Ortho Flashcards
growth in pediatrics
require 110 calories/kg (only 40 in adult) from birth, height will increase 350% and weight will increase 20- fold
growth plates
not uniform- diff bones grow at diff rates (ossification) cartilage eventually replaced by bone
subluxated radial head**
radial head slips under annular ligament- usually someone picked them up by arms not abuse annular ligament strengthens as the kid grows so condition less common after about age 5
to fix subluxated radial head
reduction- after history and exam reduction is performed by manually supinating the forearm and flexing the elbow past 90 degrees of flexion - while holding the arm supinated the elbow is then maximally flexed during this maneuver as the practitioners thumb applies pressure over the radial head and a palpable click is often heard or felt with reduction of the radial head (watched the video)
osteomyelitis
most common organism- staph aureus, in neonates group B may be difficult to localize, treated inpatient
dx osteo
radiograpahs may be normal or nonspecific for 10- 14 days, may need bone scan, CT, or MRI blood culture positive in 50- 60% of cases bone aspiration or biopsy tx is 3- 6 weeks IV abx inpatient or home infusions via PICC
septic arthritis
usually hematogenous seeding, extension of osteo or direct inoculation into joint from penetrating trauma
etiology of septic arthritis
staph aureus, h. flu (historically), kingella kingae in neonates- e. coli, candida, GBS in teens- n gonorrhea
presentation of septic arthritis
kids often very ill appearing- fever/ miserable. acute joint inflammation, swelling, redness and pain, “pseudoparalysis”- joint is held in a position to maximize intra- articular space and minimize pressure and pain, ex- hip- flexion, abduction, external rotation knee- partial flexion shoulder- adduction and internal rotation elbow- midflexion
“pseudoparalysis”- joint is held in a position to maximize intra- articular space and minimize pressure and pain, ex- hip- flexion, abduction, external rotation
this is a pic of this- septic arthritis of hip
dx of septic arthritis
blood culture + in 30- 40% of cases
elevated CPR, ESR
arthrocentesis
imaging- widening of joint space, soft tissue swelling, US useful for hip effusion
tx of septic arthritis
abx
I&D
prompt surgical drainage of hip ( and often shoulder) needed to reduce intra- articular pressure and avoid necrosis of the femoral head
consideration of spetic arthritis
transient synovitis of hip or “tixic synovitis” often simiar to septic arthritis
history is critical- **follows viral URI, viral pathogen settled inthe joint.
non- infectious, will have mild fever, limp, fussiness, minimal ROM, ESR, CRP, WBC usually normal
managed w/ rest and NSAIDS (motrin), close f/u
other considerations if thinking septic arthritis
overlying cellulitis vs septic arthritis
other causes of acute arthritis include HSP, serum sickness, JRA, lupus, tic borne illness
Avascular necrosis AVN
devastating factors- unstable slip, reduction of stable slip, superolateral pin placement, fem neck osteotomy
rare in stable slips
Legg Calve perthes
due to avascular necrosis- leads to flattening of the femoral head and may leave a deformity which results in osteoarthritis of hip in adult life
Legg Calve perthes LCP presentation
subjective- limp d/t pain, LLD, abnormal ROM, pain at groin, thigh, knee- synovitis
objective- decreased ROM: IR, ext, abduction. muscle atrophy- weakness, Trendelenburg sign, LLD
LCP treatment
short term goal is to reduce pain and stiffness, longterm goals are to improve function and minimize femoral head deformity
Osgood Schlatter Disease*
*most common reason for knee pain in kids: activity- related pain that occurs a few inches below the knee cap or patella on the front of the knee
*swelling in the area and tender to touch
Osgood Schlatter Disease- who gets it
occurs most commonly in kids 9- 16yrs, boys and girls equally vulnerable, common in very active kids- kids who play sports that require a lot of jumping, running, kneeling, and squating, happens in a growth spurt many times
hereditary/ developmental/ “packaging” disorders
torticollis/ plagiocephaly
developmental dislocation of the hip
rotational deformities
genu valgum/varum
scoliosis
torticollis
twisting of the neck- can occur congenitally or be aquired (d/t prolonged positioning of the infant’s head to 1 side)
- one muscle gets longer, other stays short
- parents need to do passive ROM, put them on opposite side- educate parents*
plagiocephaly
shape of the skull is asymmetrical, there may be a flattened area at the back of the skull as well as a forward protrusion on one side of the forehead, very often seen in kids w/ torticollis
can use helmets but controversial
tx goals for plagio
prevent contractures, stretch tight muscles, prevent delay of normal activities, facilitate normal righting reactions.
