Ortho Lecture Flashcards
Wide ranging spectrum of hip abnormalities:
- generalized hip laxity
- complete hip dislocation
- acetabular abnormality
Developmental dysplasia of the hip (DDH)
Usually present at birth
May present at 8-24 months
Affects left hip 3:1
Risks:
first child
girls>boys
breech presentation
family hx
Developmental dysplasia of hip
Initially asymptomatic
First noticed with walking (decreased leg length, limp)
Asymmetry of skin folds if unilateral
Loss of motion (abduction)
Developmental dysplasia of the hip (DDH)
PE:
Perform until walking age
Barlow’s test (dislocation test)
Ortolani test (relocation test)
Xrays:
AP view of pelvis
Developmental dysplasia of the hip (DDH)
Barlow’s test tests for….
dislocation
Ortolani’s test tests for…
Relocation
If the baby is female and was breech, perform ultrasound at..
6 weeks
Pavlik (brace/harness) for tx
best used under 6 months of age
brace until stable, usually 8-12 weeks
90-95% successful
Developmental dysplasia of the hip (DDH)
Tx for Developmental dysplasia of the hip (DDH) if kid is over 6 months old?
Casting!
spica cast for 8-12 weeks
Tx for Developmental dysplasia of the hip (DDH) if kid is over 2 years old?
Surgical reduction
Idiopathic osteonecrosis of femoral head
Legg-Calve-Perthes disease
Progression:
Loss of blood supply
Bone dies (osteonecrosis)
Loss of structural rigidity
Femoral head collapses
Legg-Calve-Perthes dz
Onset: age 2-12 yo, ususally 4-8 yo
Boys>girls 4:1
90% unilateral
Typical child:
Small stature, thin, physically active
(rare in Black children)
Legg-Calve-Perthes dz
Pain and limping
worse with activity
pain radiates to groin/proximal thigh
Decreased AROM and PROM
abduction (20-30 degrees)
internal rotation
Legg-Calve-Perthes dz
Dx made with:
X rays..AP and frog lateral
initial increased density at femoral head
crescent sign
shear fx in subchondral bone
Legg-Calve-Perthes dz
Tx:
Femoral head re-vascularizes
Usually regenerative in 12-18 months
Restrict vigorous activity
NSAIDs
Crutches if needed
Legg-Calve-Perthes dz
Slippage of femoral head epiphysis (usually posteriorly)
MC adolescent hip disorder
Girls 8-15 yo, boys 9-16 yo (MC in boys)
Bilateral in 30-40%
Slipped Capital Femoral Epiphysis (SCFE)
“Red flags”=
older child
male
obesity (over 50% are in the 95th percentile for weight)
limp
pain in hip, groin, thigh or knee
Slipped Capital Femoral Epiphysis (SCFE)
Onset may be sudden or progressive
Pain with activity
Pain in hip, groin, thigh, knee
Limp
Decreased hip motion (internal rotation)
Possible limb shortneing
Slipped Capital Femoral Epiphysis (SCFE)
Dx made with Xray:
AP and frog lateral
“fuzzy” irregularities on physis
appears that the epiphysis has slipped/rotated
Slipped Capital Femoral Epiphysis (SCFE)
What is the tx for Slipped Capital Femoral Epiphysis (SCFE)
Surgical fixation:
single cannulated screw into epiphysis
non weight bearing for ~6 weeks
(if left untreated, SLIPPAGE WILL PROGRESS)
Sterile effusion of the hip
ages 2-5 most common
2-3x more common in boys
Transient Synovitis of the Hip (Toxic Synovitis)
Acute onset (usually)
Worse in AM
Limp is initial presentation
Pain in groin/thigh
Decreased abduction
AFEBRILE!
Transient Synovitis of the Hip (Toxic Synovitis)
Rest
Monitor temp
Reassurance!
