Orthopedics Flashcards
Characteristics of the periosteum
Metabolically more active (promotes callus formation, remodeling ability)
Thicker and more durable (less likelihood of displacement and gives unique fracture presentations)
What are some apophyseal injuries?
Fibrocartilage
Fusion over time
Site of tendon or ligament attachment
Prone to overuse with inflammation or avulsion injuries
(bony prominences arising from separate ossification centers)
-growth plates that don’t add to length of bone
What are occult fractures?
Fractures not initially evident on plain radiographs
Toddlers, Salter Harris 1, non-displaced elbow fractures or stress fractures
What is the epiphysis vs metaphysis?
Epiphysis is at the end of the bone past the growth plate and metaphysis is between growth plate and shaft
Salter Harris Classification
1- Separate/straight across 2- Above into metaphysis 3- Lower/beLow into epiphysis 4- Two/Through both 5- Reduced/ERasure of growth place/cRush
What the the type 1/ slipped fracture?
“Epiphyseal slip”
Separation through the physis
Excellent prognosis- non operative management
What is the type 2 fracture?
Above physis
Fracture through part of physis that extends through metaphysis
Excellent prognosis- likely non-operative management
What is the type 3 fracture?
Lower to physis
Fracture through part of physis that extends through epiphysis and often involves joint space
Unstable prognosis
+/- operative management
What is the type 4 fracture?
Fracture through metaphysis, physis and epiphysis
Unstable prognosis and can lead to limb length discrepancies
+/- operative management
What is the type 5 fracture?
ERasure of the physis
Crush injury to the physis
Unstable prognosis can lead to limb length discrepancies
+/- operative management
Types of fractures unique to kids
Bowing
Torus/buckle
Greenstick
What are the elbow ossification centers?
CRITOE (in order of ossification)
1: Capitellum
3: Radial head
5: Internal (medial) epicondyle
7: Trochlea
9: Olecranon
11: External (lateral) epicondyle
What is the most common pediatric elbow fracture?
Supracondylar humeral fracture (most <10 YO)
MOI for supracondylar humeral fracture
Fall from moderate height (FOOSH typically with hyperextension)
Presentation of supracondylar humeral fracture
Swelling, pain, maybe deformity
Must do NV exam (median nerve at anterior interosseus nerve-pt not making an OK sign)
What diagnostics are used for a supracondylar fracture?
Xray: AP, lateral and oblique
What wouldn’t be seen on the x-ray for a supracondylar fracture?
Anterior humeral line will not intersect the capitellum
Management for type I/II supracondylar fracture
Splint with light overwrap (avoid elastic bandages)
Sling, NSAIDs
Ortho refer and maybe reduction for type II
Then immobilize for 3 wks
Management for type III supra condylar fracture or ones with neurovascular concerns
Emergent ortho consult
Closed reduction percutaneous pin fixation or open reduction
Most common Salter Harris fracture
II- above
Presentation of lateral humeral condyle fracture
Soft tissue swelling concentrated to lateral elbow
TTP over lateral condyle
How might a lateral humeral condyle fracture look on xray?
Like small sliver on the imaging due to large cartilaginous portion
Diagnostic views for lateral humeral condyle fracture
AP, lateral and internal oblique focused on lat. condyle
maybe MRI
When do you need an emergent referral and surgery for lateral humeral condyle fracture?
Displacement > 2 mm on internal oblique view
Management for lateral humeral condyle fracture
Splint, sling, NSAIDs Casting vs surgery Immobilize for 6 wks Open reduction with screw fixation High risk for complications!
MOI for medial humeral epicondyle fracture
(think baseball player) Muscle attachment avulsion- throwing or gymnast FOOSH with arm fully extended Secondary to posterior elbow dislocation Hear a "pop"
Presentation of medial humeral epicondyle fracture
Localized pain
Pain with resisted flexion
Ulnar nerve dysfunction
Imaging views for medial humeral epicondyle fracture
AP, lateral and external oblique
What do you need to r/o in medial epicondyle fracture?
Incarceration of fragment in joint (use advanced imaging if needed)
Management for medial epicondyle fracture
Emergent if trapped fragment
Splint with wrist also or sling
NSAIDs
Short term immobilization vs open fixation
Complications for medial epicondyle fracture
Ulnar nerve palsy
Nonunion
Angular deformity
Decreased ROM
Presentation of radial neck fracture
TTP over radial head/neck
Pain with supination and pronation is worse than with flexion and extension
Young kids may have wrist pain!
