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Royal College Peds 2021 > ORTHOPEDICS > Flashcards

ORTHOPEDICS Flashcards

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1
Q

What are the indications for open reduction?

A

NO CAST N - non-union

O - open fracture

C - compromise of neurovasculature

A - intra-articular fracture

S - Salter Harris type 3, 4, 5

T - polytrauma

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2
Q

In anterior shoulder dislocation, what tests can you perform to confirm the diagnosis?

A
  1. Apprehension test: abduct and externally rotate the arm and should see apprehension in the patient’s face since it re-creates a feeling of anterior dislocation
  2. Relocation test: posteriorly direct a force during the apprehension test to relieve apprehension
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3
Q

What are the 4 rotator cuff muscles, their nerve supply and their function?

A
  1. Supraspinatus - suprascapular nerve, abduction
  2. Infraspinatus - suprascapular nerve, external rotation
  3. Teres minor - axillary nerve, external rotation
  4. Subscapularis - subscapular nerve, internal rotation and adduction
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4
Q

What is the treatment of clavicle fractures? -Proximal & middle 3rd -Distal 3rd

What are the complications of clavicle fractures?

A

Proximal (5%) &

middle (80%)

3rd: -sling x 1-2 wks -early ROM and strengthening -analgesia -if ends overlap > 2 cm, consider ORIF Distal (15%) 3rd: -undisplaced (with ligaments intact): sling x 1-2 wks -displaced (CC ligament injury): ORIF or excision

Complications: -in children, usually no complications

-can have pneumothorax, brachial plexus injury, subclavian vessel injury, cosmetic bump (most common)

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5
Q

In children suspected of having an anterior shoulder dislocation, which nerves should you check are intact?

A

Axillary nerve: deltoid contraction and sensory patch over deltoid

Musculocutaneous nerve: biceps contraction and sensory patch on lateral forearm

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6
Q

Upper extremity nerves: nerve root, muscle innervation and how to test for weakness on exam?

A
  1. Axillary nerve: C5 - deltoid - flexion of arm
  2. Musculocutaneous nerve: C5-C6 - bicep - flexion of forearm (C5-C6 pick up chicks)
  3. Radial nerve: C6-C7 - triceps - extension of forearm -wrist extensors
  4. Median nerve: C8 - intrinsic hand, thenar and hypothenar muscles - look for thenar muscle wasting, thumb opposition
  5. Ulnar nerve: T1 - intrinsic hand muscles - finger abduction (fanning out the hand)
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7
Q

Which nerve is most commonly injured in supracondylar fracture?

A

Anterior interosseous nerve

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8
Q

What is the mechanism of supracondylar fractures?

What investigation should be performed to rule out supracondylar fracture?

Treatment?

A

Mechanism: >96% are extension injuries via FOOSH

Investigation:Order AP/lateral Xray of elbow

Treatment: -undisplaced: cast in flexion x 3 wks -displaced: consult ortho for percutaneous pinning followed by limb cast

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9
Q

What is the order of appearance of ossification centers in the elbow and approximate age of appearance?

A

CRITOE - helps you determine whether a small piece of bone seen on elbow xray is an avulsion fragment or an ossification centre

Capitellum - 1 yo

Radial head - 3 yo

Internal (medial) epicondyle - 5 yo

Trochlea - 7 yo

Olecrenon - 9 yo

External (lateral) epicondyle - 11 yo

*Ages are variable Example: If you see only three accessory bony fragments about an elbow joint, these bony pieces should be in the areas of the capitellum, radial head and the internal (medial) epicondyle. If one of the three bony fragments is in the area where you would expect to see the external epicondyle, then that piece actually represents an avulsion fracture of the distal, lateral humerus, rather than a normal external epicondyle.

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10
Q

Important things to check in a patient who has had a FOOSH?

A
  1. Palpate entire extremity for tenderness, including clavicles
  2. Check anatomical snuffbox for scaphoid fracture
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11
Q

How do you manage a patient with tenderness in the anatomical snuffbox?

