Ortho Flashcards
1
Q
Common ortho congenital defects?
A
- clubfoot (most common)
- developmental dysplasia of the hip (DDH)
- legg-calve-perthes disease (hip osteonecrosis)
- spine deformities (scoliosis and kyphosis)
- muscular dystrophy
- limb defects
2
Q
What is clubfoot? How common? Tx?
A
- Talipes equinovarus
- 1/1000 births, 50% bilateral
- anatomic changes: talus plantar flexed, heel cord tight, fore foot adducted/supinated
tx: - most can be tx conservatively
- Ponseti method: casting +percutaneous heel cord lengthening (gold std)
- severe, long-standing deformity may require several surgeries
- serial casting, bracing
3
Q
What is DDH? Incidence? Presentation?
A
- loss of normal femoral head-acetabular relationship/stability: 2.7-17/1000 live birhts
- caused by physiological and mechanical factors: ligamentous laxity, hormonal and familial factors, breech position and congenital deformities
- wide range of presentations:
- hip that is reduced but is unstable and can be dislocated
- dislocation can be reduced
- fixed dislocation that can’t be reduced
- bony deformities that reqr surgery
- all cases may not be detectable at birth: late cases are not always cases of missed dx
- routine sonography isn’t cost effective
4
Q
What is Barlow and ortolani test?
A
- barlow: hip is reduced but can be dislocated
- ortolani: hip is dislocated but can be reduced
(clunk positive sign while being reduced) - lack of full abduction: hip is out and it can’t be reduced
5
Q
Tx of DDH?
A
- depends on extent of defomrity and if hip can be reduced
- if hip can be reduced, harness or pillow first 6 months of life, confirm reduction with u/s after 3 weeks, effective 90% of time
- if hip won’t stay in, reduce under anesthesia, hold with spica cast: confirm reduction with U/S after 3 weeks, femoral head isn’t visible on x-ray for 4-6 months
- if it still won’t stay in: need surgery, femoral and/or acetabular osteotomy
- if femoral head can be held in normal relationship with socket: pt will develop a normal hip
6
Q
Hip abduction devices?
A
- pavlik harness (most common)
- Frejka pillow
- boch harness
7
Q
What is Legg-Calve-Perthes Disease?
A
- males 3-11
- loss of blood supply to femoral head:
head can collapse and subluxation of femoral head, eventually revascularizes, but may not occur until fixed deformity present - variable hip/knee sxs: limping and pain
- limited internal rotation and abduction of hip
8
Q
Tx of Legg-Calve-Perthes disease?
A
- reduce pressure on femoral head: relative rest braces, crutches traction adductor muscle release - correct resulting deformity: femoral and/or acetabular osteotomy (later on in life)
9
Q
What is scoliosis, diff types?
A
- lateral curvature of spine of more than 10 degrees by cobb method (become concerned when over 25 degrees)
- types:
idiopathic
congenital
secondary
neuromuscular
10
Q
Idiopathic scoliosis? Forms?
A
- infantile (birth -3 yrs): 1%
- juvenile (4-9): 12-21%
- adolescent (10 yrs - end of growth): 80-90%
- forms:
lumbar, thoracic, thoracolumbar
11
Q
Adolescent idiopathic scoliosis?
A
- lateral curvature of spine with rotation in child older than 11 without any obvious cause
- most common type
- typically right thoracic curve
- frequency: 1.9-3%
- family hx: 30%
- more severe forms more common in females
12
Q
Dx adolescent idiopathic scoliosis?
A
- adam’s forward bend test
- radiographic exam: AP and lat full length of spine while standing
- MRI: useful if neuro deficits, neck stiffness or HA
- usually R scapulae becomes more prominent
13
Q
What is kyphosis? More common in who?
A
- increased thoracic curvature in saggital plane
- postural: usually seen in girls, gentler, more pliable curve
- corrects with time/bracing
14
Q
What is Scheuermann’s disease?
A
- more severe: in boys more, but not that common
- osteochondrosis of the spine
- ring apophyses don’t develop normally, resulting in wedged vertebra
- sharper, more rigid curve
- may need surgical correction
15
Q
What is muscular dystrophy? Signs?