Diagnostic view for radial neck fracture
AP, lateral and external oblique (to flatten head of the radius)
How to diagnose a radial neck fracture in a kid younger than 3-5?
Clinical b/c radial head not ossified yet
Management of radial neck fracture
Immobilize with wrist (sling)
NSAIDs
Cast vs surgery
Complications for radial neck fractures
Premature physeal closure
Loss of ROM
Nonunion
What is nursemaid’s elbow?
Subluxation of the radial head (commonly 1-3 YO) due to sudden pull of pronated arm
Presentation of nursemaid’s elbow
Arm fully extended or slightly flexed and pronated
Refuse to use arm but maybe use fingers!
Mild pain over radial head
Pain increased with supination
Imaging for nursemaid’s elbow
Not usually required
Management of nursemaid’s elbow
Reduce by either hyperpronation with pressure over radial head OR supination/flexion with pressure over radial head
Lollipop/popsicle test (grab with injured arm)
Common causes of wrist fracture
Direct fall (FOOSH) or direct trauma
Most common wrist fracture
Distal radius at metaphysis (maybe ulnar involvement)
Presentation of wrist fracture
Point tenderness, swelling, ecchymosis
Dinner fork deformity
Imaging for wrist fracture
AP/lat and maybe oblique
SH I is clinical without any xray findings
When is a wrist fracture emergent?
Significant clinical deformity or NV compromise
Management for wrist fracture
Splint and NSAIDs
Ortho: cast, reduction vs surgery
Presentation of femur fracture
History of trauma
Pain in groin or butt
Unable bear weight/walk
If proximal femur then hold leg in slight adduction and external rotation (Shorten limb)
What is a femur fracture due to when less than 1?
Child abuse
Diagnostics for femur fracture
Must xray entire length of femur for proper eval
Management for femur fracture
Ortho: hip spica cast or surgery
complication: shorten or lengthening, angulation
What is a patellar sleeve fracture?
Unique to kids (most common patellar fx <13)
Caused by forced extension with knee in flexion
Either at superior or inferior pole of patella
*jumping/kicking etc
Management for patellar sleeve fracture
Knee immobilizer (in full extension), NWB, elevate
NSAIDs
Cast vs surgery
MOI for toddler fracture
Falling while running/twisting (slides!!)-spiral fx
Presentation of toddler fracture
Limp or NWB (might mistake for foot)
TTP along tibia typically mid to distal diaphysis
Problem with diagnostics in toddler fracture
May be occult on initial films
Management for toddler fracture
Immobilize (splint/wee walker)
NWB, NSAIDs, elevate
What is a triplane fracture of the ankle?
MOI external rotation
SH III on AP and SH II on lateral (SH IV- b/c growth plate had started to fuse)
CT to assess displacement*
Surgical fixation vs closed reduction
Management for fracture or ankle sprain
Initial the same
Posterior vs stirrup splint
Elevate, NWB, NSAIDs
Refer most pediatric ankle injuries
How do you prevent recurrence or ankle sprain or fracture?
Reconditioning (PT and home exercise programs)
What is a torticollis?
Unilateral contraction of SCM muscle with visible shortening
Cause of torticollis
Compartment syndrome of SCM secondary to venous outflow obstruction
Presentation of torticollis
Head tilt to shortened muscle and chin rotation to contralateral side
(evaluate for plagiocephaly-flat head)
Tx for torticollis
Stretching/PT and positioning education
What is scoliosis?
Lateral curvature of spine >10 degrees
Types of scoliosis
Congenital/infantile: 0-3
Juvenile: 4-9
Adolescent: over 10
(younger is more concerning)
Presentation of adolescent idiopathic scoliosis
Usually asymptomatic (maybe pain) Obstructive lung sxs if severe
Exam for adolescent scoliosis
Shoulder or pelvic obliquity
Asymmetry of scaps
Adams forward flexion exam (paraspinal prominences)
Abdominal reflexes
Imaging for adolescent scoliosis
AP/PA standing regular xray on long cassette
Cobb angle
Tx for scoliosis
TLSO:brace for 25 degrees (bending)
Surgery: 45 degrees and internal rod fixation
What is a septic hip diagnosis?
