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Pediatrics > Ortho > Flashcards

Ortho Flashcards

1
Q

growth in pediatrics

A

require 110 calories/kg (only 40 in adult) from birth, height will increase 350% and weight will increase 20- fold

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2
Q

growth plates

A

not uniform- diff bones grow at diff rates (ossification) cartilage eventually replaced by bone

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3
Q

subluxated radial head**

A

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

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4
Q

to fix subluxated radial head

A

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)

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5
Q

osteomyelitis

A

most common organism- staph aureus, in neonates group B may be difficult to localize, treated inpatient

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6
Q

dx osteo

A

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

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7
Q

septic arthritis

A

usually hematogenous seeding, extension of osteo or direct inoculation into joint from penetrating trauma

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8
Q

etiology of septic arthritis

A

staph aureus, h. flu (historically), kingella kingae in neonates- e. coli, candida, GBS in teens- n gonorrhea

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9
Q

presentation of septic arthritis

A

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

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10
Q

“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

A
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11
Q

dx of septic arthritis

A

blood culture + in 30- 40% of cases

elevated CPR, ESR

arthrocentesis

imaging- widening of joint space, soft tissue swelling, US useful for hip effusion

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12
Q

tx of septic arthritis

A

abx

I&D

prompt surgical drainage of hip ( and often shoulder) needed to reduce intra- articular pressure and avoid necrosis of the femoral head

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13
Q

consideration of spetic arthritis

A

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

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14
Q

other considerations if thinking septic arthritis

A

overlying cellulitis vs septic arthritis

other causes of acute arthritis include HSP, serum sickness, JRA, lupus, tic borne illness

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15
Q

Avascular necrosis AVN

A

devastating factors- unstable slip, reduction of stable slip, superolateral pin placement, fem neck osteotomy

rare in stable slips

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16
Q

Legg Calve perthes

A

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

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17
Q

Legg Calve perthes LCP presentation

A

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

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18
Q

LCP treatment

A

short term goal is to reduce pain and stiffness, longterm goals are to improve function and minimize femoral head deformity

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19
Q

Osgood Schlatter Disease*

A

*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

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20
Q

Osgood Schlatter Disease- who gets it

A

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

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21
Q

hereditary/ developmental/ “packaging” disorders

A

torticollis/ plagiocephaly

developmental dislocation of the hip

rotational deformities

genu valgum/varum

scoliosis

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22
Q

torticollis

A

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*
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23
Q

plagiocephaly

A

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

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24
Q

tx goals for plagio

A

prevent contractures, stretch tight muscles, prevent delay of normal activities, facilitate normal righting reactions.

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25
Q

DDH- HIP developmental hip dysplasia

A

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

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26
Q

incidence of DDH

A

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)

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27
Q

risk factors for DDH

A

1st born

breech delivery or presentation

torticollis

fam hx

culture- swaddling weird

genetics

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28
Q

etiology of DDH

A

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

29
Q

screening for DDH

A

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)
30
Q

management of DDH

A

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

31
Q

goals of tx for DDH

A

same regardless of age of presentation- obtain reduction, maintain stability- AVOID AVN- need to keep good blood flow

32
Q

Slipped capital femoral epiphysis SCFE

A

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

33
Q

tx SCFE

A

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

34
Q

SCFE exam

A

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

35
Q

rotational deformities

A

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

36
Q

metatarsus adductus

A

caused by intrauterine positioning; hereditary tendencies. incidence- occurs bilat in 50%, boys = girls, more common in first born (because moms hips havent stretched yet)

37
Q

metatarsus adductus

A

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

38
Q

metatarsus adductus physical exam

A

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

39
Q

tx for metatarsus adductus

A

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

40
Q

internal tibial torsion

A

-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
41
Q

physical exam for internal tibial torsion

A

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
42
Q

tx for internal tibial torsion

A

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

43
Q

femoral anteversion

A

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”

44
Q

femoral anteversion physical exam

A

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
45
Q

clubfoot

A

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
46
Q

genu valgum*

A

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)

47
Q

genu varum*

A

-intrauterine positioning, normal and will straighten out on own

differentials- Blount’s, metabolic bone dx- rickets, trauma

48
Q

for test know diff between genu valgum/ varum

A
49
Q

Rickets

A

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

50
Q

prevention of rickets

A

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.
51
Q

genetically linked musculoskeletal disorders

A

DMD, scoliosis

52
Q

muscular dystrophy

A

progressive skeleta neuromuscular disease characterized by persistet deterioration for striated muscle tissue.

Distinguished from other neuromuscular diseases by 4 criteria:

  1. primary myopathy
  2. genetic base
  3. pregressive nature
  4. degeneration of muscle fibers
53
Q

when muscle cells degenerate in muscular dystrophy, the muscle tissue is replaced with what

A

fat and fibrous tissue

54
Q

physical characterisctics of muscular dystrophy

A

muscle weakness, fatigue, respiratory/ heart complications

55
Q

more characterstics of muscular dystrophy

A

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
56
Q

implementing a physical activity program in muscular dystrophy

A

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

57
Q

Scoliosis

A

many varieties, etiology unknown, unpredictable, treatment disputed

58
Q

Scoliosis

A

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.

59
Q

Scoliosis grouped into

A
  1. idiopathic- w/o associated dx/ anomalies
  2. congenital- underlying anomaly
  3. neuromuscular
60
Q

osteogenic sarcoma

A

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

61
Q

osteogenic sarcoma frequently brought to attention when

A

child limps, curtails own physical activity, or is unable to hold heavy objects

62
Q

osteosarcoma

A

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

63
Q

dx of osteosarcoma

A

xrays following traumatic injry may be first indication of dx, need CT or MRI to detect areas of metastasis

  • amputation common
64
Q

therapeutic management of osteosarcoma

A

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

65
Q

Ewing Sarcoma

A

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
66
Q

Ewing Sarcoma who gets it

A

occurs most exclusively in pts under 30, majority between 4 and 25, peak incidence between 10-20*

67
Q

s/s Ewing Sarcoma

A

pain, soft tissue swelling, fever, if vertebral tumor- neuro s/s, if rib- respiratory s/s

68
Q

dx of Ewing Sarcoma

A

same as osteogenic sarcoma (xray, CT or MRI to see if mets)

69
Q

therapeutic management of Ewing Sarcoma

A

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

Pediatrics (17 decks)

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