A

Any patient with tenderness over the scaphoid bone must be treated (splinted with orthopedic referral) as an occult scaphoid fracture until proven otherwise (even if the initial scaphoid views do not reveal any evidence of a fracture)

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12
Q

Where does the anterior fat pad normally lie?

Can an anterior fat pad be seen on a normal elbow xray?

What does a “sail sign” signify?

A

Anterior fat pad normally lies just over the coronoid fossa (anterior to distal humerus).

Anterior fat pad can be seen in a normal elbow xray as a thin translucent line anterior to the coronoid fossa.

Superior and anterior displacement of the anterior fat pad of the elbow joint, signifying a distended elbow joint capsule secondary to an intraarticular fracture

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13
Q

Where does the posterior fat pad normally lie?

Can a posterior fat pad be seen on a normal elbow xray?

A

Posterior fat pad normally lies over the olecranon fossa.

It is never normal to see a posterior fat pad on elbow xray. If you do, it means there is an intraarticular fracture.

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14
Q

What is the anterior humeral line?

A

On an elbow xray, draw a line down the anterior aspect of the humerus.

  • Normal: anterior humeral line transects the middle of the capitellum.
  • Abnormal: anterior humeral line transects the anterior 3rd of the capitellum or the capitellum sits posterior to the anterior humeral line completely, signifying a supracondylar fracture or Salter Harris Type 1 fracture through the physis displacing the capitellum
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15
Q

What is the radiocapitellar line?

A

On a lateral view of an elbow xray, draw a line through the central axis of the radius.

  • Normal: radiocapitellar line should transect the middle of the capitellum. On all views, the radius should point directly at the capitellum
  • Abnormal: if it does not, then consider a radial head dislocation or fracture of radial neck
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16
Q

How can you confirm that an xray is a true lateral view of the elbow?

A

Look at the distal humerus and should see an hour-glass/figure 8 to signify a true lateral view.

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17
Q

Mnemonic for Monteggia vs. Galeazzi fracture?

A

MonteggiA is fracture of the ulnA with radial head dislocation Galeazzi is therefore fracture of the radius

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18
Q

What is the management of a Monteggia fracture?

A

Immediate referral to orthopedics for reduction of radial head dislocation asap

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19
Q

What is the systematic approach to reading an elbow xray?

A

Summary Outline: 1. Anterior fat pad. 2. Posterior fat pad. 3. Anterior humeral line. 4. Radial head contour. 5. Radiocapitellar line. 6. Ossification centers. CRITOE 7. Hourglass sign. 8. Distal humerus. 9. Ulna/Olecranon. 10. Clinical correlation.

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20
Q

What is the significance of a swollen elbow?

A

Swollen elbow almost always indicates an elbow fracture!

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21
Q

What is Legg-Calve-Perthe?

A

Interruption of vascular supply to femoral head and can lead to avascular necrosis of femoral head -age group: 4-10 years old (as opposed to SCFE: chubby teenager)

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22
Q

What type of mechanism of injury causes the majority of ankle sprains?

A

Inversion (think ankle going inwards)

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23
Q

How many ankle ligaments are there?

A

Medial: 1 fan shaped ligament -deltoid ligament connecting tibia to calcaneus, navicular and talus Lateral: 3 ligaments -two connecting fibula to talus (anterior and posterior talofibular ligament) -one connecting fibula to calcaneus (calcaneofibular ligament)

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24
Q

Which ligament is most commonly injured in lateral ankle sprains? What test can be done to assess for this ligament injury?

A

Anterior talofibular ligament (weakest of the 3) -injured during inversion injuries Anterior talofibular ligament is responding for preventing anterior subluxation of talus from the mortise. -do anterior drawer test: stabilize the distal tibia and fibula and try to move foot anteriorly to check for laxity (compare side to side)

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25
Q

What is the mortise? On a mortise view, what suggests mortise instability?

A

Joint between distal tibia and talus On a mortise view: entire joint space should be 3-4 mm at all aspects and the joint space should not differ by more than 2 mm at any area within the mortise

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26
Q

What test can be performed to check for calcaneofibular ligament sprain?