Emergent!!!!
peak in first few mos and then b/w 3-6
Reasons for a septic hip
Direct inoculation from trauma or surgery
Hematogenous seeding
Spreading of osteomyelitis from adjacent bone
Presentation of septic hip
Febrile and toxic appearing
Monoarticular pain: severely exacerbated with passive ROM
NWB
(might think psoas abscess or transient synovitis)
Most common cause of pediatric hip pain
Transient synovitis
Presentation of transient synovitis
Appear well (afebrile)
Pain worse in AM and improves during day
Recent URI
(3-8 YO and male)
Management for transient synovitis
NSAIDs (improves in first 2 days and resolve in 1 wk)
Must rule out septic arthritis
How do you differentiate septic hip and transient synovitis?
Kocher criteria: WBC>12,000 ESR>40 Fever >101.3 NWB on affected side 2/4 warrants joint aspiration (if have 3 then 93% chance of septic hip) Also CRP>2
Imaging for septic hip
AP and frog leg lateral pelvic (normal early and might see potential joint space widening)
US for effusion and aspiration and maybe MRI
Septic hip management
Operative: surgical I&D (joint aspiration or surgical ID is diagnostic)
Abx: cephalosporing IV (b/c s aureus mostly)
Older pt might be due to n gonorrhoeae so high dose penicillin
What is legg-calve-perthes?
Juvenile idiopathic osteonecrosis of the femoral head
Necrosis–fragmentation–re-ossification–healed/remodel
Who do you see legg-calve-perthes in more?
Whites (4-8) and male
maternal smoking or second hand smoke
Association of legg-calve perthes
Hyperactivity (ADHD)
Presentation of Perthes
Painless limp or insidious onset of pain (hip, groin, thigh or knee)-activity related so worse at end of day and relieve with rest
Muscle spasticity
History of minor trauma
Most useful PE finding for Perthes
Limited internal rotation or abduction of hip
(may also see antalgic limp or trendelenburg limp_
What is a later finding in Perthes?
Limp length discrepancy for positive Galeazzi
Mainstay imaging for Perthes
AP and frog lateral radiograph (usually normal initially)
What is seen on imaging with disease progression of Perthes?
Fragmentation and remodeling
Best prognostic factor in Perthes
Age (younger onset is better outcome)
Perthes tx
Symptomatic control and preserve hip function
When do you see slipped capital femoral epiphysis most?
M, African Americans (10-16)
Obesity is a risk!!
Presentation of SCFE
Limp or NWB c/o dull/achy hip or knee pain
Restricted ROM: abduction and internal rotation
Stable vs unstable based on WB status
Highly suspicious of SCFE but negative x ray
MRI (after have done AP pelvis and frog lat)
Tx for SCFE
In situ single screw fixation
NWB is admit to hospital!
What do you evaluate for in developmental dysplasia of the hip (DDH)?
Laxity, subluxation or dislocation
Risk factors for DDH
1st born, female, breech position, FHX
Test for DDH
Positive Barlow or Ortolani (clunking sensation)
Galeazzi: affected hip is shortened in comparison
Management DDH
Ortho (pavlik harness), not tight clothes
Monitor with U/s monthly and x-ray to monitor after 6 mos
What is Osgood-schlatters?
Inflammation and irritation of patellar tendon insertion on tibial tubercle (osteochondritis)
Traction at tibial tubercle apophysis
Presentation of Osgood-schlatters
Focal tenderness to tibial tubercle
Enlargment or bony protrusion of tibial tubercle
Imaging for Osgood-schlatters
Lateral xray to r/o avulsion
Management for Osgood-schlatters
Good days and bad
Rest, NSAIDs, ice, stretching, chopat strap
Pain flares at rapid growth times (10-11 in girls and 13-14 in boys)
What is calcaneal apophysitis/Severs?
Irritation and inflammation of calcaneal apophysis due to overuse and pull of achilles
Pain at apophysis
When see Severs more often
6-12 YO (soccer players and gymnasts)
Tx for severs
Stretch, Ice, NSAIDs
What is congenital talipes equinovarus?
Club foot- fixed deformity
Risks: FHX or mom smokes
Types of clubfoot?
CAVE midfoot Cavus forefoot Adductus hindfoot Varus hindfoot Equinus Might not need to memorize
How to tell which foot is affected with clubfoot
Affected limb has smaller foot and calf with shortened tibia
Tx for clubfoot
Ponseti method for 4-6 wks
Normal alignment by age
6 mos slight varus
18 mos straight
4 yrs slight valgus
Young adult straight
Blount’s disease
Varus due to vit D deficiency
