Ortho and Rheumatology Flashcards
Three main causes of toeing IN
metatarsus Varus
Tibial Torsion
Femoral anteversion
inward deviation of the forefoot due to intrauterine positioning. Most resolve spontaneously. Can usually move the foot back to midline
Metatarsus Varus/ adducutus
if metatarsus varus/ adductus is rigid what can you do?
Use serial casting
there is a small percentage of kids with metatarsus varus/ adductus that also have what?
Hip dysplasia
Rotation of leg between knee and ankle
most common cause of in-toeing <2 years
Tibial torsion
when will the tibia rotate itself back out by
16 months
what can exacerbate tibial torsion
Sit with feet behind them
tx for tibial torsion
splints if needed, most get better by age 2
what causes toeing in beyond 2-3 years?
Femoral Anteversion
when is femoral anteversion the worst?
4-6 years
more common in girls
Tx for femoral anteversion
Bicycling and skating/ exercises
stop sitting in “w” position
what is there the foot is bent very far towards the shin? (dorsiflexion and eversion)
Calcaneovalgus
Tx for calcaneovalgus
Resolves sponteaneously
Complete disruption in the bones, not just positional. Tarsal bones espeically Talus are hypoplastic
Talipes equinovarus
Club feet
Plantar flexion of foot at the ankle joint (equinus)
Inversion deformity or heel (varus)
Medial deviation of the forefoot (varus
talipes equinovarus
3 cateogires of talipes equinovarus
congenital
teratologic (meningomyelocele or arthrogryposis)
positional
Tx for talipes equinovarus
Manipulation of foot
stretching, splinting
may need surgical tendon release
best to start early
when is bowleg (varum) normal?
infancy to 2-3 years
what is the term for knock knee’d?
valgum
when should valgum straighten out?
by 8 years old
when do you refer for genus varum?
bowing of only one leg
worsening bowlegs
abnormal growth of the medial aspect of the proximal tibial epiphysis, resulting in a progressive varus deformity. unilateral
typically affects overweight AA males
Blout’s disease
tx for blout’s dz before age 4
orthotics
tx for blout’s dz after 4 years
surgery
anterior knee pain that is worse with activity, stairs, and prolonged sitting. more common in female athletes
Patellofemoral pain sydomre (chrondomalacia patella)
tx for patellofemoral pain syndrome
RICE
PT eval
complex
Found in young athletes, more common males. Age of 11-15 during fast growth and open growth plates. WIll have knee pain during and activity and will limp, stop playing.
Osgood Schlatter Dz
What will you see on x-ray with osgood schlatter dz
fragmentation
microfractures of tibial tuberosity
Tx for osgood-schlatter
rest + activity
NSAIDs, ice, stretching quads and hamstrings
how long can symptoms of osgood-schlatter last for?
1-2 years
Will there be pain on rest with osgood-schlatter
no pain at rest
Abnormal relationship between acetabulum and proximal femur
hip dysplasia
first factors for developmental hip dysplasia
first born
female
breech
family hx
if an infant has positive hip dysplasia tests on PE when should they get an US?
4-6 weeks
when should an infant get an AP pelvis for suspicion of hip dysplasia on PE
> 4 months old
how may hip dysplasia present in a walking child?
Limb length discrepancy
are asymmetric skin fold diagnostic of hip dysplasia
No, need them with a positive barlow or ortalani or pertinent hx.
what is the most useful initial evaluation of DDH?
Ultrasound
tx of hip dysplasia
Pavlik harness in first 4-6 months in flexion and abduction
The most common cause of limping and pain in the hip in children in US.
Acute inflammatory reaction that often follows an URI
generally self limiting
Transient Synovitis of the Hip
will transient synovitis have elevated ESR, WBC or temp >38.3 C?
No
what age group is transient synovitis common in ? and sex
boys aged 3-8 years old
what limitations will a child with transient synovitis of the hip have?
Limitations in internal rotation of hip
pain in groin/ hip
Tx for transient synovitis of teh hip
Rest
anti-inflammatory
traction
slight flexion of the hip
what is a possible complication of transient synovitis
avascular necrosis
F/U with xrays
what will labs show with septic arthritis of hip?
elevated ESR, WBC
most common organism for septic arthritis of hip
Staph aureus
tx for septic arthritis
First 24-72 hours may use ABX alone
aspirate joint to determine if sx is needed
Idiopathic Avascular Necrosis of Proximal Femoral Head
Highest incidence 4-8 years, boys 4x girls
Legg-Calve-Perthes Dz
Symptoms of Legg-Calve-Perthes Dz
pain and limp, no fever
worse w/ activity
decreased internal rotation and abduction
Tx for legg-calve-perthes dz
protect joint, not splinting
track through x-rays
eventually bone will regrow
what hip problem is a surgical emergency
Slipped Capital Femoral Epiphysis (SCFE)
Displacement of proximal femoral epiphysis due to disruption of growth plate
Ice cream off the cone
Head displaced medially and posteriorly
Slipped Capital Femoral Epiphysis
who is SCFE common in?
Adolescents ages 10-16 yaers old, obses males
Symptoms of SCFE
vague over time
pain in hip, medial knee, anterior thigh
tx for SCFE
immediate non weight bearing
ortho referral- need sx
Lateral curvature of spine, with internal rotation of involved vertebrae. Usually idiopathic.
scoliosis
do children get joint infections as much as adults
no
who is scoliosis more common in?