A

Talar tilt test: only positive if both anterior talofibular ligament and calcaneofibular ligament are ruptured -stablize the distal tibia and fibular with one hand and with other hand, attempt inversion and check for laxity compared with the other side

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27
Q

If a patient is tender over the fibular physis but xray does not show evidence of a fracture, what is the diagnosis? -how can you differentiate fibular physis fracture vs. ligament sprain on exam?

A

Remember that in prepubertal chidlren, fractures are way more common than sprains! -SALTER HARRIS TYPE I fracture (only if they have a growth plate still!)–> immobilize and ortho to see Exam: -Ankle sprain: tends to be more tender at the distal and posterior fibula where the ligaments attach to the talus -apply medial force to the ankle (will hurt laterally if there is a fracture)

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28
Q

What is a “comminuted” fracture?

A

A bone injury that results in more than 2 bone fragments

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29
Q

When does the distal fibular physis usually fuse? What about distal tibial physis?

A

Distal fibular physis: fuses at 20 years old but takes several years to strengthen Distal tibial physis: fuses at 18 years old

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30
Q

Which type of supracondylar fractures can be repaired under closed reduction?

A

Type I

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31
Q

Name 4 signs to look for on a radiograph in a suspected elbow injury.

A
  1. Anterior fat pad (can be normal) 2. Posterior fat pad (always abnormal if present) 3. Radiocapitellar line 4. Anterior humeral line
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32
Q

What happens in a pulled elbow?

A

Dislocation of radial head (subluxation)

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33
Q

Name 3 tests to perform in a patient presenting with hip pain.

A
  1. Xray 2. BW: CBC, ESR, CRP 3. Ultrasound
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34
Q

What is the treatment of a SH-1 fracture of tibia or fibula?

A

Splint or brace and see family dr/ortho in 2 weeks -for all kids who have tenderness at the growth plate and a N xray, must classify as SH-1

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35
Q

What is the mortise view?

A

Tibia/fibula joint with navicular/calcaneus

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36
Q

What is the classic presentation of Anterior cruciate ligament tear?

A

Acute onset knee pain Feeling a “pop” when landing from a jump Knee swelling after injury Most do not have tenderness on examination

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37
Q

What is the most common cause of ACL tears?

A

Most result from noncontact injury mechanism such as a pivot or twisting motion or landing from a jump

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38
Q

What is the diagnosis for reproducible bone tenderness near a joint with an open epiphysis?

A

Salter Harris I fracture: sufficient indication for splinting even without radiographic evidence of fracture. -“sprains” are relatively rare in children and are treated as SH type I until f/u assessment in 1 week by ortho.

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39
Q

For patients with splints, what discharge instructions should be provided?

A
  1. Injured limb should be elevated and iced x 48 hrs 2. Splint should be kept dry 3. RTMD if increased pain or decreased sensation 4. F/U with ortho
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40
Q

What is a Colles’ fracture?

A

Fracture of distal radius with dorsal displacement

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41
Q

What are the indications for radial or ulnar gutter splints?

A

Metacarpal and/or proximal phalangeal fractures -ulnar gutter: immobilizes ulna to the 4th and 5th digits -radial gutter: immobilizes radius to the 2nd and 3rd digits with a hole cut for the thumb

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42
Q

What are the indications for a thumb spica splint?

A
  1. 1st metacarpal bone fracture 2. Proximal phalynx fracture of thumb 3. Scaphoid fracture
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43
Q

What is a Toddler’s fracture?

A

Fracture of distal tibia (usually undisplaced and spiral pattern due to rotation)

44
Q

What are the indications for a sugar tong splint?

A
  1. Stable forearm and wrist fractures 2. Humerus injuries
45
Q

What is the indication for a long arm splint?

A

Elbow injuries

46
Q

What are the indications for a posterior short leg splint?

A
  1. Distal tibia and fibula fractures 2. Ankle fractures/sprains 3. Foot fractures **Can add an ankle stirrup for additional support/immobilization to prevent inversion/eversion
47
Q

What is a Jones fracture?

