Ortho/Rheum Flashcards
Legg-Calve-Perthes Disease (Avascular Necrosis of Femur) definition, sx, dx, tx
*idiopathic avascular osteonecrosis of the femoral head in children due to ischemia of capital femoral epiphysis; usually unilateral
Risk Factors: children 4-10yrs, 4x MC in males, obesity, coagulation abnormalities (e.g., Factor V Leiden)
Decreased Risk Factors: AA
sx
*painless limp for weeks (worsen w/ continued activity esp. at the end of the day)
*may have intermittent hip, thigh, knee, or groin pain
*may have an antalgic or Trendelenburg gait
*restricted ROM (loss of abduction & internal rotation)
*may have atrophy of the thigh muscles
*pts may lag in bone age & height
dx
X-ray:
*early: ↑ density of the femoral epiphysis, widening of the cartilage space
*advanced: deformity, (+) crescent sign (microfractures w/ collapse of the bone)
MRI – test of choice for early detection
tx
Observation:
*activity restriction (NWB initially) w/ ortho f/u (usually self-limiting w/ revascularization within 2yrs)
*may advocate for protected weight bearing during early stages until reossification is complete
*PT or brace/cast; NSAIDs for pain
Surgical:
*pelvic osteotomy may be indicated in some children >8yo, more advanced disease
Congenital Hip Dysplasia definition, sx, dx, tx
Abnormality in the shape &/or stability of the shape of the femoral head & acetabulum
Examination of the hip is performed during newborn assessment soon after birth & at every well-check visit until about 9mo of age &/or the child is walking independently
Risk Factors: breech presentation, first-born, females, + family hx
sx
PE: assessed for hip instability, asymmetry, or limited abduction
*Barlow maneuver: gentle adduction w/ downward pressure to feel for dislocatability, resulting in a “click,” “clunk,” or “jerk”
*Ortolani maneuver: abduction & elevation to feel for reducibility, resulting in a “click,” “clunk,” or “jerk”
Other findings may include asymmetry (skin folds, femur length, or gait) & restricted hip abduction
dx
Clinical w/ imaging to confirm
U/S: often used in children <4mo
AP x-ray in older children – unreliable until 4mo because of radiolucency of femoral head
tx
<6mo: Pavlik harness
6mo-15mo: hip spica cast
15mo-24mo: open reduction then hip spica
Monitoring w/ routine hip radiographs until the child is skeletally mature
Hip dislocation assessment using the Barlow & Ortolani maneuvers
Juvenile Idiopathic (Rheumatoid) Arthritis definition, sx, dx, tx
Autoimmune mono or polyarthritis in children <16yrs for >6wks
Types:
1) Systemic (Still’s Disease) – least common; fever + systemic sxs
2) Oligoarticular (40-60%) – MC form; usually affects young girls
3) Polyarticular – 2nd MC
*RF (-): young girls, better prognosis
*RF (+): adolescent girls, similar to adult RA
sx
Should be suspected in children w/ sxs of arthritis, signs of iridocyclitis (eye redness, pain, blurred vision, photophobia, miosis), generalized adenopathy, splenomegaly, or unexplained rash or prolonged fever
TYPES:
1. Systemic (Still’s Disease)
*daily or diurnal high fever, daily arthritis
*salmon-colored pink migratory rash
*hepatosplenomegaly, lymphadenopathy
- Pauci (oligo) articular
*≤4 joints involved
*medium/large joints (knees, ankle)
*iridocyclitis (anterior uveitis) - Polyarticular
*≥5 small joints (symmetric)
*most similar to adult RA (including morning stiffness)
*iridocyclitis (anterior uveitis)
*RF (+) & RF (-)
dx
Primarily a clinical diagnosis
↑ ESR & CRP
↑ ferritin
Workup: RF, ANA, HLA-B27
Oligoarticular: (+) ANA
(+) RF = only 15%
Still’s Disease: usually (-) RF & ANA
tx
First line: NSAIDs
Second line: glucocorticoids
PT
Severe disease: anakinra, methotrexate
(+) ANA = increased risk of iridocyclitis
*eye exam every 3mo
Osteosarcoma defintion, sx, dx, tx
*malignant
Malignant tumor of osteoblastic proliferation
MC primary bone malignancy in children & young adults
MC in distal femur (long bones); MC METS to lungs
*kids 10-14yrs
sx
*localized bone pain – may be worse at night
*joint swelling
PE:
*palpable soft tissue mass (may be tender to palpation)
dx
x-ray: “hair on end” or “sunburst” appearance
*mixed sclerotic & lytic lesions
*Codman’s triangle: ossification of raised periosteum
MRI
Bx – definitive
tx
Chemotherapy + surgical removal
