
- Goal: Restore alignment, allow for weight bearing and ambulation
40
Congenital Limb Deficiencies - % of the two categories? Most are? How common? Typically? Most common type?
- 40% acquired
- 60% congenital
- Most are spontaneous mutations
- 30% of children are effected in more than one limb
- Typically unilateral
- Left elbow in females
41
Spranger’s Classifications? (4)
malformation
disruption
deformation
dysplasia
42
What is a malformation? (3)
- incomplete in development
- Longitudinal deficiencies
- Cleft palate, atrial septal defect
43
What is disruption? (3)
- cessation of development due to outside force
- Transverse deficiencies
- Amniotic band syndrome
44
What is deformation? (3)
- developed in full, but the wrong shape
- Can be corrected with bracing, taping, splinting, casting
- Rotational changes, LCPD, SCFE
45
What is dysplasia? (3)
- developed in full, but atypical differentiation throughout
- Effects a whole system
- Osteogenesis imperfecta, arthrogryposis
46
Skeletal deficiencies? (2)
- Transverse: Typical development to a particular point, then stops
- Longitudinal: Elements missing along the long axis
47
Congenital Limb Deficiencies most are from? 20-30% of kids effected have? Most transverse deficiencies are? Most common?
- Most are from sporadic mutations
- 20-30% of children effected have more than 1 limb involved
- Most transverse deficiencies are unilateral
- Most common: Left, transverse below elbow, females
48
Proximal Femoral Focal Deficiency (PFFD) is a? What may be involved? (5) Severity graded how? (5)
- Congenital absence or hypoplasia of the proximal femur.
- Acetabulum, femoral head, patella, tibia and fibula may be involved.
- Severity graded A – D
- Femoral head presence, shape
- Acetabulum presence, shape
- Femur length
- Joint presence, articulation
49
Acquired Amputations majority to? Minority due to? (3)
70-85% due to trauma
15-30% due to disease
Ewing’s Sarcoma
Osteosarcoma
50
Acquired Amputations: Surgical Interventions? (4)
- Further amputation to revise residual limb
- Limb replantation
- Upper more successful than lower extremity
- Children achieve better functional outcomes than adults
51
Phantom Sensations? (2)
Increasing prevalence with age
| Not always pain
52
Scoliosis: Evaluation? Screening? (4)
Deviation of spinal axis
Shoulder and pelvic asymmetries
Forward bend test
Scoliometer
Radiography
53
Risser Sign? (3)
Skeletal Maturity
Graded 0-5
Based on ossification of iliac crest
54
Cobb Angle? (4)
- Severity of Curvature
- End vertebrae are cephalic and caudal with most tilt
- Intersection of lines perpendicular to end vertebrae
- >10 is diagnostic
55
Scoliosis Descriptors? (3)
Direction of curve: Convex side
Magnitude: with Cobb Angle
Flexibility
56
Scioliotic flexibility? (2) Non-structural? (2)
- Structural
>> Cannot be corrected
>> Vertebrae rotate towards the convex side -> Rib hump
- Non-Structural
>> Corrects with sidebend towards the convex side
>> Usually non-progressive
57
Most curves are? If L is identified...? Non-structural corrects with? Non-struc is usually?
- 90% of thoracic curves are R. If Left curve is identified, more extensive evaluation is needed
- Non-structural corrects with side bend towards apex – the “direction of the curve” side.
- Non- structural is usually non-progressive
58
Types of Scoliosis? (3)
Congenital
Neuromuscular
Idiopathic
59
Congenital Scoliosis caused by? (3) May have? Many become?
Go back
```
- Caused by anomalous vertebral development
>> Error in segmentation
>> Error in formation
- May have a rotational component
>> Kyphoscoliosis
>> Lordoscoliosis
- Many become stable and do not progress
```
60
Neuromuscular Scoliosis - types? (2) Develop when? Tend to be? Most associated with? Tx? (3)
- Long, C type curves, may become S curves with compensation
- Develop at a young age
- Tend to be progressive
- Most associated with SCI in young children, SMA or MD
Treatment
Botox
Custom seating
Surgery
61
Idiopathic Scoliosis - type? Cause? How common? Types? (3)
- Lateral curvature of unknown cause
- Most common form in children
- Infantile, Juvenile or Adolescent
62
Adolescent Idiopathic Scoliosis (AIS) - most cases are? Who gets them more? Most curves are? Performance levels? (2)
- 80% of all idiopathic scoliosis cases
- 3.6:1 Female:Male ratio
- 5:1 with curves > 20o
- 1.4:1 with curves
63
Adolescent Idiopathic Scoliosis - progression is defined as? Increased risk for? (5)
- Progression is defined as a change of > 5o on two consecutive exams
- Increased risk for progression
- Younger age/lower Risser sign at dx
- Double curve patterns
- Inc Curvature
- Females
64
Females are...?