A

Fracture in the proximal diaphysis of the 5th metatarsal (very uncommon in children)

48
Q

What are possible fractures of the 5th metatarsal? -treatment?

A
  1. Avulsion fractures of the base of the 5th metatarsal (common in peds) 2. Shaft fracture (common in peds) 3. Jones fracture: fracture of the proximal diaphysis of the 5th metatarsal (rare in peds) Treatment: short-leg splint +/- closed reduction if displaced
49
Q

What are the 3 main causes of intoeing?

A
  1. Femoral anteversion 2. Metatarsus adductus 3. Internal tibial torsion
50
Q

What is femoral anteversion? -age group? -incidence in girls vs. boys? -natural course? -potential complications? -treatment? -evidence for use of braces/inserts/physiotherapy/sitting restrictions?

A

Increased anteversion of the femoral neck relative to the femur with compensatory internal rotation of the femur -age group: 3-6 yo -F:M 2:1 -natural course: most spontaneously resolve by age 10 -potential complications: NONE! This is a benign condition with no increased risk of arthritis/back issues/etc -treatment: observation and parental reassurance (most resolve spontaneously by age 10) -NO BENEFIT with braces/inserts/PT/sitting restrictions -operative treatment (derotational femoral osteotomy) may be considered if

51
Q

What are clinical features of femoral anteversion? -history -physical exam

A

History: -parents complain of intoeing gait in early childhood -child classically sits in W position -awkward running style, sometimes trips and falls Physical exam: -place child prone and flex knees. Then check internal rotation by rotating hips outwards and check the angle relative to the thigh -will see increased internal rotation of > 70 degrees (normal = 20-60) -then check external rotation by rotating hips inwards to make an X and check the angle relative to the thigh -will see decreased external rotation of < 20 degrees (normal 30-60)

52
Q

What are the physical exam maneuvers for evaluation for intoeing?

A
  1. R/O metatarsus adductus: have pt lie prone and straighten out feet. Look for adducted forefoot deformity, a curved lateral border, medial soft-tissue crease -overall: HEEL-BISECTOR ANGLE 2. R/O tibial torsion: have pt lie prone and look at thigh-foot angle. clock position normally; if they are not, this is tibial torsion -look at foot progression angle as they walk (normal for feet to be turned outward slightly) -overall: FOOT PROGRESSION ANGLE, TRANSMALLEOLAR AXIS, THIGH-FOOT AXIS 3. R/O femoral anteversion -Internal and external hip rotation
53
Q

What is the most common cause of in-toeing? -age group? -associated with what condition? -prognosis?

A

Internal tibial torsion -internal rotation of the tibia at the knee joint -age group: 1-3 yo (toddlers) -can be associated with DDH (15-20% of cases) -prognosis: resolves by age 6 usually

54
Q

What are the indications for further work-up of in-toeing? (4)

A
  1. Pain 2. Limb length discrepancy 3. Progressive defmority 4. Family history positive for rickets/skeletal dysplasias/mucopolysaccharidoses
55
Q

What is the treatment of tibial torsion? -indications for operative treatment?

A

Treatment: observation and parental education -usually spontaneously resolve by age 6 -braces/PT does not change natural history of condition -operate only if child > 6 yo with > 10 degrees of internal rotation or severe cases with functional problems

56
Q

What is metatarsus adductus?

A

Adduction of forefoot at tarsometatarsal joint with normal hindfoot alignment (thought to be due to intrauterine positioning)

57
Q

What factors increase the incidence of metatarsus adductus? -prognosis? -treatment?

A
  1. Late pregnancy 2. First pregnancy 3. Twin pregnancy 4. Oligohydramnios ***Think of conditions that will cause squishing of baby Prognosis: no complications! Most resolves spontaneously in 90% of children by 4 yo Treatment: -if flexible deformity that can ACTIVELY be corrected to midline (tickle the foot to see if the child corrects themselves) = no treatment -if flexible deformity that can be PASSIVELY corrected to midline = serial stretching by parent -if rigid deformity with a medial crease = serial casting with the lateral border of foot -if resistant metatarsus adductus that persists > 5 yo with severe deformity = surgery
58
Q

What muscles does the anterior interosseus nerve innervate? -how to check AIN function on exam?

