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Orthopedic Changes Flashcards

1
Q

Out-toeing

A

Decreases over time

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2
Q

Anteversion

A

Head of the femur is directed anteriorly

Internal rotation

In-toeing

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3
Q

Retroversion

A

Head of the femur is directed posteriorly

External rotation

Out-toeing

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4
Q

Infants and Contractures

A

Anteversion and ER contractures

Appears to be out-toeing

Resolve by 5-6 years and anteversion becomes more apparent

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5
Q

Total hip rotation (ER + IR)

A

Up to age 2 - 120

Thereafter - 95-110

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6
Q

Thigh Foot Axis

A

Spontaneous de-rotation with growth and onset of walking

Infants - internal -30 to +20

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7
Q

Metatarsus (forefoot) ADD

A

Most common positional deformity in infants

Forefoot - curved medially
Hindfoot - slight Valgus as is typical for infants
Full DF ROM

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8
Q

Forefoot ADD tx

A

Mild - resolves naturally

Moderate - corrective shoes

Severe - joint manipulation and serial casting

If left untreated, increased risk of stress fractures

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9
Q

Calcaneovalgus

A

Forefoot - curved laterally
Full or excessive DF

Treatment - none, resolves naturally

Differential - vertical talus

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10
Q

Knee alignment progression

A

Peak varum - newborn

Straight - 1-2 years

Peak valgum - 2-4 years

Sex-specific norm 4-16 years

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11
Q

IN toeing rotational profile

A

Foot - metatarsus ADD

Tibia - internal tibial torsion

Hip - femoral anteversion

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12
Q

OUT toeing rotational profile

A

Foot - calcanealvalgus

Tibia - external tibial torsion

Hip - contractures of external rotators

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13
Q

Developmental Dysplasia of the hip

A

General looseness or instability of the hip

Wide range of severity...
Normal
Subluxable
Dislocatable
Subluxed
Dislocated
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14
Q

DDH Risk Factors

A

Mechanical…
Small intrauterine space
Breech position
Hips on mother’s sacrum

Physiologic…
Estrogen and relaxin effecting female fetus
6:1 female risk factor

Environmental…
Swaddling
Positioning
Carrying

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15
Q

DDH Evaluation

A

Limited hip ABD

Thigh fold asymmetry

Apparent shortening of femur/uneven knees

Hip “clicks” are usually insignificant

Imaging (US)

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16
Q

Barlow

A

Dislocates over posterior rim

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17
Q

Ortolani

A

Reduces dislocation

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18
Q

Barlow and Ortolani sign disappear by…

A

2 mos

Limited ABD is only sign after that

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19
Q

DDH Goal - Relocate and preserve joint shape

A

Infants - Pavlick harness ( 12 mos)

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20
Q

DDH sans intervention

A

Hip replacement

AVN

Femoral nerve palsy

Erosion of acetabular rim

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21
Q

Legg Calve Perthes Disease (LCPD)

A

AVN of the ossific nucleus of the femoral circumflex artery

Spontaneous resolution 1-3 years

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22
Q

LCPD Cause

A

Unknown cause

2nd hand smoke?
Small, active children
5-10 years old
Learning disabilities
More common in males
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23
Q

