Orthopedics Flashcards
1
Q
Torticollis
A
- Infancy
- wry (twisted) neck deformity
- contracture of the sternocleidomastoid
- caused in newborns by
- uterine malposition (breech delivery)
- birth trauma
- Differential Diagnosis in older children
- neurogenic/CNS mass
- inflammatory (local head & neck infections)
- traumatic
- ocular strabismus
- hysterical & psychiatric
- Diagnosis often requires simple radiographs, though brain imaging should be considered to uncover neurogenic causes
- Treatment
- range of motion exercises
- occasionally surgically released
2
Q
scoliosis
A
- Lateral curvature of the spine
- idiopathic in 80% of cases
- Historical factors suggesting a pathologic cause
- pain
- left thoracic curves are more often associated with spinal pathology (syrinx or tumor)
- stiffness
- midline skin lesion
- Screening exam- AAOS, SRS, POSNA, and AAP believe that screening examinations for spine deformity should be part of the medical home preventative services visit for females at age 10 and 12 years, and males once at age 13 or 14 years.
- Forward Bend
- Scoliometer
- Radiographs - indicated for 5 degrees or more
- higher risk of progression
- Cobb Angle – DON’T NEED TO KNOW HOW TO CALCULATE ON EXAM
3
Q
pathologic scoliosis
A
- differential diagnosis
- secondary
- muscle spasm, leg length discrepancy
- congenital
- disorders of spinal development
- often with bone, renal, urogenital or neural abnormalities
- neuromuscular
- cerebral palsy, polio, muscular dystrophy, spinal muscular atrophy
- constitutional
- metabolic disorders, arthritides
- traumatic
- neoplastic
- secondary
4
Q
scoliosis curve severity and management
A
- curve severity
- 0-15 degrees
- 15-25 degrees
- 25-45 degrees
- 45 + degrees
- 60 + degrees
- management
- unlikely to progress
- monitor regularly
- bracing vs. operative
- operative intervention
- may cause pulmonary compromise
5
Q
salter harris fracture
A
- Fractures that involve the growth plate are of prime importance in pediatrics because they may affect the growth of the bone.
- SH I: Through the physis. May not be seen on x-ray. Unlikely to affect growth
- SH II: Through the physis and metaphysis. Most common. Good prognosis.
- SH III: Through the physis and epiphysis. Requires surgical intervention to avoid problems with growth. Involves the joint
- SH IV: Through the physis, epiphysis and metaphysis. Requires reduction and there is risk for growth problems with the bone.
- SH V: Crush injury with obliteration of the growth plate. Can be mistaken for a SH I. High risk for growth arrest
6
Q
suptracondylar fracture
A
- Uncommon in adults but very common in children.
- Fall on an outstretched hand forces olecranon of the ulna into the humerus.
- Evaluate for neuromuscular compromise
- Refer to ortho/immobilize
7
Q
nursemaids elbow
A
- Subluxation of the radial head with axial traction on a pronated fore arm.
- Common in ages 1-4yo. By 5 yo the annular ligament stiffens and is less likely to slip and allow for subluxation.
- History of pulling or swinging from the arms.
- Exam is significant for pain over the anterolateral aspect of the radial head.
- There should not be bony tenderness, deformity or swelling. If these are present then x-ray is required to rule out fracture.
- X-ray is generally useful only to rule out fracture and is not used to diagnose nursemaid’s elbow.