Full resolution in 3-14 days
Transient Synovitis of the Hip (Toxic Synovitis)
Intrauterine constraint (ie: small uterus, twins, uterine fibroids) can cause…
Rotational deformities (in-toeing, out-toeing)
MC cause of “toeing in”
Exaggerated with weight-bearing
Amount of rotation is non-progressive
no treatment necessary
(spontaneous resolution, may use braces or orthotic shoes)
Internal tibial torsion
MC cause of “toeing in” after age 3
Patella may be shifted medially
Usually corrected by age 8
Braces, orthotics not helpful
Femoral Anteversion
Normal in older children/adults
Pes planus may be evident
No tx
External tibial torsion
Foot progression angle..watching the angle the foot is rotated while walking
in-toeing expressed as “-“
out-toeing expressed as “+”
A diagnostic to use if kid has a rotational disorder
(normal adults walk 0-30 degrees)
assesses the amount of tibial rotation
patient must be prone with knees at 90º
look for rotation of foot compared to femur
20-30º of external tibial rotation is normal
Measurement of thigh-foot angle
patient be prone with knees at 90º
swing lower legs toward/away from each other
40-50º in both directions is normal
compare bilaterally
Measurement of femoral ante/retroversion
Inflammation at the tibial tubercle apophysis
Presents early adolescence
Usually around increased growth
Caused by: repetitive motion
jumping, running
Osgood-Schlatter’s
Usually a gradual onset
Pain worsens with jumping, running, kneeling
Usually have some deformity of tibial tubercle
Point tender at tibial tubercle
Often bilateral
MC in boys
Osgood Schlatter’s
Tx of Osgood Schlatter’s?
Ice, heat, NSAIDs
active rest, knee pads
rarely immobilize
May take several months for results
Medially rotated forefoot
Occurs at tarsometatarsal joints
most likely due to position of fetus in utero
Usually spontaneously resolve by 6 mos
If not, serial casting at 6 mos (for about 2 mos)
Metatarsus Adductus
Congenital deformity of foot
4 components
plantar flexion (equinus) of ankle
adduction (varus) of heel
high arch (pes cavus) of midfoot
adduction (varus) of forefoot
Talipes Equinovarus (Club foot)
Tx:
Immediate casting (before leaving hospital)
serial casts every 1-2 weeks
treat for 2-4 months
may brace after casting
(surgery if no results after 4 months)
Talipes Equinovarus (Club foot)
Lateral curvature of the spine greater than 10º
Usually thoracic or lumbar spine
May involve rotation, kyphosis and/or lordosis
Scoliosis
(majority are idiopathic)
Most sensitive test for scoliosis?
Forward bend (Adam’s forward bend test)
Looks for unilateral elevation
Measure with inclinometer
Diagnostics:
X-Rays
AP and lateral
measure the Cobb angle
measured from beginning and end of curve
provides objective method for monitoring curve progression
Scoliosis
young age at diagnosis
female
initial curve >11º
if mature, <30º curve seldom progresses
>50º may progress, develop symptoms
Risks for progression of scoliosis
Scoliosis angle of 20-40, what is tx?
Brace
Scoliosis angle greater than 50 degrees, what is the tx?
Surgical intervention
(fusion or rodding)
Unilateral contraction of the sternocleidomastoid (SCM) muscle
Torticolis
First noticed at 4-6 weeks old
“cock robin” position
tilted toward affected side
rotated away from affected side
Possible palpable “tumor” in muscle belly
Decreased cervical motion
Torticolis
Passive stretching exercises
Usually resolves within a year
Surgical intervention:
longer than 18 months
release of SCM
tx for?
Torticolis
Most common elbow injury in children
Caused by increased joint laxity
Radial head is wedged in annular ligament
Occurs between ages 2-3, rarely over 7
“Nursemaid elbow”
subluxation of the radial head
Caused from forceful pronation/extension
Pain initially, then minimal
Unwillingness to use arm
Arm held in extension by side
dx: HISTORY MOST IMPORTANT!
Subluxation of radial head
Tx of subluxation of radial head?
Manipulation fo radial head:
pressure on radial head
forcefully flex and supinate forearm
Growth plate (physis) injuries/fractures
15% of pediatric long bone fractures
Mechanism is same as other traumatic injuries, sprains or fractures
75% are type II
Salter-Harris fractures
Genetically transmitted disease
Defect in Type I collagen
Fragility of skeleton
Sx:
Short stature
Lax ligaments
Several bony deformities
Blue sclera
Decreased hearing
Poor dentition
Osteogenesis Imperfecta
(tx symptomatically, tx fractures routinely)
