Orthopedics evaluation and intervention Flashcards
What is etiology of developmental dysplasia of hip and who gets it?
70% female, usually first born, hereditary, breech birth
Etiology of multiple factors: mechanical-positional, cultural, increased incidence with torticollis
What are classifications of developmental dysplasia of hip?
Normal, Subluxtable, Dislocatable, Subluxed, Dislocated
What are evaluation instability tests for DDH?
Barlow: dislocates a reduced hip, “bad”, adduct and apply posterior pressure, listening for clunk
Ortalani: reduces a hip that is out, one leg at a time “out”, abduct and lift left anteriorly, feel clunk
These tests may be negative even if dyplastic because: irreducible, patient tolerance, difficult after 3-4 months of age
What is appearance of kids with DDH?
LLD, galeazzi, uneven thigh folds
Waddling gait with lordosis
Limited hip abduction: unilateral late diagnosis- difference of 10 deg, bilateral less than 60 deg
What imaging is used to evaluate DDH?
US: 6-8 weeks
Radiographs: > 4 mo, femoral head ossification 4-9 mo, AP, frog leg, Von Rosen view (45 deg abduction, 25 deg IR)
What are the lines drawn on Xrays when evaluating DDH?
Hilgenreiner’s line: horizontal through triradiate cartilages
Shenton’s line: inferior neck and inferior border of superior pubic ramus
Perkin’s line: perpendicular to Hilgenreiner’s, intersect lateral acetabular roof
Acetabular angle: Hilgenreiner’s line at triradiate to acetabular roof, less than 20 deg at 24 months, greater than 40 deg significant at birth
What is treatment for DDH?
Less than 6 months: observation, abduction orthosis
6-12 months: orthotics
What is orthotic for DDH?
Pavlik or Rhino
Pavlik: good for younger immobile kids, watch for brachial plexus and femoral nerve injury, stop if fail to reduce in 3 weeks or palsy signs, 90-95% success in 6 weeks
Factors to succeed are diagnosed under 6 weeks, bilateral, acetabular angle under 35 degrees
Factors for failure: parent education, parent motivation, “off the shelf” (because they fail to fit properly, difficult to don/doff, poor follow up)
Rhino: older, more mobile; ortolani positive
What if braces and orthotics don’t work for DDH?
Closed reduction and spica casts: 6-12 mo of age
Surgical intervention: 12 mo of age and older, muscle release and proximal femur osteotomy, spica until stable
What is PT intervention for DDH?
orthotic management
Range, strength, and gross motor skills: during immobilization, after immobilization, after surgery
What are the types of clubfoot and what is treatment?
Equinus, varus, adductus
If mild and due to fetal positioning: serial cast, weekly progressions
If severe and due to underlying neuromuscular diagnosis: surgical correction at 4-6 mo of age; night splint; PT for PROM, strength, and gross motor concerns
What is metatarsus adductus and calcaneovalgus?
Adductus: forefoot curves medially
Calcaneovalgus: forefoot curves laterally, hindfoot valgus, navicular on the floor; foot appears dorsiflexed; vertical talus or rocker bottom deformity
What is evaluation and treatment for pes planus?
Arch develops age 3-5
Compensatory posture: must determine cause, WB vs. NWB, bilateral vs. unilateral
Treatment: keep eye on it, if there’s no pain they are probably ok
What is cause of congenital muscular torticollis?
Abnormal intrauterine posture: too much baby not enough space, contracture
Injury to SCM during delivery: direct muscle trauma (fibrosis, contracture), compartment syndrome (nerve and muscle damage, swelling, fibrosis)
What is torticollis posture?
Contralateral head rotation coupled with ipsilateral tilt.
Name to side of the tilt.
What is plagiocephaly?
occurs in torticollis or craniosynostosis
Torticollis: flattened occiput, eye will appear larger on one side, ear will be lower and more anterior
Craniosynostosis: cranial sutures are sealed and you will only see a flattened occiput
What is etiology of torticollis?
Right > Left
Mean age of dx= 4 months
Associated conditions: hip dysplasia, plagiocephaly, progressive facial asymmetry, vision deficits
What is part of the exam for torticollis?
History: birth weight/multiples, unplanned events, NICU/ventilator use
Postural deviations: palpation of cervical muscles, cranial asymmetry, extremities and spine, resting and active
Range and strength: active and passive, cervical, extremities
Neuro: gross motor development, tone and posture, vision, language delays
What are torticollis differential diagnosis?
Full AROM and no fibrosis: normal radiograph- BPT, congenital absence of cervical muscle, CNS lesions or tumors, visual involvement
Without full AROM and no fibrosis: abnormal radiograph- congenital structurally absent (hemivertebrae, unsegmented bar vertebrae, scoliosis, subluxation), rule out syndromes and trauma
What is treatment for torticollis?
Begin as soon as possible: with consistent timely therapy 85-90% should resolve within 4-5 mo PROM Strength HEP shaping helmets?
What is refractory torticollis? What are concerns and approach for this?