8
Q
differential diagnosis of limp in a child
A
- Causes localized to the limb
- strain, sprain, and contusion
- fracture
- limb length equality
- transient (“toxic”) synovitis
- septic arthritis
- osteomyelitis
- developmental dysplasia of the hip (DDH)
- slipped capital femoral epiphysis (SCFE)
- Legg-Calvé-Perthes disease (LCPD)
- Osgood-Schlatter
- patellofemoral syndrome
- osteoid osteoma
- neoplasm of bone, joint or soft tissue
- Trivial causes
- hair tourniquets (may be NOT trivial)
- blisters
- nail trauma
- ill-fitting shoes
- feel inside for seams or objects
- subcutaneous foreign bodies
- plantar warts
- Systemic causes of arthritis
- Henöch-Schoenlein purpura (HSP)
- rheumatologic disease
- Kawasaki disease
- serum sickness
- Lyme disease
- inflammatory bowel disease
- gonorrhea and meningococcemia
- neoplasm
- Causes outside the limb
- abdominal pathology
- appendicitis
- psoas muscle abscess
- pelvic pathology
- pelvic inflammatory disease or abscess
- ovarian torsion/cysts
- genitourinary pathology
- testicular torsion/epididymitis
- urolithiasis
- inguinal hernia
- back pathology
- muscle strain
- discitis, herniated disc
- spondylysis/spondylolisthesis
- neurologic pathology
- tumor: spinal/cerebral/cerebellar/retroperitoneal
- abdominal pathology
9
Q
transient synovitis
A
- Idiopathic inflammation of the hip. Etiology is unknown, but often follows a viral illness.
- Patients may present with a limp or limited ROM of the affected hip joint.
- Patients are well appearing and white count, CRP, and ESR should be low.
- May cause severe pain.
- Arthrocentesis may be needed for diagnosis.
- Treatment is with NSAIDS and rest.
- Pt looks well, nontoxic, but don’t want to walk
10
Q
septic joint
A
- Infection of the joint space that causes pain and inflammation.
- Children may appear more ill with fever, red and swollen joint and signs of sepsis.
- Kocher Criteria- Calculates likelihood of septic joint. Having 1 criteria is 3% change, 2 criteria 40%, 3 criteria 93%, 4 criteria 99%.
- Non-weight bearing
- ESR >40
- Fever >38.5
- WBC >12
- CRP > 2.5*
- Diagnostics:
- Joint aspiration with culture
- Ultrasound or MRI
- Common Pathogens:
- Staph aureus-Most common!
- Group A Strep- Children >5yo
- Group B Strep <5 mo
- Kingella kingae- <2-3. Difficult to grow in culture.
- You may get a kid with a classic septic hip but none of the cultures are growing anything out. You need to consider this pathogen and treat for it even though you have no actual proof
- Neisseria gonorrhea- teenagers
- Salmonella- Sickle Cell patients
11
Q
trauma
A
- Most common cause of limp in children
- Greenstick fractures reflect the unique ability of kids’ bones to bend – heal really well
- Toddler’s fractures - mechanism is usually by twisting or tripping
- Soft tissue injury more common than bone injury
- Always make sure the story fits the injury.
12
Q
toddler’s fracture
A
- most common identified fracture in preschool children presenting with a limp
- patients between the ages 9 months and 3 years
- nondisplaced spiral or oblique fracture of lower third of tibial shaft
- AP and lateral films may show obvious fracture
- most common presentation:
- child refuses to bear weight on affected leg
- history of minimal or no trauma
- physical exam may show warmth and pain with palpation
- usually no swelling
- pain with gentle torsion of the foot
- Pathophysiology
- sudden twisting of tibia
- fracture more obvious 10-14 days after injury
- callus formation
- generally heals with subperiosteal new bone formation running entire length of tibia
- indicates fracture more extensive and likely extends up the shaft through middle and proximal one third
- Treatment
- long leg cast immobilization
13
Q
developmental dysplasia of the hip
A
- displacement of femoral head from its normal position in the acetabulum
- affects normal development of both
- 1-2 per 1000 births
- Terminology
- dislocation - femoral head completely outside of the acetabulum
- subluxable - femoral head can be displaced outside of acetabulum
- dysplasia - radiographic abnormality
- despite neonatal screening, occasionally a child presents after walking age.
- children often walk on affected side’s toes to compensate for short limb.
