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Pediatrics > Orthopedics > Flashcards

Orthopedics Flashcards

1
Q

Brachial Plexus injury most commonly occurs as a result of ______ ______

A

birth trauma

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2
Q

Where is the injury in Erb’s palsy? What are the clinical features?

A

Upper brachial plexus injury involving the C5 and C6 nerve roots

Clinical features includ a flaccid arm and an asymmetric Moro reflex; Arm held in internal rotation with the elbow extended and forearm pronated (waiters tip)

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3
Q

Where is the injury in Klumpke’s palsy? What are the clinical features?

A

Lower brachial plexus injury involving C7 and C8 nerve roots

Clinical features include a claw hand owing to the unopposed finger flexion and decreased ability to extend the elbow and flex the wrist

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4
Q

How is congenital aplasia of the brachial plexus (Erb’s and Klumpke’s) diagnosed?

A

Diagnosis is on basis of history and physical examination

May include a plain radiograph of the shoulder to evaluate for associated clavicular fracture

EMG and nerve conduction studies to assess for neuropathy or myopathy

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5
Q

For congeital brachial plexus aplasias, improvement is often noted within ______ hours

A

48

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6
Q

What is nursemaid’s elbow? What is the mechanism of injury?

A

Subluxation of the radial head; Upward force on the arm causes the radial head to slip out of the annular ligament which normally keeps it in place

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7
Q

What are the clinical features of Nursemaid’s elbow?

A
  • Sudden onset of pain which is difficult to localize
  • Elbow is held flexed and no swelling is present; hand function is normal
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8
Q

What is the management for nursemaids elbow? Why is radiograph not needed?

A

Management: Treatment of the subluxation is to reduce it by simultaneously flexing the elbow and supinating the hand

Diagnosis is on the basis of clinical presenation; if a film is ordered, the technologist may accidentally reduce the subluxation in the process of positioning the arm for the radiograph

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9
Q

How are anterior shoulder dislocations diagnosed?

A

Diagnosis is based on radiographs (axillary view) of the glenohumeral joint to visualize the dislocation

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10
Q

What is the treatment of anterior shoulder dislocation? What is the recurrence rate in adolescents?

A

Treatment is immobilzation after closed reduction

Recurrence of dislocation approaches 90% in the adolescent population

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11
Q

What is torticollis?

A

Tilting of the head to one side; either congenital or acquired

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12
Q

What causes congenital torticollis?

A

Usually the result of uterine constraint or birth trauma, either of which causes conracture of the sternocleidomastoid muscle

Can also be caused by Klippel-Feil syndrome, a cervical spine deformity

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13
Q

What are the clinical features of torticollis?

A
  • Head is tilted toward the affected side with the chin pointed away from the contracture
  • Decreased range of motion and stiffness are noted when stretching the head to the opposite side
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14
Q

What is the management for Torticollis?

A

Treatment includes stretching exercises to relieve the muscle contracture; if head asymmetry is noted, helmet therapy must be initiated by 4-6 months of age to correct head shape as the head grows

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15
Q

What can cause acquired torticollis?

A

Causes may include cervical adenitis, peritonsillar or retropharyngeal abscess, cervical diskitis or osteomyelitis….

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16
Q

What is atlantoaxial instability?

A

Caused by an unstable joint between the occiput and the first cervical vertebrae or between the first and second cervical vertebrae

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17
Q

What are the clinical features of atlantoaxial instability?

A

Physical exam is usually normal and patients are usually asymptomatic

Spinal cord injury may occur if a patient with instability sustains injury

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18
Q

How is atlantoaxial instability diagnosed?

How is it managed when severe?

A

Diagnosis is made on the basis of lateral flexion-extension radiographs of the cervical spine

Mangement includes fusion of C1 and C2

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19
Q

What is Klippel-Feil syndrome?

A

Failure of normal vertebral segmentation that results in relative fusion of the involved vertebrae

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20
Q

What is Sprengel’s deformity (associated with Klippel-Feil syndrome)?