LCPD Exam Findings

A

Limp
Trendelenberg gait
Limited ABD, IR

Xray - subchondral fx, femoral head collapse

Pain - groin, medial thigh, medial knee

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24
Q

LCPD tx

A

WIDE RANGE

Observation, casting, derotational osteotomy

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25
Slipped Capital Femoral Epiphysis (SCFE) Types
Acute - significant trauma Acute on Chronic - Chronic slip, trauma makes it worse Chronic - Most common type (progression over the course of 3 weeks)
26
SCFE Risk Factors
Obesity African American Males
27
SCFE Exam Findings
Pain - groin, medial thigh, medial knee Hip held in ER Hip moves passively in ER when hip flexion 50% cases bilateral
28
SCFE Intervention
Pinning surgery | Non WB
29
Blount's Disease
Infantile tibial Vara Compression at medial knee causes suppression of growth Differential from typical genu varum, Ricket's, Vitamin D deficiency
30
Blount's Evaluation
Thickening of medial tibial cortex Breaking of medial metaphysics Lateral thrust of knee in stance Overweight, early walkers
31
Blount's Intervention
HKAFO 23 hours per day Surgery
32
Leg Length Discrepancies
ASIS to Medial malleolus, Lat malleolus, Heel pad Umbilicus to Heel pad You can measure it via X-Ray
33
Causes LLD
Epiphyseal - injury Congenital - hemihypertrophy, hemimelia Neuromm - decreased mm forces, decreased growth
34
LLD Impairments
Pelvic obliquity, spinal alignment Increased energy expenditure for ambulation
35
Measuring for LLD
ASIS to medial malleolus, lat malleolus, Heel pad Umbilicus to Heel pad
36
LLD Intervention
Conservative - shoe lift Surgical - Illizarov procedure, stop growth of other limb
37
How much movement for Illizarov Procedure
1 mm per day 1/4 mm 4 times a day
38
Talipes Equinovarus
Club foot Hypo plastic mm ``` Position... Ankle PF Forefoot MEDIALLY curved (ADD and pron) Hindfoot varus Calcaneus small Talar head small and flattened ```
39
Club Foot Intervention
Ponseti Method... Serial casting Talonavicular joint reduction Percutaneous Achilles' tendon lengthening
40
Goal for Club Foot
Restore alignment | Allow for WB and ambulation
41
Congenital Limb Deficiencies
40% Acquired 60% Congenital... Typical unilateral Most are spontaneous mutations Most common - Left below elbow congenital amputation in females
42
Embryonic Failure CLD
``` Failure of formation Failure of differentiation Duplication Overgrowth Undergrowth Band Syndrome ```
43
Skeletal CLD
Transverse | Longitudinal
44
Proximal Femoral Focal Deficiency (PFFD)
Congenital absence or hypo plasma of the proximal femur Acetabulum, femoral head, patella, tibia, and fibula may be involved Severity graded A-D
45
PFFD Severity Determined By...
Femoral head presence, shape Acetabulum presence, shape Femur length Joint presence, articulation
46
Acquired Amputation Break Down
70-85% due to trauma 15-30% due to disease... Ewing's sarcoma Osteosarcoma
47
Acquired Amputations Intervention
Surgical tx... Further amputation to revise residual limb Limb replantation... UE more successful than LE Children achieve better functional outcomes than adults Phantom sensations... Increasing prevalence with age Not always pain
48
Scoliosis
Deviation of spinal axis
49
Scoliosis screening
Shoulder and pelvic asymmetries Forward bend test Scoliometer Radiography
50
Risser Sign
Scoliosis evaluation tool Skeletal maturity Graded 0-5 Based on ossification of iliac crest
51
Cobb Angle
Scoliosis evaluation tool Severity of curvature End vertebrae are cephalon and caudal with most tilt Intersection of lines perpendicular to end vertebrae > 10-degrees is diagnostic
52
Scoliosis Descriptors
Direction of curve - convex side Magnitude - with Cobb Angle Flexibility - structural vs non-structural
53
Structural Scoliosis
Cannot be corrected Vertebrae rotate towards the convex side - Rib hump
54
Non-structural Scoliosis
Corrects with sidebend towards convex side Usually non-progressive
55
Scoliosis Types
Congenital Neuromm Idiopathic
56
Congenital Scoliosis
Caused by anomalous vertebral development... Error in segmentation Error in formation May have a rotational component Kyphoscoliosis Lordoscoliosis Many become stable and do not progress