Females are 10 times more likely to progress than males with the same magnitude
65
Adolescent Idiopathic Scoliosis: Intervention, Non-Surgical candidates? (2) Exam how often? Tx?
- Idiopathic curves
66
One technique for tx?
Shroth technique - kids learn to understand movement of their spine and how to pelvic tilt
67
Adolescent Idiopathic Scoliosis: Intervention, Exercise - used as? Exercise goals? (4) Exercise alone has?
- Used as first line of intervention for curves >20o
- Exercise goals
> Maintain or improve trunk and pelvic strength
> Improve lateral flexion and trunk shift ROM
> Stretching: Pectorals and lower extremities
> Increase lung capacity and volume
- Exercise alone has not been shown to prevent progression, even with high patient compliance
68
Adolescent Idiopathic Scoliosis: Intervention, Orthotic Management - indications? (2) Impact of orthotic mgmt?
- Skeletally immature (Risser Sign 0-2)
- Curve from 25-45o
- Impact of orthotic management decreases as size of curve increases.
69
Types of braces? (3)
- Charleston: Worn only at night, positions in significant sidebend
- Milwaukee: rarely used
- Boston: worn during day; causes PPT to increase invertebral space
70
Adolescent Idiopathic Scoliosis continues until? Exercise should be? How long to wean from brace? May progress how? Tx is successful if?
- Continues until curve is no longer controlled or skeletal maturity is reached
- Exercise should still be performed while wearing the brace
- 12 months to wean from brace
- May progress a small amount after brace is discontinued
- Treatment is “successful” if curve is no more than 5o different from when brace was discontinued
71
Curve is uncontrolled when? 1/4 do what?
Curve is “uncontrolled“ when >40 degrees. About ¼ of curves progress even with orthotics
72
Adolescent Idiopathic Scoliosis: Intervention, Surgical for what curves? Goals of surgical intervention? (5) What approach most common? More advanced curves may?
- For curves >40o
Goals of surgical intervention
- Halt progression
- Prevent complications
- Achieve maximal correction
- Balanced trunk
- Solid fusion
- Posterior approach is most common
- More advanced curves may include both anterior and posterior approach
73
Surgery complications? (2)
pain, pulmonary dysfuncition
74
Adolescent Idiopathic Scoliosis: Intervention, Surgical - two other forms?
- Bone graft packed into disk spaces and facet joints
| - Metal stabilization “rods”
75
Three types of rods used? Describe each (3), (2)
```
- Harrington
> Does not allow sagittal plane correction
> Rarely used
> Flattened lumbar lordosis
- Luque
> Prevents loss of lumbar lordosis
> Risk of neurological damage
- Cotrel-Dubousset
```
76
Adolescent Idiopathic Scoliosis: Intervention, Post-Op Care (2)
- Orthosis for 9-12 months – until fusion is “solid” on radiographs
- Average hospital stay: 5-7 days
77
Role of PT? (5)
- Precautions lifted gradually over 1 year by MD
- No trunk rotation
- No lifting >5 lbs.
- Donning/doffing prosthesis – to be done in bed (may be limited in overhead motion)
- Encourage functional mobility, isometrics
78
Arthrogryposis Multiplex Congenita (AMC) present when? Etiology? Hallmarks? (5) Most kids? Majority are?
- Present at birth, non-progressive
- Unknown etiology
- Hallmarks of the disease
> Joint contractures in 2 or more body areas
> Lack of muscle development/weakness
> Featureless, cylindrical extremities
> Fibrosis
> Decreased DTRs
- Most children effected are bright and motivated
- Majority of cases are not genetically based
79
Arthrogryposis Multiplex Congenita (AMC) - findings?
xx
80
xx
xx
81
Arthrogryposis Multiplex Congenita (AMC): Intervention? (5)
- Well timed surgical intervention
- Club foot repair when standing
- Debate over surgically reducing dislocated hips
- Knee flexion contracture when ambulating
- Shoulders are rarely addressed surgically
82
AMC PT? (8)
```
Positioning
Splinting
Stretching
Normalizing development
Balance Skills
With aging
Pain management
Wheelchair training
```
83
Osteogenesis Imperfecta - what kind of problem? (2) Manifestations? (3)
- Inherited connective tissue disorder – many different mutations
- matrix, type I collagen problem
Bowing of long bones
Spinal deformities
Recurrent fractures with minimal trauma
84
Osteogenesis Imperfecta May also exhibit? (6)
```
Blue sclera
Dental deformities
Hearing loss
Growth deficiency
Easy bruising
Excessive sweating
```
85
Osteogenesis Imperfecta: Intervention - goal? (5)
- Goal: Prevent deformities
- Limit immobilization
- Scoliosis cannot be managed with brace
- Internal fixation with IM rods and/or spinal fusion
- Fracture risk decreases by puberty in most patients
86
Osteogenesis Imperfecta: PT Interventions? (4)
Strengthening
Environmental adaptation
Caregiver education
Encouraging independence and social integration