A

Congenital abnormality of the scapula in which the scapula is rotated laterally leading to should asymmetry and diminished shoulder motion

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21
Q

What are the clinical features of scoliosis?

A

Asymmetry of the shoulder height, scapular position and the waistline may be present; Pain is absent

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22
Q

What positional should radiographs be taken to diagnose scoliosis? What is calculated to measure the degree of scoliosis?

A

Standing posterior-anterior (PA) and lateral radiographs of the spine

Cobb angle

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23
Q

Describe the management for the following levels of scoliosis

  • 10-20° of scoliosis:
  • 20-40° of scoliosis:
  • >40° of scoliosis:
A
  • 10-20° of scoliosis: Follow up scoliosis film is obtained 4-6 months later; 5° of progression is considered significant
  • 20-40° of scoliosis: Bracing is indicated
  • >40° of scoliosis: Surgery is indicated
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24
Q

After growth has concluded, surgery is considered if scoliosis is > __°

A

50°

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25
Q

What is kyphosis?

A

Anterior-posterior (AP) curvature of the thoracic spine

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26
Q

Most adolescents with kyphosis have _______ _______ in which they can voluntarily correct the rounded area

A

flexible kyphosis

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27
Q

What is Scheuermann’s kyphosis?

A

A stiff idiopathic kyphosis in which three consecutive vertebrae are wedged; develops in previously normal adolescents

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28
Q

What is the most common cause of back pain in children?

A

Back strain - muscular soreness from overuse or bad body mechanics

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29
Q

What is spondylolysis? In what region is it located?

A

A stress fracture in the pars interarticularis secondary to repetitive hyperextension of the spine; typically involves the lumbar region, particularly L5

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30
Q

In spondylolysis, pain increases with ______

A

hyperextension

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31
Q

How is spondylolysis diagnosed when the fracture is acute? Why?

A

Because it is a stress fracture, plain films may not detect the fracture

Bone scan or single photon-emission computed tomographic (SPECT) scan may be used for diagnosis

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32
Q

What causes spondylolysis to progress to spondylolisthesis?

A

When the body of the vertebra involved in spondylolysis slips anteriorly; the subluxed vertebra can impinge on nerve roots

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33
Q

What is the most common infectious agent in diskitis? Where is the inflammation?

A

Staphylococcus aureus is the most commonly identified causeal organism

Inflammation of the intervertebral disk

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34
Q

What are the clinical features of diskitis?

A

Typically begins with signs and symptoms of an upper respiratory illness or minor trauma - followed by back pain with tenderness over the involved disk

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35
Q

What lab finding is elevated in diskitis? What imaging can confirm the diagnosis?

A

ESR is elevated

MRI and bone scan can confirm the diagnosis

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36
Q

What is the management of diskitis?

A

Treatment includes bed rest; may use antistaphylococcal antibiotics

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37
Q

What is the most commonly affected region for a herniated intervertebral disk?

A

The lumbar region is most commonly affected

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38
Q

What anatomic abnormality leads to developmental dysplasia of the hip?

A

Occurs when the acetabulum is abnormally flat, leading to the easy dislocation of the head of the femur

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39
Q

Developmental dysplasia of the hip (DDH) is more common in ____ (6:1 ratio)

A

girls

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40
Q

What are the risk factors for DDH?

A

Female sex, first born, breech presentation, family history and oligohydramnios

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41
Q

What two maneuvers are positive in physical examination of DDH?

A
  • Positive Barlow maneuver: with the hips at 90° flexion, place thumb on medial side of thigh and middle finger on the greater trochanter and apply gentle pressure posteriorly and laterally - “clunk” is positive
  • Positive Ortolani manuever: Abduct the hip, applying gentle pressure upward with the middle finger to slide the head of the femur back into the acetabulm - feeling the hip slipping into the acetabulum is positive
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42
Q

What is the Galeazzi sign in DDH?

A

Assesses the asymmetry of femur position; place hips in 90° flexion and if the hip is dislocated the affected femur is shifted posteriorly compared with the normal limb

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43
Q

How is DDH diagnosed if the physical exam is equivocal?