57
Neuromm Scoliosis
Long, C type curve, may become S curves with compensation Develop at a young age Tend to be progressive Most associated with SCI in young children, SMA, or MD To - Botox, custom seating, surgery
58
Idiopathic Scoliosis
Lateral curvature of unknown cause Most common form in children Infantile, juvenile, or adolescent
59
Adolescent Idiopathic Scoliosis
80% of all idiopathic scoliosis cases Decreased high level balance activities Decreased lung capacity on the convex side, increased on the concave More common in females
60
Progression AIS
Defined as a change of greater than 5-degrees on two consecutive exams ``` Increased risk... Younger age/lower Risser sign at dx Double curve pattern Increased curvature Females ```
61
AIS Non-surgical Intervention
Idiopathic curves
62
AIS Exercise Intervention
Used as first line of intervention for curves > 20 Goals... Maintain or improve trunk and pelvic strength Improve lateral flexion and trunk shift ROM Stretching - pectorals and LEs Increase lung capacity and volume Exercise alone has not been shown to prevent progression, even with high patient compliance
63
AIS Indications for Orthotic Management
Skeletally immature - Risser Sign 0-2 Curve from 25-45 Impact of orthotic management decreases as size of curve increases
64
Milwaukee
Controls thoracic the most
65
Charleston
Worn at night
66
Brace weaning in scoliosis
12 mos
67
Successful scoliosis treatment
If curve is no more than 5-degrees different from when brace was discontinued
68
AIS Goals of Surgical Intervention
``` Halt progression Prevent complications Achieve maximal correction Balanced trunk Solid fusion ``` Posterior approach most common More advanced curves may include BOTH anterior and posterior approach
69
Foot Progression Angle
Angle between long axis of foot and progression of body - in-toeing + out-toeing Normal -3 to +20 Mean +10
70
Harrington
Metal stabilization rod Does not allow sagittal plane correction Rarely used Flattened lumbar lordosis
71
Luque
Metal stabilization rod Prevents loss of lumbar lordosis Risk of neurological damage
72
Scoliosis Post-Op Care
Orthosis for 9-12 mos until fusion is solid on radiographs Avg hospital stay 5-7 days PT role... Precautions lifted gradually over 1 year by MD - no trunk rotation, no lifting > 5 lbs Donning/doffing prosthesis - to be done in bed Encourage functional mobility, isometrics
73
Arthrogryposis Multiplex Congenita (AMC)
Present at birth Non-progressive Unknown etiology Most children affected are bright and motivated Majority of cases not genetically based
74
Hallmarks AMC
Joint contractures in 2 or more body areas Lack of mm development/weakness Featureless, cylindrical extremities Fibrosis Decreased DTRs
75
AMC Type A Evaluation
``` Flexed and dislocated hips Extended knees Equinovarus IR shoulders Flexed elbows Flexed and ulnarly deviated wrists ```
76
AMC Type B Evaluation
``` ABD and ER hips Flexed knees Equinovarus IR shoulders Ext elbows Flexed and UD wrists ```
77
Type A AMC
More UE flexion
78
Type B AMC
More UE extension
79
AMC Intervention
Well-timed surgical intervention Club foot repair when standing Debate over surgically reducing dislocated hips Knee flexion contracture when ambulation G Shoulders are rarely addressed surgically
80
AMC PT
``` Positioning Splinting Stretching Normalizing development Balance skills With aging... Pain management, WC training ```
81
Osteogenesis Imperfecta
Inherited connective tissue disorder - many different mutations Wide variability in manifestations... Bowing of long bones Spinal deformities Recurrent fractures with minimal trauma
82
OI may also exhibit
``` Blue sclera Dental deformities Hearing loss Growth deficiency Easy bruising Excessive sweating ```
83
OI Intervention
Goal - prevent deformities Limit immobilization Scoliosis cannot be managed with brace Internal fixation with IM rods and/or spinal fusion Fracture risk decreased by puberty in MOST patients Strengthening Environmental adaptation Caregiver education Encouraging independence and social integration

Peds (25 decks)

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