DDH- HIP developmental hip dysplasia
any hip can be provoked to subluxate (partial contact between femoral head and acetabulum) or dislocate (no contact between femoral head and acetabulum), or any subluxated or dislocated hip that can be reduced
incidence of DDH
1.5/ 1000 births
70% females
left > right, 20% bilat
lower incidence in native americans, african americans and asians
instability at birth- 1/1000 newborns (loose hips but don’t come out of the socket)
risk factors for DDH
1st born
breech delivery or presentation
torticollis
fam hx
culture- swaddling weird
genetics
etiology of DDH
mechanical theory- perinatal “packaging disorders”
primary acetabular dysplasia- predisposes dislocation
ligamentous laxity- increased incidence in neonatal DDh patients and 1st degree relatives, effects of prenatal hormones on the infant are similar to mom, fetal/infant girls estrogen
screening for DDH
assess with Barlow/ Ortolani, look at creases/ gluteal folds should be symmetrical. US not recommended for all newborns only if + Barlow/ Ortolani sign- should also be referred to ortho
- hips should be examined at every well visit (2-4 days for newborns discharged in less than 48 hours after delivery, by 1 month, 2 months, 4 months, 6 months, 9 months, 12 months)
management of DDH
early reduction of hip beneficial for remodeling, could use Pavlik harness for 6-8 wks, or closed/ open recution and spica cast- should be following up through skeletal maturity
goals of tx for DDH
same regardless of age of presentation- obtain reduction, maintain stability- AVOID AVN- need to keep good blood flow
Slipped capital femoral epiphysis SCFE
older kid presents w/ hip pain, 8- 15 years, male> female, common in obese kids, could be knee and/ or hip pain, could be acute or chronic, minimal trauma, pain could be anywhere in affected limb, will limp
tx SCFE
urgent ortho referral especially if they can’t bear any weight- will need pinning to reconnect. Goal is to prevent further slipping of joint out of socket and AVN
SCFE exam
may reveal decreased external hip rotation, vague pain to knee groin or thigh, one leg may be shorter than other, limp, loss of or pain with IR- remember to always examine other hip (25% bilat involvement)
need AP/ frog lateral xrays
rotational deformities
children are often referred to ortho for intoeing- 1 in 10 children intoes between ages 2 and 5, parents notice that the child trips/ falls and appears to to have feet that turn in, sometimes called pigeon- toed
metatarsus adductus
caused by intrauterine positioning; hereditary tendencies. incidence- occurs bilat in 50%, boys = girls, more common in first born (because moms hips havent stretched yet)
metatarsus adductus
clinical manifestations- forefoot adducted and occasionally supinated; the lateral border of the foot is convex; can range in severity from very flexible to extremely rigid
metatarsus adductus physical exam
examine the forefoot alignment: classification can be determined by line bisecting the hindfoot and the flexibility of the forefoot.
- normal- line bisecting the hindfoot passes through the 2nd toe or between the 2nd and 3rd toes
- mild (or type 1)- line bisects 3rd toe
- moderate (or type 2)- line bisects 3rd and 4th toe
- severe (or type 2)- line bisects the 4th and 5th toes
fexibility:
actively flexible- when foot is tickled it corrects
passively flexible- able to correct w/ gentle pressure on 1st metatarsal head
rigid- does not correct with stretching
tx for metatarsus adductus
don’t routinely need radiographs
tx- for actively flexible feet- no tx needed
for passively flexible feet- stretching exercises by the parents (5x per foot each diaper change, hloding for 10sec at a time)
for rigid feet- serial casting or the Wheaton brace
internal tibial torsion
-caused by intrauterine positioning, genetic, positioning during activities.
*Is most common cause of intoeing in children <2 years, may be associated w/ metatarsus adductus (33%)
- parent may say kid sits on their feet more than other positions
physical exam for internal tibial torsion
foot- thigh angle- pt in prone position, let feet fall free to their placement so it is not affected by examiner’s movement
- inward rotation- internal tibial torsion
- external rotation- external tibial torsion
tx for internal tibial torsion
no xrays needed. many diff treatments have been tried, night splints, shoe wedges, orthotics, attempts to control sleeping/ sitting/ walking patterns of kids
-studies have shown it resolves spontaneouosly about 24 months w/o non- operative treatments listed above, therefore tx not necessary
femoral anteversion
cause is controversial, congenital vs abnormal sitting habits
*most commmon cause of intoeing in >2 years old
associated w/ ligamentous laxity
parents often say the kid “W sits”
femoral anteversion physical exam
patient lies in the prone position w/ knees flexed at 90 degrees. let the legs fall into medial and lateral rotation by gravity
normal- at birth anteversion is 30- 40 degrees and decreases progressively; adults range from 8- 14 degrees
- if there is any asymmetry in hip rotation, suspect hip disorder and get xrays
clubfoot
1/1000 births
foot is turned to the side and it may even appear that the top of the foot is where the bottom should be
Important: must distinguish b/w metatarsus adductus and clubfoot
- metatarsus adductus- forefoot adduction
- clubfoot- hindfoot equinus, hindfoot varus, midfoot cavus, and forefoot adduction
genu valgum*
peaks in late childhood, +anterior/ medial knee pain, circumduction/ out toe gait, typically symmetric
differentials- metabolic bone dx= rickets, post traumatic valgus, skeletal dysplasia
(to remember- L is for love- the knees love each other, they are pointing towards each other, making the toes point out)
genu varum*
-intrauterine positioning, normal and will straighten out on own
differentials- Blount’s, metabolic bone dx- rickets, trauma
for test know diff between genu valgum/ varum
Rickets
failure of calcium to be depositied in bone matrix and epiphysis. Vit D and PTH play important role at maintaining homeostasis
classified by cause- Vit D def, chronic renal insuff, or renal tubular insuff
prevention of rickets
adequate ultraviolet light of 10mcg/ 400IU PO daily of a vitamin D preparation and an adequate dietary supply of calcium and phosphorus to prevent rickets
- 20 min/ do of ultraviolet light to face of a light- skinned baby is sufficient, longer in pigment.