A

Ultrasound is used to assess DDH in young infants because the femoral head does not ossify until 4-6 months of age

AP radiographs of the pelvis may be used to assess for DDH if the infant is older than 6 months

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44
Q

What are the two methods of treating DDH? When is each used?

A
  • Pavlik harness: typically used for 2-3 months if the diagnosis is made by 6 weeks of age
  • Surgery may be required if the diagnosis is made beyond 6 weeks of age, the hips are bilaterally dislocated, irreducible on exam or the Pavlik harness fails to stabilize the hip
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45
Q

What are some possible complications of DDH

A
  • Avascular necrosis of the femoral head
  • Limb length discrepancy
  • Painful abnormal gait
  • Osteoarthritis
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46
Q

What cause of limping in a child is considered an orthopedic emergency?

A

Septic arthritis of the hip

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47
Q

What is the differential diagnosis for a painful limp?

Mnemonic: the joint STARTSS HOTT

A
  • Septic arthritis
  • Transient synovitis
  • Acute rheumatic fever
  • Rheumatoid arthritis
  • Trauma (fracture, strain, sprain)
  • Sickle cell disease
  • Slipped capital femoral epiphysis
  • Henoch-Schonlein purpura
  • Osteomyelitis
  • Tuberculosis
  • Tumor (osteosarcoma, leukemia)
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48
Q

What are the most common organisms associated with septic arthritis of the hip?

A

Staphylococcus aureus and Streptococcus pyogenes; Neisseria gonrrhoeae may cause septic arthritis in adolescents

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49
Q

What are the clinical features of septic hip?

A
  • Fever and irritability
  • Limp, refusal to walk and pain with movement of joint
  • Erythema, welling, asymmetry of soft tissue folds
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50
Q

What lab findings are there with Septic arthritis of the hip?

A
  • Elevated WBC count
  • Elevated ESR
  • Elevated C-reactive protein
  • Blood culture positive in 30-50% of all cases
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51
Q

What is the best imaging for septic arthritis of the hip?

A

Ultrasound (demonstrates fluid in the joint capsule)

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52
Q

What is the management for septic hip?

A
  • Surgical decompression by joint aspiration
  • Empiric intravenous antibiotics for 4-6 weeks
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53
Q

What is transient synovitis?

A

A common self-limited postinfectious response of the hip joint

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54
Q

What is the most common cause of painful limp in toddlers?

A

Transient synovitis

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55
Q

When is the peak age range of presentation for transient synovitis?

A

2-7 years

56
Q

What are the clinical features of transient synovitis?

A
  • Low grade fever
  • Limp
  • Hip pain (may be acute or insidious in onset)
57
Q

What is the management for transient synovitis? What happens to WBC count and ESR?

A

Treatment includes NSAIDs, bed rest, and observation

WBC count and ESR are normal or only slightly elevated

58
Q

What is Legg-Calve-Perthes disease?

A

Idiopathic avascular necrosis fo the femoral head

59
Q

What is the age of onset for Legg-Calve-Perthes? Who is the typical patient?

A

Age of onset is 4-9 years

Patients are typically active, thin boys who are small for their age

60
Q

Children with Legg-Calve-Perthes havve decreased ________ rotation and ______ of the hip

A

internal; abduction

61
Q

In Legg-Calve-Perthes, where can the pain be referred?

A

Pain may be referred to the knee and to the groin

62
Q

What type of radiographs are used to see Legg-Calve-Perthes disease? What is seen on imaging?

A

AP and frog-leg lateral radiographs of the pelvis

Increased density in the affected femoral head or a subchondral fracture in the femoral head, termed the “crescent sign”

63
Q

What is the management for Legg-Calve-Perthes disease? When is surgery indicated?

A

Physical therapy and restriction of vigorous exercise

Surgery is indicated if there is more than 50% damage to the femoral head or if there is movement of the femoral head out of the acetabulum

64
Q

Who is the typical patient with a slipped capital femoral epiphysis?