A
- progressive weakness and wasting of muscles
- onset: 3-5, genetic: primarily males
- clumsiness, frequent falls, **difficulty climbing stairs, running, riding bike, waddling gait, breathing muscles become affected, life threatening infections common
16
Q
Dx and tx of muscular dystrophy?
A
- dx: bx, EMG
- tx: PT/OT, bracing, surgery (scoliosis)
17
Q
Tx of limb defects?
A
- live with deformity
- referral to ortho specialist for reconstruction surgery
18
Q
Normal musculoskeletal variants?
A
- metatarsus adductus
- axial rotation
- idiopathic toe walking
- pes cavus (flat foot)
- angular variations:
genu varus (bow legged)
genu valgus (knock-knees)
19
Q
What is metatarsus adductus?
A
- excessive amt of adduction of metatarsals relative to long axis of foot
- **most common congenital foot deformity
- female more than males affected
- left more than right
- most likely cause: intrauterine restriction
- 85-90% resolve spontaneously by 1
20
Q
Management of metataruss adductus?
A
- flexible metatarsus adductus: stretching 5x at each diaper change
- flexible MA beyond 8 mo: referral for biweekly casting, correction usually achieved in 3-4 casts
- extreme adduction of great toe: surgical release of abductor hallucis done b/t 6-18 months of age
21
Q
Toe in axial rotation causes?
A
- internal femoral torsion (too much hip anteversion) - results from W sitting
- internal tibial torsion (most common cause): results from intrauterine positioning
- metatarsus adductus
22
Q
Toe-out axial rotation causes?
A
- external femoral torsion (too much hip retroversion): results from intrauterine positioning
- external rotation contracture
- external tibial torsion
- flat foot
23
Q
Tx of axial rotation at diff ages? When is surgery considered?
A
- infant: good sleeping positions (back or side)
- toddler: good sitting habits (avoid sitting in positions with exaggerated lower limb deformation)
- nocturnal bar (dennis browne bar) for internal tibial torsion present after 18 months
- weekly corrective casting for 4-5 weeks if no better by age 4
surgery if:
-failure to correct spontaneously with growth, gross asymmetric deformity, sx evolving congenital or neuromuscular conditions
24
Q
What is idiopathic toe walking? Assoc with?
A
- walk with toe-toe gait pattern in absence of any known cause
- dx of exclusion
- prevalence not well described
- may have good ankle ROM or more fixed contractures
- etiology unclear
- typically seen in kids less than 4
- often assoc with subtle neuro abnormalities such as speech and language delay
25
What is tx if contracture is present in idiopathic toe walking?
- PT/OT (stretching, strengthening, and gait training)
- orthotics (night and day)
- serial casting (if past age 4)
- surgical heel cord lengthening if pt fails conservative tx and are older than 4-5
26
What is flat foot? Tx?
- immature foot - normal foot variant (most toddlers have flat feet)
- low arch heel valgus
- arch starts to form around age 4
- no need for formal tx
- can try wedge but orthotics not necessary and are costly (esp in growing child)
27
What is genu varum? Etiologies?
- bow legs
- physiologic bowing: usually corrects by age 2
- metabolic bowing: vit D deficiency (rickets)
- blounts disease: damage to epiphysis - may need bracing or surgery
28
What is genu valgum?
- knock knees
- most correct spontaneously
- braces and modified shoes not effective
- after 11-13 may need surgery for marked deformity
- likely to have patellar instability later on if not fixed early on
29
Common ped ortho injuries?
- slipped capital femoral epiphysis (SCFE)
- radial head dislocation (nursemaid elbow)
- ped fractures
- osteochondrosis
- patellofemoral arthralgia (PFA) - anterior knee pain
- spondylolysis
30
SCFE - Most common in who and increased with what?
Unstable and stable?
What movements are restricted?