Girls
if scoliosis is painful what should you look for?
underlying disorder ie tumor
Testing for scoliosis
have pt bend forward 90 degrees with hands held in midline.
Asymmetry of scapula, ribs, paravertebral muscles.
When do you tx for scoliosis
Over 20 degrees
when do you use bracing for scoliosis
20-50 degrees
when may someone with scoliosis need spinal sx
> 40 degrees
Greater than what degree for scoliosis will have poor pulmonary function as adults
> 60 degrees
Injury to sternocleidomastoid (during delivery)
Head twisted away from affected side
Palpable mass in muscle = fibrous ( not tumor)
Torticollis
Tx of torticollis
passive stretching, massage
causes of torticollis in older children
muscular spasm
ENT infections
diagnostics to do with troticollis?
xrays to r/o cervical deformity
No using arm, held in flexion with hand pronated, tenderness over radial head. may have some swelling.
Nursemaid’s elbow
radial head subluxation
tx for radial head subluxation
pressure on radial head
grasp wrist and provide slight traction
suprine wrist while flexing elbow to 90 degrees
what should you watch out with radial head subluxation
supracondylar fractures
compartment syndrome
Buckling of cortex
Usually distal ulna or radius
Usually at metaphyseal / diaphyseal junction
Torus fracture (stable)
tx for torus fractures
immobilize x 3 weeks
Disruption of cortex on one side of bone
Angulated but not displaced
Greenstick fracture
tx for greenstick fracture
external reduction and cast
Fracture of the distal tibia without a fibula fracture. Often no significant trauma, and initial radiographs don’t always show fracture.
Toddlers fracture
transverse fracture through the physis, growth disturbance is unusual
Type I SH
most common type of SH fracture
Type II
- fracture through a portion of the physis and epiphysis into the joint that may result in complication because of intra-articular component and because of disruption of the growing or hypertrophic zone of the physis
Type III SH
fracture through the metaphysis, physis, and epiphysis with a high risk of complication
Type IV SH
fracture through a portion of the physis and metaphysis
Type II SH
a crush injury to the physis with a poor functional prognosis
Type V SH
Benign, pain free bony growth
most common bone tumor in children
osteochondroma
pain in a long bone, pathologic fracture common
Malignant
osteosarcoma
tx for osteosarcoma
surgical excision or amputation (after chemo)
Tumor that destroys cortex, pain and tenderness. Will have fever, leukocytosis. inflammatory type presentation
Ewing Sarcoma
Tx for ewing sarcoma
chemo
radiation
sx
Connective tissue disorder
can have subluxation of ocular lenses (cataracts, colobomas strabismus)
Marfan syndrome
multiple and recurrent fractures
blue sclera
osteogenesis imperfecta
tx for osteogensis imperfecta
bisphosphonates to help w/ pain
Upper arms and thighs proportionally shorter than forearms and legs.
Extreme lumbar lordosis
achondroplasia
infection in the synovium
synovitis
inflammation of the insertion of a ligament
enthesitis
labs for rheumatic dz
CBC with diff
ANA
RF
ESR
what type of JRA is associated w/ uveitis
pauciarticular
to have polyarticular JRA what must you have
5 or more joints involved
type of JRA that is in spine and lower extremity
spondyloarthropathy
who are at highest risk of uveitis with JRA
young girls, with pauciarticular JRA and a positive antinuclear antibody are at highest
most common form, most commonly asymmetric, in kneed, weight bearing joints can occur with uveitis
Pauciarticular
symmetric pattern large and small joints. can have nodules, may start to have low grade fevers
polyarticular JA
high spike in fevers a couple times a day. salmon-pink macular rash will have arthritis after systemic sx. can be any joint large or small. Will have pleurisy and pain
systemic form JA
what does the lupus rash look like?
is round or disk shaped (discoid) and is characterized by red, raised patches with adherent scales.
What is ANA?
Antinuclear antibody
test for lupus
what sex does lupus affect more?
girls
what is the most common presenting symptom of lupus?
joint pain
what skin effects does lupus have?
butterfly rash
purpura
alopecia
Raynauds phenomenon
What can happen in the pleural lining with lupus?
Pleurisy with effusion
peritonitis
pericarditis
What happens to the GI system with lupus?
HSM
lymphadenopathy
acute pancreatitis (uncommon)
what is the reading cause of death from lupus?
diffuse proliferative nephritis… nephrosis and uremia
what is the treatment for lupus?
steroids
NSAID from pleuritic pain
hydroxycholorquin for skin, arthritis, fatigue
what other antibody (besides ANA) is found in lupus
anticardiolipin antibody
lupus coagulant
Rare inflammatory dz of muscles and skin. - face and hands, scaley red plaques on knuckles or extensor surfaces, proximal muscle pain.
Dermatomyositis
what sex is affected more by dermatomyositis?
females
What muscles does dermatomyositis affect?
pelvic and should girdle muscles
symmetric
what labs will be abnormal with deramtomyositis?
abnormal muscle enzymes (CK, LDH, ALT, AST)
+/- ANA
WBC, ESR and CRP often normal
Treatment for dermatomyositis
steroids
usually induces remission
what is the most most common vasculitis in childhood?
henoch schonlein purpura
what sex does HSP affect more?
boys
what time of year is HSP more common?
winter
where is palpable purpura most often found with HSP?
below waist
knees and ankles most common
what labs will be elevated with HSP?
ESR
WBC
CRP