A

Obese adolescent boy

65
Q

What are the clinical features of slipped capital femoral epiphyssis (SCFE)? How often is it bilateral?

A
  • Patients have a painful limp with pain in the groin, hip or knee
  • Internal rotation, flexion, and abdubtion are usually decreased in the affected hip
  • Bilateral in 30% of cases
66
Q

What is the significance of the klein line in patients with SCFE?

A

A line drawn flanking the superior edge of the femoral neck (Klein line) crosses 10-20% of the epiphysis in a normal hip; In SCFE, the Klein line will not cross the epiphysis at all

67
Q

What is the treatment for SCFE?

A

Treatment involves pinning the epiphysis to prevent further slippage

68
Q

What are four possible complications of SCFE?

A
  • Avascular necrosis
  • Chondrolysis (degeneration of aurticular cartilage)
  • Limb length discrepancy
  • Osteoarthritis
69
Q

What are the most common organisms responsible for osteomyelitis?

When should salmonella be considered?

When should pseudomonas aeruginosa be considered?

A

S. Aureus and S. pyogenes are the most common organisms

Salmonella should be considered in patients with sickle cell anemia

Pseudomonas aeruginosa infection can occur if a child steps on a nail

70
Q

Children most commonly acquire osteomylitis by _______ ________

A

hematogenous seeding

71
Q

What are the clinical features of osteomyelitis?

A
  • Fever and irritability
  • Bone pain, erythema, swelling, and induration
  • Painful limp
72
Q

What is elevated in laboratory studies of osteomyelitis?

A

Elevated WBC count, ESR, and C-reactive protein

73
Q

What imaging technique is used to detect osteomyelitis a few days after the onset of symptoms?

When is a plain radiograph used?

A

Bone scan or MRI detects osteomyelitis a few days after the onset of symptoms

Plain radiograph begins to reveal elevation of the periosteum suggesting osteomylitis, after 10-14 days

74
Q

How long should antibiotics be used for osteomyelitis?

When should IV antibiotics be switched to oral antibiotics during management?

A

Antibiotics should be given for 6 weeks

Decreasing ESR indicates a response to IV antibiotics at which time oral antibiotics usually can be use to complete the antibiotic course

75
Q

What can cause chronic osteomyelitis?

A

A nidus of residual infection, such as a sequestrum (focus of necrotic bone) or an involucrum (formation of new bone or fibrosis surrounding the necrotic, infected bone)

76
Q

What is metatarsus adductus?

A

Medial curvature of the mid-foot (metatarsals)

77
Q

Metatarsus adductus occurs in children younger than ___

A

1 year of age

78
Q

What causes metatarsus adductus?

A

Intrauterine constraint

79
Q

What are the clinical features of metatarsus adductus?

When should clubfoot be considered?

A

Clinical features include a C-shaped foot that can be straightened to varying degrees by gentle manipulation

If the ankle cannot dorsiflex, clubfoot should be considered

80
Q

What is the management for metatarsus adductus where….

  • Flexible foot that can overcorrect with passive motion:
  • Flexible foot that can correct with passive motion, but not overcorrect:
  • Stiff foot that cannot be straightened:
A
  • Flexible foot that can overcorrect with passive motion: observation only
  • Flexible foot that can correct with passive motion, but not overcorrect: exercises to stretch the foot
  • Stiff foot that cannot be straightened: Evaluation by pediatric orthopedic specialist; casting may be necessary
81
Q

What is talipes equinovarus?

A

Clubfoot; fixed foot in inversion with no flexibility

82
Q

What other disorders are associated with talipes equinovarus?

A

DDH, myelomeningocele, myotonic dystrophy, some skeletal dysplasias

83
Q

How is talipes equinovarus managed?

A

Treatment involves casting within the first week of life

84
Q

What is the most common cause of in-toeing in children younger than 2 years of age?