A

Branch of median nerve -flexors of fingers and thumbs -pronator quadratus **On exam: check AIN by asking patient to make “A-OK” sign (flexion of interphalangeal joint of thumb and distal interphalangeal joint of index finger)

59
Q

What are the 3 types of supracondylar fractures?

A

Type I: nondisplaced Type II: displaced with posterior cortex intact Type III: Completely displaced

60
Q

What is the management of each type of supracondylar fracture?

A

-Type I: posterior backslab splint to allow for swelling, then long arm casting at 90 degrees or less x 3 weeks -Type II: same as treatment for Type I only if anterior humeral line intersects capitellum and minimal swelling. If not, need to have closed reduction and pinning in OR -Type III: closed reduction and pinning in OR ***majority of supracondylar fractures are treated with closed reduction and pinning

61
Q

What is an indication of supracondylar fracture on elbow xray?

A

Displacement of anterior humeral line = normally, anterior humeral line should intersect the middle third of the capitellum -in supracondylar fractures, capitellum moves posteriorly

62
Q

What is the most common type of nerve injury seen in extension type supracondylar fracture? -what about flexion type supracondylar fracture?

A

Extension type supracondylar fracture: anterior interosseous nerve -flexion type supracondylar fracture: ulnar nerve

63
Q

What is a “floating elbow” injury? -treatment?

A

Displaced fractures of both the elbow (ie supracondylar fracture) and the wrist so that the elbow is not stabilized by anything! -treatment: prompt closed reduction and pinning in OR -never cast elbow injuries right away since they swell ALOT and have increased risk of compartment syndrome

64
Q

Which upper extremity injuries should NEVER be casted by you in ED?

A

Supracondylar fractures (ie. elbow fractures) = high risk of compartment syndrome due to increased swelling

65
Q

How can you differentiate between extension type supracondylar fracture vs. flexion type supracondylar fracture?

A

On xray: -extension type: will see the anterior humeral line IN FRONT of the capitellum (capitellum will be posterior to the humerus) -flexion type: will see the anterior humeral line BEHIND the capitellum (capitellum will be anterior to the humerus)

66
Q

What innervates the intrinsic hand muscles?

A

Ulnar nerve

67
Q

What is the most common complication following a supracondylar humerus fracture?

A

Gunstock deformity = cubitus varus = the extended forearm is deviated medially -caused by malunion due to failure of reduction -see this in kids who got reduced and casted instead of closed reduction/pinning in displaced supracondylar fractures -does not affect ROM/growth or cause pain but there are cosmetic concerns

68
Q

What is the management of both ulnar/radial fractures? -duration of casting? -indications for open reduction?

A

Closed reduction and immobilization -most forearm fractures can be treated without surgery -short-arm cast if distal forearm fractures -long arm cast if mid-shaft or proximal forearm fractures -need weekly xrays for first 3-4 weeks following reduction -casting x 6-12 wks total -indications for open reduction: 1. children < 10 yo: angulation > 15 degrees, rotation > 45 degrees post closed reduction 2. Children > 10 yo: angulation >10 degrees, rotation > 30 degrees post closed reduction 3. Both bone forearm fractures in children > 13

69
Q

What is a common complication of type I SCHF involving the medial epicondyle?

A

Increased risk of cubitus valgus (gunstock deformity)

70
Q

What are 2 things on the differential diagnosis when you see a bone lesion involving the epiphysis?

A
  1. Osteoblastoma (benign) 2. Infection
71
Q

How can you reliably check for scaphoid fracture?

A

If you push in the anatomical snuff box, people will always complain of pain even if there is no fracture. SO push instead on the volar aspect at the base of the scaphoid to try to elicit tenderness

72
Q

What is KEY in making a posterior elbow backslab splint for stabilizing SCHF?