*if neovascular 🡪 limb amputation
Ewing Sarcoma
*malignant
2nd MC primary bone malignancy in children & young adults
PATHO: translocation between chromosomes 11 & 22
MC in femur, pelvis
*kids 5-25yrs
sx
*localized bone pain & swelling
+/- fever, malaise, weight loss
PE:
*palpable mass
*local tenderness
*joint swelling
dx
x-ray:
*layered periosteal reaction “onion skin” appearance
*lytic lesions w/ a “moth eaten” appearance
*Codman’s triangle: ossification of raised periosteum
Labs: ↑ ESR, leukocytosis
Histology: sheets of monotonous small round blue cells
*+/- pseudo-rosettes (circle of cells w/ central necrosis)
tx
Chemotherapy
Resection (limb-sparing)
Radiation when excision not possible
Osteochondroma definition, sx, dx, tx
*benign
Cartilage-capped bony overgrowth arising on the external surface of a bone & areas of tendon insertion (e.g., proximal tibia, femur, & proximal humerus)
MC benign bone tumor *kids 10-20yrs (males MC)
sx
*painless, palpable mass
*may develop sxs of neurovascular compression
dx
x-ray:
*pedunculated (narrow stalk) that grows away from the growth plate & involves the medullary tissues
Bx – definitive
tx
Asymptomatic 🡪 observation
Marginal resection
*painful
*located in pelvis (MC for malignant transformation)
Nursemaid’s Elbow (Radial Head Subluxation) definition, sx, dx, tx
Radial head is wedged into the stretched annular ligament
MC children 2-5yrs
sx
*lifting, swinging, or pulling a child while the forearm is pronated & extended
PE:
*arm slightly flexed
*child refuses to move the arm
*lateral elbow TTP
dx
Clinical dx
x-ray: normal
tx
Closed reduction – pressure on the radial head w/ supination of the elbow followed by flexion of the elbow
Osgood-Schlatter Disease definition, sx, dx, tx
Apophysitis of the tibial tuberosity (inflammation of the patellar tendon at the insertion of the tibial tubercle) due to overuse (repetitive stress microtrauma) or small avulsions from repetitive knee extension & quadriceps contraction
Risk Factors: males, 10-15yrs, growth spurts, athletes
sx
*activity-related anterior knee pain & swelling
*prominence, swelling, & tenderness to the anterior tibial tubercle
dx
Imaging usually not necessary
x-ray: elevation, heterotopic ossification, &/or bone fragmentation of the tibial tuberosity
tx
Conservative
*RICE, NSAIDs, quad stretching, knee immobilization
*most resolve within 12-24mo
Refractory 🡪 surgery
Scoliosis defintion, sx, dx, tx
Lateral curvature of the spine; S & C
May be associated w/ kyphosis (humpback) or lordosis (sway back)
MC in girls & + family hx; MC begins at 8-10y
sx
Back pain
Uneven hips/shoulders
dx
Adams forward bend test
*pt flexes forward; scoliosis indicated by asymmetry in scapular height
x-ray: Cobb’s angle ≥10 degrees
*PA & lateral
MRI 🡪 atypical curve pattern, rapid progression, neuro sxs of pain, reflex abnormalities
PFTs 🡪 to see if scoliosis is affecting breathing; will show restrictive pattern
tx
10-15 degrees: 6-12mo f/u w/ clinical evaluation & possible x-ray
15-20 degrees: serial AP radiographic f/u
*q3-4mo – larger curves
*q6-8mo – small curves, pt near end of growth
> 20 degrees: orthopedist referral for continuous monitoring/management
*20-40 degrees: PT, bracing
*>40 degrees: surgery
Slipped Capital Femoral Epiphysis definition, sx, dx, tx
Displacement of the femoral head from the femoral neck through the growth plate
Risk Factors:
*children 8-16yrs, obese, males, AA, growth spurt
If seen in children before puberty, suspect hormonal or systemic disorders (hypothyroidism)
sx
*ipsilateral dull, achy hip, groin, thigh, or knee pain
*painful limp
PE:
*leg externally rotated
dx
x-ray: posterior displacement of femoral epiphysis
tx
NWB 🡪 internal fixation w/ pinning
Osteogenesis Imperfecta definition, sx, dx, tx
*Autosomal dominant disease leading to defects in the gene that encodes for type I collagen
*Associated w/ fetal or perinatal death & intrauterine growth retardation in its most severe form
sx
Severe premature osteoporosis
*multiple recurrent spontaneous fractures w/ minimal or no trauma in childhood leading to limb deformities & shortening
*presenile deafness
PE: blue-tinted sclerae, brown teeth
dx
Clinical & radiologic findings
Confirmation 🡪 DNA or protein testing
tx
*bisphosphonates
*PT
*surgical interventions
