Orthopedic problems in Pediatrics Flashcards
Growing pains?
benign and intermittent
4-8 yo
usually bilateral
relieved by hear, massage, ibuprofen, tylenol
Plastic deformation?
unique to children
most common in ulna
force produces a microscopic failure on the tensile side of bone
bone is angulated beyond its elastic limit
no fracture evident radiographically
Buckle (Torus) fracture?
Compression failure of bone (usually at junction of metaphysis and diaphysis, common in distal radius)
heals in 3-4 weeks with immobilization
Greenstick fracture?
occurs when the bone is bent
not a complete fracture (is a slight fracture just not all the way through the bone)
will have bone failure on the tension side and bend deformity on the compression side
Epiphyseal fractures?
involve the growth plate
potential for deformity to occur (requires long term observation)
Classified by Salter Harris
Salter Harris Mneumonic?
Slipped Above Lower Together Ruined
Salter-Harris type I?
separation through the physis
X-rays are often normal
Diagnosis
-may have some lateral displacement of the epiphysis, point tenderness over the growth plate
Salter-Harris type I manage?
closed reduction techniques
no not require perfect alignment
tend to remodel with growth
Salter Harris type II?
fracture through a portion of the physis, but extending through the metaphysis
Salter Harris type II manage?
usually can be managed with closed reduction techniques
do not require perfect alignment
tend to remodel with growth
Salter Harris type III?
fracture through a portion of the physis extending through the epiphysis and into the joint
Salter Harris type III manage?
Require anatomic alignment
-to prevent any stepoff, and realign the growth cells of the physis
Salter Harris type IV?
fracture across the metaphysis, physis, and epiphysis
prognosis may be poor
Salter Harris type IV manage?
requires anatomic alignment
-to prevent stepoff, realign the growth cells of the physis
Salter Harris type V?
crush injury to the physis
-no physeal fracture or displacement
Causes growth arrest and poor prognosis
-disruption of the germinal matrix, hypertophic regions and vascular supply
Salter Harris type V causes?
electric shock, frostbite, irradiation
Salter Harris type V diagnose?
difficult to differentiate from Type I
Usually not diagnosed initially
-present with growth disturbance
Clavicular fractures neonates vs children?
a direct trauma during birth
fall on the affected shoulder or direct trauma to the clavicle
Clavicular fractures diagnosis?
suggested by tenderness over the clavicle
AP xray of the clavicle
do neurovascular exam to diagnose any brachial plexus injury
Clavicular features treatment?
figure eight clavicle strap
fractures heal rapidly, usually in 3-6 wks
a palpable callus may be seen in thin children
complete restoration of shoulder motion and function is uniformly achieved
Toddler’s fracture?
occur in young ambulatory children (typically 1-4 yrs of age)
often occurs after a seemingly harmless twist or fall and is frequently unwitnessed
Radiographs may show no fracture
-nondisplaced spiral no fracture
Treat a toddler’s fracture?
above knee cast for 3 wks
Diagnose Toddler’s fracture?
physical exam-refusal to bear weight
When to suspect abuse?
femur fractures in nonambulatory children unexplained spiral fractures posterior rib fractures scapular spinous process fractures proximal humerus fractures
Craniosynostosis?
premature closure of cranial sutures
Primary (closure of one or more sutures due to abnormalities of skull development)
Secondary (failure of brain growth and expansion)
Treatment (surgery)
Plagiocephaly?
asymmetric cranium
may be caused by deformational mechanisms (in utero positioning, back to sleep)
Treatment
-reposition or tummy time, OMT, Helmet, surgery
Plagiocephaly vs Craniosynstosis?
plagio- ipsilateral lateral frontal bosing
cranio- contralaeral frontal bosing
Congenital muscular torticollis?
lateral bending of head with rotation to opposite side
may result from abnormal positioning in utero
involves contracture of the SCM
Treat torticollis?
gentle streching
exercise and crib positioning
surgical release of SCM
Cleft lip?
hypoplasia of the mesenchyal layer
failure of the medial nasal and maxillary processes to join
Cleft palate?
Failure of the palatal shelves to approximate or fuse
problem with cleft palate and cleft lip?
immediate issue is feeding
-soft, artificial nipples with a squeezable bottle
Treatment cleft lip/ cleft palate?
cleft lip- usually by 3 months of age, cosmetic results vary
cleft palate- usually before 1 yr of age to enhance normal speech development, recurrent OM and hearing loss are frequent
Scoliosis?
lateral curvature of the spine
Cause scoliosis?
Idiopathic Congenital Associated with neuromuscular disease or syndromes Compensatory from leg-length discrepancy Intraspinal abnormality
Idiopathic scoliosis?
unknown etiology
most common in adolescents
incidence equal in boys and girls, females have higher risk of developing curvature greater 30 degreees
Idiopathic scoliosis presentation?
change in appearance
back pain
may have
-asymmetry of shoulder height, leg-length discrepancy, loss of the normal thoracic kyphosis in the region of curvature
The adams test?
asymmetry of the posterior chest wall on forward bending
used for scoliosis
Idiopathic scoliosis work-up?
complete neurological exam
PA and lateral radiographs (cobb angle)
Cobb angle?
the angle between the superior and inferior end vertebra is measured
Idiopathic scoliosis treatment guidelines?