A

Internal tibial torsion

85
Q

In Internal tibial torsion, the patella faces _______ and the foot points ______ when the knee is flexed to 90º

A

forward; medially

86
Q

Management of internal tibial torsion is…

A

observation only

87
Q

What is the most common cause of in-toeing in children older than 2 years of age?

A

Femoral anteversion

88
Q

In Femoral anteversion, feet point ______ and patella points _______

A

both point medially

89
Q

Children with Femoral anteversion sit in a ____ position

A

“W” (opposite of sitting cross legged on the floor)

90
Q

Managment of Femoral anteversion is….

A

observation

91
Q

What is the major cause of out-toeing?

A

Calcaneovalgus foot - which is a flexible foot held in a lateral position

92
Q

Clinical features of cacaneovalgus foot are a flexible foot with toes pointed ______; plantar ______ is restricted

A

Outward; flexion

93
Q

Management of a calcaneovalgus foot includes….

A

stretching the foot (rarely casting may be needed)

94
Q

Bowed legs (genu varum) are a normal variation until ___ years of age

A

2

95
Q

What is the “cowboy” stance associated with genu varum?

A

When child stands erect with the feet together, the knees bow laterally and the patella point forward

96
Q

When is a standing AP radiograph indicated with genu varum?

A

Indicated only if bowing is unilateral, is severe, or persists after 2 years of age to assess for pathologic bowing

97
Q

What is Blount’s disease?

What causes it?

A

A progressive angulation of the proximal tibia

It is thought to be a result of overload injury to the medial tibial growth plate

98
Q

When is Blount’s disease suspected?

A

In any child with progressive bowing, unilateral bowing, or persistent bowing after 2 years of age

99
Q

A metaphyseal-diaphyseal (M-D) angle > __º is consistent with Blount’s disease

A

11º

100
Q

What is the management for Blount’s disease and when is it indicated?

A

Bracing for 1 year if the M-D angle is greater than 16º or if the patient is 2-3 years of age

Surgical osteotomy if there is no improvement with bracing, if the patient is older than 4 years of age, if there is recurrence or angulation

101
Q

When is recurrence of blount’s disease common?

A

Common in obese children if treatment is started after 4 years of age or if the epiphysis is fragmented from injury

102
Q

What are the clinical features of knock-knees (genu valgum)?

A
  • Separation of the ankles when standing erect with knees together
  • Swinging legs laterally with walking or running
103
Q

Surgery is indicated only if genu valgum persists beyond ___ years of age or causes ______ pain

A

10 years of age; knee pain

104
Q

What is Osgood-Schlatter disease?

A

Inflammation or microfacture of the tibial tuberosity caused by overuse injury

105
Q

Age of onset of Osgood-Schlatter disease is commonly _ -_ years

A

10-17 years

106
Q

What are the clinical features of Osgood-Schlatter disease?

A

Swelling of the tibial tuberosity

Tenderness over the tibial tubercle

107
Q

Management of Osgood-Schlatter disease includes…

A

Rest, stretching of the quadriceps and hamstrings, and analgesics

108
Q

Patellofemoral syndrome is common in ______ _____

A

adolescent girls

109
Q

What are the clincal features of patellofemoral syndrome?

A
  • Knee pain directly under or around patella
  • Pain is worse with activity or with walking up and down stairs; relieved with rest
  • Physical examination of the knee may show the patella in a lateral position
110
Q

What is the management of patellofemoral syndrome?

A

Includes stretch, stretching, and strengthening of the medial quadriceps

111
Q

What are growin pains?

A

Idiopathic bilateral leg pains that occur in the late afternoon or evening but do not interfere with play during the day

112
Q

Treatment of growing pains is…

A

analgesics and reassurance

113
Q

What is the difference between an open fracture and a closed fracture?

A

In a closed fracture, the skin is intact; In an open fracture, the skin is broken and antibiotics are required because of the risks of infection

114
Q

What terms are used to describe the spatial relationship of the fractured ends of a broken bone?

A
  • Nondisplaced or nonangulated (well approximated)
  • Displaced (Fractured ends that are shifted)
    Angulated (Fractured ends that form an agnle)
  • Overriding (fracture whose ends override without cortical contact)
115
Q

What is compression fracture? Where does it usually occur and how is it treated?