A

The arm needs to be in 30 degrees extension, hand in neutral position, and the splint needs to go all the way up to the armpit in order to fully stabilize the elbow (ie. not stop midway up the humerus)

73
Q

What is SCFE? -clinical presentation? -most worrisome complication? -most commonly seen in what population?

A

Slipped Capital Femoral Epiphysis = failure of the physis and displacement of the femoral head relative to the neck -clinical presentation: can be acute, chronic or acute-on-chronic -acute: symptoms < 3 weeks and usually has groin, thigh or knee pain -chronic: few month history of groin, thigh or knee pain with limp -most worrisome complication: osteonecrosis of the femoral head due to vascular injury from displacement of the femoral head (ie . avascular necrosis of femoral head) -present with knee pain due to referred pain along obturator nerve ***Most commonly seen in adolescents, obese and African-American

74
Q

Underlying pathophysiology of SCFE? -What are the risk factors for SCFE and why? (5)

A

Pathophysiology of SCFE: -mechanical + endocrine factors = during puberty, physis becomes more vertical and thus, mechanical forces needed to shear the femoral head is less. Also, physis becomes more elongated and widened with increased circulating hormones, thus making it weaker 1. Obesity: affects mechanical load on the physis and level of circulating hormones 2. Hypothyroidism 3. Hypopituitarism 4. Renal osteodystrophy: decreased vitamin D and calcium thus weaker physis 5. Growth hormone therapy

75
Q

What are findings on clinical exam of SCFE? -diagnosis?

A

Flexed, abducted, externally rotated hip with limp or refusal to weight bear -diagnosis: AP and frog leg views of both hips is the only imaging study needed to make the diagnosis -50% of patients have contralateral slip too so look at both hips! -on XRAY: 1. Widening and irregularity of physis 2. Klein line abnormality = draw a line from the superior femoral neck on the AP radiograph and the line should intersect the femoral head. If it doesn’t, then this is diagnostic

76
Q

What is the treatment for SCFE?

A

Admit to hospital immediately and place on bed rest with no weight bearing!!!! -Ortho consult asap for pinning with one screw with partial weight bearing x 4-6 wks

77
Q

A thin 8 yo child presents with SCFE. What is your management?

A
  1. Admit to hospital immediately and place on bed rest 2. Need to send screening labs to rule out underlying endocrinopathy (ie. hypothyroidism, hypopituitarism, vitamin D or calcium deficiency) because this is ATYPICAL for a child who is thin and not a teenager
78
Q

4 physical exam maneuvres for working up scoliosis?

A
  1. Assymetrical level of pelvis = put thumbs on ASIS and compare 2. Leg length discrepancy 3. Adam’s forward bend test: asymmetrical ribcage 4. Shoulder asymmetry 5. Abdominal reflex = tells you if there is a spinal abnormality
79
Q

What is the clinical criteria for clubfeet? (3)

A

Clinical criteria for clubfeet: 1. Extreme plantarflexion (equino) 2. Medial angulation of hindfoot (varus) 3. Adduction and supination of forefoot (metatarsus adductus)

80
Q

For scoliosis, what direction does the spine curve towards in the following: -thoracic curve -thoracolumbar curve ***Why is this important to know?

A

Thoracic curve = normally points right Thoracolumbar curve = normally points left ***Important because if you have a spine that points to the left, should order an MRI because more likely to be associated with neurological issues

81
Q

What is the most common cause of lateral foot pain?

A

Peroneal brevis tendonitis

82
Q

A patient fractures their first toe phalanx. What is your management?

A

Aircast x 4-6 weeks with gradual return to activities

83
Q

How long do pins stay in for type 2 & 3 SCHF?

A

3-4 weeks

84
Q

What age group do children with Osgood-Schlatter usually present? -pathophysiology? -treatment? -resolution time? -complication?