Plateau in gains after 4-5 months of PT and/or 7-8 months of age.
Concerns: facial asymmetry, plagiocephaly, irreversible contracture
Approach: consider/evaluate other causes for torticollis, modify treatment approach, get physician involved (focused neuro/developmental eval, radiograph)
What is plan for treatment of refractory torticollis based on the radiograph results?
Radiograph normal/physician eval normal: continue program, consider botox injections, consider CT scan if no improvement after botox
Radiograph normal/physician abnormal: neuro findings, developmental delay, MRI scan of c spine brainstem brain, may continue program
Radiograph abnormal/physician normal: refrain from PROM continue AROM, refer to ortho surgery clinic, consider botox injections
What are injection sites for botox?
Rotational deficits: SCM, upper trap
Lateral flexion deficits: scalenes
After all conservative measures have failed what is treatment for torticollis?
Surgical intervention
Age > 18-24 months
What is Legg-Calve-Perthes?
Self limiting avascular necrosis of femoral head: from trauma, vascular anomalies, infection, thrombosis
See it in boys 3-13 years
What is presentation for legg-calve-perthes?
loss of IR, abduction, extension of hip
Antalgic gait with trendelendberg
What are the stages of legg calve perthes?
Condensation- femoral head turns necrotic
Fragmentation: necrotic bone fragments and reabsorbed, revascularization occurs, deformation of femoral head with flattening of acetabulum
Reossification with return of vascular supply.
Remodeling at acetabulum
what is management of legg calve perthes?
What is a slipped capital femoral epiphysis (SCFE)?
Displacement from normal position on femoral neck: from obesity, trauma, rapid growth
See more in males
What is presentation for SCFE?
Loss of IR, abduction, flexion of hip
Antalgic gait with decreased weight bearing
ER with attempts at flexion
How is SCFE classified?
By duration: acute is sudden onset, pain less than 3 weeks; chronic is gradual onset, pain greater than 3 weeks; acute on chronic is greater than 3 weeks with exacerbation
By severity: grade 1 is up to 1/3 width of neck, grade 2 is 1/3-1/2 width of neck, grade 3 is greater than 1/2 width of neck
What is treatment for SCFE?
Surgical management: stabilize growth plate, immediate correction, non surgical intervention is not successful
PT: gait train with AD after surgery, NWB initially, strength and PROM with focus on core
What are unique qualities of pediatric bones?
Increased malleability: more avulsions because ligaments are stronger then bones, bending fractures
Increased remodeling: malunion and non union rare, femur fracture healing rates (2-3 weeks for infants, 4 weeks preschool, 6 weeks 7-10 years, 8-10 weeks in adolescent)
What are the types of pediatric fractures?
Avulsion: ligament stronger, ORIF Bend: deformation w/o fracture Buckle: compression equal bulge in cortex Greenstick: fracture on tension side only Transverse: horizontal fracture Oblique: angled fracture Spiral: looks like pre made biscuit tube Comminuted: multiple fragments
What are they types of physeal injuries?
I: closed reduction, good prognosis
II: closed reduction, good prognosis
III: open or closed reduction, good if vascular intact
IV: open reduction, growth disturbance
V: not detected until growth disturbed, growth arrest and angular deformity, may need for surgical correction
What is tibial eminence (spine) fracture? MOI? When does it occur?
Fracture through subchondral bone beneath ACL insertion.
Hyperextension injury
8-12 years of age
What are signs and symptoms found on examination for tibia eminence fractures?
Clinical exam: pain, hemarthrosis, instability, limited ROM
Imaging: x ray, MRI
What is management of eminence fractures?
Type I: cast in slight flexion (arthrocentesis)
Type II: evaluate in operating room, confirm reduction via CT
Type III: operative treatment
What is operative management of eminence fractures?
Arthroscopy vs. arthrotomy
Screw vs. suture
Entrapment
Return to sports: PT use ACL reconstruction protocols
What are complications of tibial eminence fractures?
Laxity/instability
Arthrofibrosis
Extension block/malunion/nonunion
What is MOI for tibial tubercle fracture?
Result of violent quadriceps contraction or passive flexion of knee with contracted quad
12-17 years of age
See a lot in kids who had Osgood schlatter
What are clinical findings in tibia tubercle fracture?
Pain, hemarthrosis, inability to extend knee, x-rays
What is treatment for tibial tubercle fractures?
Type I: immobilization
Type II and III: ORIF
What are complications for tibia tubercle fractures?
Compartment syndrome, recurvatum deformity, extension lag, patella baja, fixation complications (prominence)
What are types of epiphysitis or apophysitis?
Osgood Schlatter: tibial tubercle epiphysis
Sinding-larsen-johansson: inferior patella epiphysis
Sever’s disease: calcaneal epiphysis
Little league shoulder: proximal humeral epiphysis
Little league elbow: medial humeral epiphysis
What is treatment for epiphysitis?
Address acute symptoms: modalities, active rest
Address underlying cause: postural imbalances from strength or flexibility
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