A

Occurs if the soft bony cortex buckles under compressive force; Commonly occurs in the metaphysis; Requires only splinting for 3-4 weeks

116
Q

What is an incomplete fracture?

A

Occurs if only one side of the cortex is fractured with the other side intact

117
Q

What are the four types of complete fractures?

A
  • Transverse: horizontal across the bone
  • Oblique: Diagnoal fracture across the bone
  • Spiral: Oblique fracture encircling the bone (may be associated with child abuse)
  • Comminuted: Fracture that is composed of multiple fracture fragments
118
Q

What are different locations where fractures can occur in the bone?

A
  • Epihyseal: end of the bone
  • Metaphyseal: Ends of the central shaft
  • Diaphyseal: Central shaft of the bone
  • Physeal: Involves the growth plate
119
Q

What grade Salter-Harris fracture may affect subsequent bone growth

A

Some grade 2-3 fractures and all grade 4-5 fractures

120
Q

What are the clinical features of a clavicular fracture?

A
  • Infants may be asymptomatic or may present with asymmetric moro reflex or pseudoparalysis
  • Crepitus felt over the fracture
  • Children typically hold the affected limb with the opposite hand
121
Q

What is the treatment for a clavicular fracture?

A

Treatment includes placement in a sling for 4-6 weeks to assist immobilization of the limb; A firgure of eight bandage can be used to draw the shoulder back but is combersome

122
Q

What causes supracondylar fracture

A

Occurs when a child falls onto an outstretched arm or elbow

123
Q

When is a supracondylar fracture an emergency?

A

Orthopedic emergency if the fracture is displaced and angulated because of the risk of neurovascular injury and comparment syndrome

124
Q

What are some clinical features of supracondylar fractures?

A

Point tenderness, swelling, and deformity of the elbow may be seen

125
Q

Pain with passive extension of the fingers after a supracondylar fracture is suggestive of ________ ______

A

comparment syndrome

126
Q

What sign on AP and lateral radiographs may be observed if a supracondylar fracture is present?

A

Posterior fat pad sign: a triangular fat pad shadow posterior to the humerus

127
Q

Compartment syndrome occurs when the pressure within the anterior fascial comparment is greater than __-__ mm Hg

A

30-45 mmHg

128
Q

What are the 5 Ps of compartment syndrome (late signs)

A
  • Pallor
  • Pulselessness
  • Paralysis
  • Pain
  • Paresthesias
129
Q

What is cubitus varus (associated with supracondylar fracture)?

A

Decreased or absent carrying angle as a result of poor positioning of the distal fragment

130
Q

What are the three common types of forearm fractures?

A
  • Colles fracture: distal radius
  • Monteggia fracture: Proximal ulna with dislocation of the radial head
  • Galeazzi fracture: Radius with distal radioulnar joint
131
Q

Forearm fractures heal within __ - __ weeks

A

6-8

132
Q

Why must radiographs of femur fractures include the joint above and below the area of injury?

A

Femur fractures require a great deal of mechanical force

133
Q

What is the management of femur fractures?

A

Treatment includes casting for 8 weeks

Some femur fractures require traction for callus formation before casting

134
Q

What is a toddler’s fracture?

A

A spiral fracture of the tibia (fibula remains intact)

135
Q

Toddler’s fractures usually occur between __ and __ of age

A

9 months and 3 years

136
Q

What are the clinical features of a toddler’s fracture?

How long is casting done?

A

Child refuses to bear weight but is willing to crawl; erythema, swelling, and mild point tenderness may be found over the distal tibia on examination

Long leg cast for 3-4 weeks

137
Q

What types of fractures should make the clinician suspect abuse?

A
  • Metaphyseal fractures
  • Posterior or first rib fractures
  • Multiple fractures at various ages of healing
  • Complex skull fractures
  • Scapular, sternal, and vertebral spinous process fractures

Pediatrics (24 decks)

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