Curvature under 25 degrees needs observation
Curvature 25-40 degrees with more than 2 yrs of growth expected, needs bracing
Lumbar or thoracic curve over 40 degrees needs surgery
Congenital scoliosis?
abnormal growth and development of the vertebral column
evident at birth or early in childhood
Need to rule out other malformations in other organ systems
-GU abnormalities, Cardiac anomalies
Congenital scoliosis most pronounced?
during the periods of rapid growth (first 2-3 yrs of life) adolescent growth spurt
treat congenital scoliosis?
bracing is not indicated
often requires both anterior and posterior spinal fusion, ideally performed before singificant deformity
Subluxation of the radial head?
nursemaid’s elbow
annular ligament slips off radial head and into the elbow joint
mechanism is sudden traction applied to the extended arm (catching by arm when child falls)
History or nurse maid’s elbow?
parent pulling childs arm to prevent fall
child being swung by arms
child attempts to pull away from parents
Clinical symptoms of radial head subluxation?
immediate pain
arm held close to body (elbow flexed and forearm pronated)
no tenderness or swelling on exam
limited on supination
Xray radial head sublux?
normal, not necessary
Treatment radial head sublux?
apply pressure over radial head and supinate the forearm
pain relief immediate
return of function is evident quickly
Developmental dysplasia of the hip? DDH
subluxation-partial contact between the femoral head and acetabulum
dislocation- hip with no contact between the articulating surfaces of the hip
Associated conditions with DDH?
anything causing tighter intrauterine space
breech presentation
female gender
Presentation of DDH?
Barlow
Ortolani
Barlow?
adduct the flexed hip and gently push the thigh posterior to try and disloacte the femoral head
pos: hip is felt to side out the acetabulum
Ortolani?
lift the greater trochanter whild abducint the hip
palpable clunk signifies femoral head slipping into the hip socket
Developmental dysplasia of the hip?
asymmetry of skin folds of thighs and buttocks
Imaging Developmental dysplasia of the hip?
hip ultraosound under 4 mths
hip xray if 4-5 mths of age
Treat Developmental dysplasia of the hip?
palvik harness:keeps hips flexed and abducted
doesn’t work= closed reduction and immbolization in a spica cast
Legg-Calve-Perthes Disease?
caused by temporary interruption of the blood supple to the femoral head
etioloy unknown
more common in boys
peak incidence btw 4-8
Legg-Calve-Perthes Disease presentation?
limp
pain in groin, knee, thigh
Physical exam Legg-Calve-Perthes Disease?
hip painful and limited on internal rotation and abduction
atrophy of the muscles of the thigh, calf, or buttock from disuse secondary to pain
leg length discrepancy
Legg-Calve-Perthes Disease long term?
self limited
typically lasts 1-2 years
long term prognosis- most patients are active, pain free, and have a good ROM
Legg-Calve-Perthes Disease treatment?
goal is to create a spherical, well covered femoral head with ROM close to normal
Mainstay: non-operative
more severe cases
Slipped Capital Femoral Epiphysis (SCFE)?
Displacement of femoral head through epiphyseal plate 12-15 yo males>females associated obesity unknown etiology
SCFE presentation?
pain in hip, thigh or knee
change in hip ROM
painful limp
affected extremity held in external rotation with patient refusing to bear weight
Slipped Capital Femoral Epiphysis (SCFE) xrays?
AP and lateral views
widening and irregularity of the physis
displacement of femoral head on proximal femur (ice cream falling off the cone)
Slipped Capital Femoral Epiphysis (SCFE) treatment?
surgical pinning
Blount disease?
Tibia vera
growth disorder of the medial tibial epiphysis (varus agnulation, medial roation of the tibia)
incidence greater in female black obese children
etiology unknown
Blount disease radiographs?
weight bearing radiographs
- allow max presentation of deformity, fragmentation of epiphysis, breaking of the medial tibial epiphysis, depression of the medial tibial plateau
Osgood-schlatter disease?
pain over tibial tubercle in a growing child
traction apophysitis of the tibial tubercle
late childhood or adolescence
boys
due to repetitive tensile microtrauma
History Osgood-schlatter disease?
pain and swelling over tibial tubercle
pain aggrevated by activity, but persists at rest
Phyiscal exam Osgood-schlatter disease?
point tenderness over the tibial tubercle and patellar tendon
Radiographs Osgood-schlatter disease?
soft tissue swelling around the tibia apophysis
fragmentary ossification of the tibial tubercle may be noted
Treatment Osgood-schlatter disease?
rest, restrict activities, knee immobilize occasionally, NSAIDs for pain relief, complete resolution may require 12-24 months
Clubfoot deformity?
Talipes equinovarus
apparent after birth
more common in males
unilateral of bilateral
Clubfoot deformity positional?
held in a deformed position in utero
flexible on exam
Clubfoot deformity congenital?
spectrum of severity
those associated with neurovascular causes or syndromes are more rigid and difficult to treat
Clubfoot deformity physical exam?
watch for musculoskeletal or neuromuscular problems
calf atrophy
xray clubfoot?
may not be necessary
Treat Clubfoot deformity?
manipulation with serial casting
surgical realignment if nonoperative measures have failed or for clubfeet that are rigid
Metatarsus adductus?
adduction of the forefront relative to the hindfoot
metatarsals are deviated medially
most likely form intrauterine molding
no pathologic changes in structures of foot
should be distinguished from congenital clubfoot
may be passively correctable by examiner
xray Metatarsus adductus?
abnormal deviation of metatarsals medially
no other osseous abnormality
treatment Metatarsus adductus?
ranges from passive manipulation to casting to surgery
should be started prior to walking age