A

10-15 yo -more common in boys -pathophysiology: repetitive injury with point tenderness at tibial tubercle, worse with activity. Thought to be caused by tight quads pulling on tibial tubercle -treatment: 1. Rest and activity modification x 2-3 months 2. Restriction of activities 3. Knee immobilizer (protective gear, NOT cast) 4. Ice 5. Physio with quadriceps strengthening and loosening exercises -resolution time: 12-24 months -complication: patellar tendon rupture

85
Q

What is the differential diagnosis for bony pain that wakes child up at night? (2)

A
  1. Bone malignancy: Ewing, osteosarcoma 2. Osteoid osteoma
86
Q

What are the risk factors for flexible flat feet? (3) -differential diagnosis for RIGID flat feet? (4)

A
  1. Increased BMI 2. Laxity of ligaments 3. Wearing shoes too early Rigid flat feet: 1. Tarsal coalition 2. Inflammatory arthritis 3. Congenital vertical talus 4. Neuromuscular cause (CP)
87
Q

What are the advantages and disadvantages of skeletal survey vs. bone scan for potential child abuse?

A

-Bone scan: good for ribs, bad for skull and metaphyses (because they light up anyway due to area of growth), bad for acute fractures since there has not been enough time for increased bone intake -skeletal survey: bad for ribs, bad for metaphyses, good for everything else

88
Q

What are possible causes of bilateral toe walking? (8)

A
  1. Tight heel cord (isolated congenital shortening of the achilles tendon) 2. Idiopathic (variation of normal development) 3. Hereditary or acquired polyneuropathy 4. Behavioural (autism) 5. Intraspinal tumor 6. Spinal dysraphism 7. Spastic CP 8. Talipes equinovarus (clubfoot)
89
Q

What is the classic characteristic of the hip pain in transient synovitis?

A
  1. Pain and refusal to weight bear 2. Active movement usually worse than passive = usually will let you move their hip and can still get full ROM
90
Q

What are 4 factors differentiating transient synovitis from septic arthritis?

A
  1. History of fever 2. History of non weight bearing 3. ESR > 40 4. WBC > 12 ***If you don’t have ANY of these, then your risk of having septic arthritis is <0.2%. If you have all 4, then your risk is 99.6%.
91
Q

What are the 4 types of developmental dysplasia of the hip?

A
  1. Subluxation: head not centered in joint 2. Dislocation: head not located in joint 3. Hip dislocatable: head can be pushed out of joint 4. Hip dysplastic: steep acetabulum but head within joint
92
Q

What are the 4 risk factors for DDH? -what are the 3 physical exam maneuvers to investigate for DDH? -when do the physical exam maneuvers become unreliable?

A
  1. First born 2. Female 3. Foot first (breech) 4. Family history 1. Barlows: dislocate a reduced hip 2. Ortolani: reduce a dislocated hip 3. Galleazi: hips and knees flexed at 90 degrees and see different knee heights (can be falsely negative if both hips are dislocated) -these become reliable when baby > 3 mo = then must rely on leg length discrepancy, extra groin fold, delayed running, limp, tredelenburg gait (painless limp)
93
Q

What is the natural history of DDH? -wjat are

A

Most spontaneously resolve within 4 wks

94
Q

You are examining a newborn baby and you find a positive Barlow test. What is your management? -what about if you find a positive Ortolani? -what if your exam is equivocal but the baby has risk factors? -what if the baby is not high risk but your exam is equivocal?

A

Positive barlow: high chance of sponanteous resolution = repeat exam at 4 wks and ultrasound if still positive. If not improved, then TREAT with Pavlik Harness Positive ortolani: this means the hip is already dislocated and you don’t know how long it’s been dislocated for so you need to treat asap with pavlik harness and then follow treatment with US If baby is high risk with equivocal exam: ultrasound right away If baby is not high risk with equivocal exam: repeat exam in 3 wks and ultrasound then if still equivocal or positive findings

95
Q

What is the treatment of DDH?