- most common from 9 yrs to end of growth
- more prevalent in males
- increased frequency with endocrine disorders; hypothyroid, renal disease, growth and sex hormone imbalance
- obesity increases likelihood ( places more stress across femoral epiphysis)
- unstable: sudden, severe pain with limp
- stable: limp with groin pain, variable medial knee and or anterior thigh pain
- 36% will later involve opp side
- restricted internal rotation, abduction and flexion
31
Dx and tx of SCFE?
- X-rays: AP, frog leg lateral
- mild slips: subtle changes on frog leg view only
- complications: avascular necrosis (AVN), chondrolysis, osteoarthritis
- immediate referral: surgical pin or screw placement
32
What is radial head dislocation? Tx?
- Nursemaid's elbow
- subluxation or dislocation injury from sudden pull of child's arm
- elbow becomes locked in slight flexion with forearm pronation
dx:
- patient guards elbow and refuses to use arm
- may be swollen and tender with palpation of radial head
- xray often normal
tx:
gentle supination of hand while flexing elbow with thumb placing gentle pressure over radial head, may use sling for a few days as needed for comfort
33
Common ped fractures?
- growth plate (epiphyseal) fractures (high %, pt of least resistance of bone)
- supracondylar humerus fracture
- wrist/forerm fractures
- clavicle fractures
34
Why do kids have such a good ability to heal fractures?
- kids have ability to remodel bone unlike adults
- this ability diminishes with age and closure of growth plates
- can accept a surprising amt of displacement and plastic deformity
35
Growth plate (physeal) fractures complications?
- many childhood fractures involve the physis
- 20% of all skeletal injuries in children
- can disrupt bone growth
- injury near but not at physis can stim bone to grow more
36
Salter harris classification of growth plate fractures?
SALTR
- type 1: slip
- type 2: above
- type 3: lower
- type 4: through
- type 5: rammed
37
Supracondylar humerus fractures - when do thes occur? may be assoc with what kind of fracture? What other type of injury are you worried about?
- most common fracture around elbow in kids: 60% of elbow fractures
- occurs from fall on outstretched hand (trampolines!): ligamentous laxity and hyperextension of elbow impt mechanical factors
- may be assoc with distal radial or forearm fractures so check wrist and forearm as well!
- worried about nerve injury - incidence is high, b/t 7-16%: median, radial and ulnar nerve
- anterior interosseous nerve injury most comonly injured nerve
- do neurovascular exam - pulse, cap refill!!
- carefully document pre-manipulation exam: post manipulation neuro deficits can alter decision making
38
Tx of supracondylar humerus fracture?
- long arm cast for stable/non-displaced fractures
- percutaneous fixation with K wires for unstable fractures
- look at rotation!
39
Common wrist/forearm fractures?
- 1. torus (buckle) fractures: usually nondisplaced - strong periosteum, subtlem may be best seen on lateral
- 2. greenstick fractures: disruption of only one cortex
- 3. complete (transverse) fractures: break through both cortices
40
Tx of torus fractures?
- no reduction needed: if older than 48 hrs, ok to cast at first visit
- otherwise splint and cast at 5-7 days
- short arm cast for 4 weeks
- repeat x-rays at weeks to show evidence of healing
- splint add 2 weeks after cast removal
41
Tx of greenstick fractures?
- short arm cast if non-displaced
if displaced more than 15 degrees:
- reduce and immobilize in long arm splint, 4 weeks in cast after swelling improves, 2 weeks in splint after cast is removed
- usually do long cast, don't want to allow arm to supinate or pronate
42
Tx of complete fractures?
- non-displaced fractures =short arm cast for 2-6 weeks
- displaced fractures= reduce ASAP and cast
- older the child, longer the immbolization
- if x-rays are normal initially but there is tenderness over growth plate: immobilize for 2 weeks, bring child back in 2 weeks to re-examine and re-xray
- if no callus - fracture unlikely
43
Distal radius fractures? Why so common, result from what? What should you check?
- peak injury time coorelates with peak growth time
- bone is more porous
- most injuries result from FOOSH
- check sensation: median and ulnar nerve: nerve injury more likely to occur with significant angulation of fragment or with sig swelling
- examine elbow (supracondylar) and wrist (scaphoid)
- bleeding and swelling can cause acute carpal tunnel syndrome
44
Clavicle fractures - how common? Most occur when? Tx?