genetically linked musculoskeletal disorders
DMD, scoliosis
muscular dystrophy
progressive skeleta neuromuscular disease characterized by persistet deterioration for striated muscle tissue.
Distinguished from other neuromuscular diseases by 4 criteria:
- primary myopathy
- genetic base
- pregressive nature
- degeneration of muscle fibers
when muscle cells degenerate in muscular dystrophy, the muscle tissue is replaced with what
fat and fibrous tissue
physical characterisctics of muscular dystrophy
muscle weakness, fatigue, respiratory/ heart complications
more characterstics of muscular dystrophy
progression through stages of functional ability:
- low strength/ endurance; normal ambulation w/ posible overwork weakness; slight deficiency in function
- reduction in activity; tendency to fatigue easily; reduced strength/ endurance; habitual activity, mild contractures and possible overwork weakness; ambulation with assistance
- poor stregth/ endurance; overwork weakness; contractures; limited ambulation and decrease in physical activity and standing
- ambulation significantly decreased; functional use of wheelchair; severe contractures and muscular weakness; pulmonary difficulties and cardiomyopathy
implementing a physical activity program in muscular dystrophy
components of an exercise program should include strength, endurance, and aerobic power that is essential for standing, walking, and funtional tasks. Goals to provide short term/ realistic goals, reduce rate of deterioration, prevent contractures, focus on submaximal exercises and reduce to intensity to avoid fatigue
Scoliosis
many varieties, etiology unknown, unpredictable, treatment disputed
Scoliosis
lateral curvature of spine with a minimum Cobb angle of >10 degrees (found by radiologist). can use a scoliometer to screen- normal is less than 7.
Scoliosis grouped into
- idiopathic- w/o associated dx/ anomalies
- congenital- underlying anomaly
- neuromuscular
osteogenic sarcoma
85% of malignant bone tumors in kids
clinical manifestations- pain localized at affected site, may be severe or dull, often relieved by position of flexion
osteogenic sarcoma frequently brought to attention when
child limps, curtails own physical activity, or is unable to hold heavy objects
osteosarcoma
most common bone cancer in kids*
peak incidence- 10- 25 yrs
associated w/ growth spurts of adolesence
most frequently affects the distal portion of the femur; also humerus, tibia, pelvis, jaw and phalanges
localized pain in affected site- often relieved by flexing extremity
progressive, insidious or intermittent pain at tumor site
limping, limited ROM, palpable mass, eventually pathological fracture
frequently metastasizes to lungs
dx of osteosarcoma
xrays following traumatic injry may be first indication of dx, need CT or MRI to detect areas of metastasis
- amputation common
therapeutic management of osteosarcoma
goals: remove tumor so doesn’t spread, tx may include resection or amputation depending on location and/ or surgeon, chemo before and after surgery, thoracotomy if mets to lungs, cure rate 75% w/o mets
Ewing Sarcoma
second most common bone tumor in kids
- arises in marrow spaces of bone rather than the oxxeous tissue
- tumor originates in shaft of long bones, trunk bones, or skull
- most commonly affects femus, ribs, vertebrae, pelvic bones
Ewing Sarcoma who gets it
occurs most exclusively in pts under 30, majority between 4 and 25, peak incidence between 10-20*
s/s Ewing Sarcoma
pain, soft tissue swelling, fever, if vertebral tumor- neuro s/s, if rib- respiratory s/s
dx of Ewing Sarcoma
same as osteogenic sarcoma (xray, CT or MRI to see if mets)
therapeutic management of Ewing Sarcoma
intensive radiation of involved bone, combined with chemo
chemo- reduces tumor bulk to maybe do surgery resection to salvage limb
cure rate approx 70% w/ small extremity tumors and no mets