A

For babies < 6 mo: Pavlik Harness x 3 mo For babies > 6 mo: closed reduction and casting babies (hip spica x 3 mo) because when they are this old, they can overcome the Pavlik Harness since they’re stronger

96
Q

What is the differential diagnosis for genu varum? -usually seen in what age group? -natural history? -at what age should you consider further investigations if the genu varum still persists?

A

Bowlegs: 1. Physiological bowing (99% of cases) 2. Pathological Tibia varum (Blounts disease) 3. Skeletal Dysplasia 4. Rickets Physiological bowing usually present at age 12-18 mo -natural history: gradual normalization by 2 years of age!!! -if still present OR worsening by 2 yo, need full length weight bearing xrays to rule out pathological causes

97
Q

What is the differential diagnosis for genu valgum?

A

Knocked knees: 1. Physiologic valgus 2. Apparent valgus (seen in overweight teenagers because of thigh girth) 3. Rickets 4. Post trauma valgus overgrowth 5. Skeletal dysplasias

98
Q

What are the 3 types of scoliosis?

A
  1. Infantile (<10 yo) 3. Adolescent
99
Q

What are important KEY questions to ask on history of an adolescent patient with scoliosis?

A
  1. Menarchal status??? Tells you how much more pubertal growth potential they have which tells you how much progression can be expected with the scoliosis 2. Painful?? = painful curve usually indicates other causes (intraspinal tumor) 3. Neurological symptoms? 4. Family history?
100
Q

What are the indications for MRI in scoliosis? (5)

A
  1. Neurological abnormalities 2. Rapid progression with severe deformity (ie. over 6-12 mo) 3. Left sided curve 4. Early onset age < 10 5. Significant pain
101
Q

What is the treatment for scoliosis with the following cobb angles: -40

A

This really all depends on the sexual maturity rating of the child (ie. what is their Risser score and have they reached menarche?) -ie. how much skeletal growth do they have remaining at presentation? -if growth spurt hasn’t started yet, then the scoliosis can worsen 1-2 degrees/month during puberty Overall: 40: consider surgery IF risk for further progression

102
Q

What is the best test to investigate for DDH in: -baby < 6 mo -baby > 6 mo

A

Baby < 6 mo: ultrasound (since femoral heads have not ossified yet) Baby > 6 mo: pelvic xray

103
Q

What is the diagnosis?

A

Metatarsus adductus (medial deviation of the forefoot)

104
Q

Metatarsus adductus what are the clincial Features?

A
  • most common congenital foot deformity
  • medial deviation (adduction) of the forefoot while the hindfoot remains in a normal position
  • often bilateral; when unilateral left > than on the right
  • most common cause of in-toeing gait in the infant
  • 3 percent of term newborns, more in girls than boys and -appears to run in families
  • more commonly in first-born children due to the increased
  • higher in twin compared with singleton births
  • similar in preterm and term infants
  • outcome for patients without intervention or with nonsurgical treatment for metatarsus adductus is excellent.
105
Q

What is the diagnosis?

A

Talipes equinovarus

106
Q

What are the causes of talipes equinovarus (Clubfoot)?

A
  1. Positional clubfoot - intrauterine crowding or breech position. It is not a true club foot. It is a normal foot that has been held in a deformed position in utero. The positional clubfoot easily corrects to a normal position with manipulation.

2. Congenital clubfoot is the most common type. isolated idiopathic anomaly. manipulation - includes casting and bracing (Ponseti method)

  1. Pathological:
    a. Syndromic clubfoot-trisomy 18, chromosome 22q11 deletion syndrome
    b. MSK- arthrogryphosis, skeletal dysplasia

c- Neuromuscular

-Neuro: SMA, NTD

- Muscular; myopathy, myotonic dystrophy

107
Q

What are the clincial features of TEV

A

Malalignment of the calcaneotalar-navicular complex.

(predominantly a hindfoot deformity)

CAVE Mnemonic (cavus, adductus, varus, equinus)

Cavus-plantarflexion of the first ray

Adductus- adduction of the forefoot/midfoot on the hindfoot

Varus and Equinus - The hindfoot is in varus and equinus.

Royal College Peds 2021 (55 decks)

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