- most common ped fracture
- in children, 90% of middle third (good blood supply)
- almost half of all clavicle fractures occur under age 7
- younger than 10, most are non-displaced, older than 10, most are displaced
- stable injuries, tx with sling or figure of 8 splint for 2 weeks
45
What is osteochondrosis? Causes?
- apophyseal injury
- pain at tendonous insertions at secondary ossification centers (apophyses)
- causes: increase in activity level, increase in mass, and puberty
- common examples: osgood schlatter (patellar tendon-tibial tuberosity), and sever disease (achilles-calcaneus)
46
Osgood schlatter - general features? Tx?
- inflammation where patellar tendon inserts on tibia
- leaves a lump - prominent, tender tibial tubercle
- clinical dx
- x-rays may show aphophysitis (widening of growth plate)
- majority of the time: pt outgrow it (closure of physis)
tx:
- conservative (same as PFA)
- eccentric strengthening
- iontophoresis/steroid (US)
- brace/pressure band
- excision of detached/fragmented bone fragment (risk: weakening tendon insertion)
47
Tx of osteochondrosis?
- conservative: rest, NSAIDs, ice, PT, casting/boot (sever's disease - prevents pulling of achilles)
- surgical: indicated for avulsion of apophysis greater than 1 cm
48
What is patella-femoral arthralgia (PFA)? CLinical dx?
- chondromalacia patellae: more common in girls (4:1)
- means sore kneecap, common, frustrating but not serious
- inflammation of articular surface of patella, vague, diffuse anterior discomfort
- clinical dx:
overuse more than acute injury
- anterior knee discomfort, pain with stairs, can't sit with bent knee
- increased Q angle, tender undersurface of patella, tight hamstrings, weak quadriceps
- if you have valgus knees (tibial or femoral torsion): at risk for developing this
49
Tx of PFA?
- responds to good management: PT -
exercise programs, setting realistic goals, may need to involve parents
- conservative:
relative rest
PT (quad strengthening)
ice and NSAIDs
patellar stabilization brace (if assoc instability)
-surgical: rarely indicated
where underlying anatomy is abnormal may need lateral release and/or tibial tubercle osteotomy
50
What is spondylolysis? Dx? tx?
- stress fracture of pars
- repetitive hyperextension of back: gymnastics, football, wrestling, rowing
- progressive low back pain with activity: radicular sxs are rare, may progress to slip (spondylolisthesis)
- Dx: xray, CT, bone scan or MRI: look for neuro sxs
- Tx: rest, brace, rare cases: fusion
51
What is acute septic arthritis and why is it an emergency? most common jt affected? most common organism?
- pyogenic bacteria invade a synovial jt
- ped incidence has close correlation with osteomyelitis!!
- most common jt: hip* and elbow
- most common organism: staph aureus (cover for MRSA)
- emergency!!!
52
Presentation of acute septic arthritis in infants?
- may develop with few clinical manifestations
- tenderness
- increased warmth over jt in question
- pseudoparalysis: pain with movement of jt
- painful restriction
- fever and WBC misleadingly slight (jt will be red hot!!!)
53
Presentation of acute septic arthritis in older kids?
- severe pain: pain with passive motion, won't move jt themselves
- protective muscle spasm (guarding)
- marked tenderness
- fever (not all the time)
- elevated WBC
- elevated ESR/CRP
54
Eval of acute septic arthritis? Tx?
- C&S blood,urine
- xray
- US: very useful for guiding injection, esp in hip jts
- immediate needle aspiration: inspect aspirate (cloudy), C&S, gram stain, crystals (rule out gout)
- refer immediately for surgical washout (I&D)
- empiric IV abx:
3rd gen cephalosporin and penicillinase resistant synthetic PCN
- MRSA should be covered with either clindamycin or vanco
55
Open fractures - how serious are these? Easy to see?
- fracture with overlying skin compromise - may be subtle
| - reqrs IMMEDIATE referral to ortho: must be washed out w/in 24 hrs