- Risk Factors
- female gender
- breech malposition
- family history of DDH
- limited fetal mobility
- clinical evidence of joint instability
- significant persistent hip asymmetry
- Examination
- screen on every well child visit
- 0-4 months - check hip instability
- Ortolani maneuver
- Barlow maneuver
- 4 months leg length/abduction
- Galeazzi sign
- 12 months and beyond
- Trendelenburg’s sign
- Imaging
- Plain films
- increase in usefulness beyond 4 months of age
- widened pelvic floor
- decreased femoral head coverage
- femoral ossific nucleus
- ultrasonography
- Plain films
- Requires static and dynamic images, trained
- Diagnosis
- Regular well child visit screening
- follow clicks for first 2 weeks
- refer clunks (subluxation, dislocation on exam)
- work-up
- ultrasound < 5 months
- plain films > 4 months
- Regular well child visit screening
- Treatment
- < 6 months of age
- Pavlik harness - prevent hip extension and abduction
- > 6 months of age
- open or closed reduction
- < 6 months of age
14
Q
legg-calve perthes disease
A
- avascular necrosis of proximal femoral head
- predominantly unilateral
- both hips are involved in less than 10% of cases
- hips are involved successively, not simultaneously
- both hips are involved in less than 10% of cases
- insidious onset and may occur after hip injury coagulation or endocrine abnormalities may also contribute to cause
- Pathophysiology
- rapid growth relative to blood supply
- causes interruption of adequate blood flow and results in avascular necrosis
- Frequency
- incidence is 4 cases per 100,000 people
- usually occurs in children aged 4-10 years
- mean age 7 years
- occurs more commonly in boys than in girls
- male-to-female ratio 4:1
- white children affected more
- Symptoms
- antalgic limp, pain typically mild
- pain often gradual onset, intermittent & referred to thigh or knee
- pain usually worsens with activity
- Exam
- loss of medial rotation
- loss of abduction
- radiographic signs (acute)
- small femoral epiphysis (96%)
- sclerosis of femoral head with sequestration and collapse (82%)
- widening of joint space due to thickening of the cartilage, failure of epiphyseal growth, the presence of joint fluid, or joint laxity (60%)
- fracture line between avascular center of the femoral head and the subchondral bone
- bone scan
- reduced uptake
- MRI
- marrow necrosis, irregularity of the femoral head, loss of signal from affected side
- Non-operative management
- aims of therapy is to prevent deformity & osteoarthritis
- restoration/maintenance of range of motion
- prevention of subluxation
- attainment of a spherical femoral head at healing
- bed rest & NSAIDs
- abduction bracing until lateral portion of femoral head has regenerated (12-18 months)
- aims of therapy is to prevent deformity & osteoarthritis
- surgery for severe disease
15
Q
slipped capital femoral epiphysis (SCFE)
A
- structural failure of the upper femoral physis that allows displacement of the femoral head on the neck
- most common hip abnormality presenting in school age or adolescence (ages 7-15)
- a primary cause of early osteoarthritis
- Pathophysiology:
- Salter-Harris type 1 fracture through proximal femoral physis
- stress on hip causes epiphysis to move posteriorly and medially
- almost exclusive incidence of SCFE during adolescent growth spurt suggests hormonal role
- obesity is key predisposing factor
- Salter-Harris type 1 fracture through proximal femoral physis
- Frequency:
- incidence is 1 case per 100,000 people
- slightly greater incidence in males than females
- slightly greater incidence in those of African ancestry
- typically occurs just after onset of puberty
- frequently in overweight, skeletally immature boys
- slippage is bilateral in 20-37%
- symptoms
- hip & knee pain, insidious in onset
- antalgic limp
- out-toeing (to avoid internal rotation)
- signs
- thigh may be shortened, externally rotated, and abducted.
- Rotation in any direction may be limited by pain
- tenderness on palpation of hip with discomfort often referred to hip, groin or thigh
- Early:
- widening of growth plate and osteopenia of the involved femoral head and neck
- Late:
- displacement of the femoral neck relative to the femoral head
- “ice cream scoop falling off the cone”
- Line of Klein:
- line drawn along lateral aspect of femoral neck on AP view
- line should intersect a portion of femoral head
- Treatment
- fixation
- screw fixation
- osteotomy – attempts to change head alignment may predispose to avascular necrosis
- goal – avoid avascular necrosis, degenerative arthritis
- fixation
