Orthopedics For Kids

Question 1

Legg-Calve-Perthes disease

Answer 1

●Idiopathic avascular necrosis of the epiphysis of the femoral head
●2-4 year progression and almost
  always heals itself
●Usually occurs b/w 3 & 12 yo
●Most common in boys 5-7 yo
●4 times more common in boys
●Girls often develop it later and more
  severe
●Bilateral 20% of cases

Question 2

Legg Calve Perthes Disease cause

Answer 2

Unknown etiology

Trauma-> temporary blood loss to femoral head
Maternal smoking in utero

Question 3

Legg Calve Perthes disease presentation & subjective complaint

Answer 3

●Present with mild pain at hip/thigh/knee with activity, but subsides with rest
●Progresses to limp
• Trendelenberg gait pattern

Question 4

Treatment of Legg Calve Perthes Disease

Answer 4

-Gait training
• assistive device as needed
-Treatment controversial
•1° goal of treatment: avoid severe degenerative arthritis and encourage proper formation of femoral head.
*conservative: observation, ROM, w/c to decrease WBing, Petrie casts (best positioning of hip is abd/ER).

• Bracing with Petrie casts (long leg casts with bar holding legs in ER)
• Surgery: triple osteotomy

Question 5

Slipped Capital Femoral Epiphysis

Answer 5

●Most commonly diagnosed in 10-15 yo
●Growth plate abnormality
●More common in African-American pop than Caucasians
●More common in males than females
●Surgery
•spica cast
•maintain ROM elsewhere
•Gait training
•WC
•Home assessment

Question 6

Classification of SCFE

Answer 6

• Grade I: displacement of epiphysis less than 30% of width of femoral neck
• Grade II: slip between 30%-60%
• Grade III: includes slips of greater than 60% the width of neck

Question 7

How can you tell the difference between SCFE and LCP?

Answer 7

• Similar in presentation
• LCP usually younger
• SCFE usually more pain

Question 8

Osgood-Schlatter Syndrome

Answer 8

• Traction apophysitis (inflammation of the tendon insertion) of the patellar tendon aggravated by activity
• Osteochondrosis- degeneration followed by reossification of one or more ossification centers in children

Question 9

Prevalence of Osgood-Schlatter’s Syndrome

Answer 9

• Common in the 8-15 year range
• More common in males
• One of the most common causes of knee pain in adolescents

Question 10

Treatment of Osgood-Schlatter’s Syndrome

Answer 10

●Rest, ice, decrease activity
●Modalities
•Estim to reduce inflammation
●Assess for:
•Patella tracking problems
•Patella mobility

Question 11

Where can Apophysitis occur?

Answer 11

In addition to tibial tubercle apophysitis (Osgood-Schlatter’s disease), traction apophysitis may occur at the calcaneus, navicular and, rarely, the hip, most often as a result of repetitive trauma/overuse.

Question 12

Prevalence of Developmental Dysplasia of the Hip (DDH)/ Congenital dislocation of the hip (CDH)/Infantile hip dislocation

Answer 12

• More common in female
• Most are unilateral
• can be due to intrauterine positioning
• can accompany torticollis

Question 13

Developmental Dysplasia of the Hip (DDH)/ Congenital dislocation of the hip (CDH)/Infantile hip dislocation DIAGNOSIS AND TREATMENT

Answer 13

Barlow maneuver & Ortolani maneuver

Question 14

Barlow maneuver

Answer 14

•Barlow maneuver (to determine if hip will dislocate):
●This is part of the standard infant exam performed until 8–12 weeks of age.
●Hip is adducted and gently pushed posteriorly.
●“Clunk” is heard (+)…the less pronounced the clunk, the more poorly formed the acetabulum.

Question 15

Ortolani maneuver

Answer 15

•Ortolani maneuver (for posterior dislocation):
●passive flexion, keep flexion and abduct, then bring hip into neutral/extension.
●feel a click/pop (hip is reducing)

Question 16

If you have a baby younger than 6 months and you want to immobilize their hips into abduction, what do you use?

Answer 16

Pavlik Harness

Question 17

If you have a baby older than 6 months and you want to immobilize their hips into abduction, what do you use?

Answer 17

Spica cast

Question 18

What is the number 1 cause of brachial plexus injuries in babies?

Answer 18

Ninety percent of brachial plexus injuries in children are caused by a traumatic stretching of the plexus during birth

Question 19

What percent of babies will recover without surgery after a brachial plexus injury?

Answer 19

80%!

Question 20

What is the incidence of brachial plexus injury?

Answer 20

1-2/1000 births

Question 21

Brachial Plexus Avulsion

Answer 21

Nerve is torn from the spine

Most severe

Question 22

Brachial Plexus rupture

Answer 22

Nerve is torn but not at the spinal attachment

Question 23

Brachial Plexus Neuroma

Answer 23

The nerve has tried to heal itself but scar tissue has grown around the injury, putting pressure on the injured nerve and preventing the nerve from conducting signals to the muscles

Question 24

Brachial Plexus Neuropraxia

Answer 24

Stretch
The nerve has been damaged but not torn
most common

Question 25

Erb’s Palsy

Answer 25

●Paralysis involving C5 & C6 and sometimes C7.
• the arm is turned towards the body
•the elbow does not bend and the hand is in a “waiters tip” (turning backwards) position.

Question 26

Klumpke’s palsy

Answer 26

●Paralysis involving C7, C8 & T1.
•the hand is limp
• fingers do not move
• there is often an associated Horner’s Syndrome (Horners Syndrome is when the eyelid droops, the cheek does not sweat and the pupil is smaller than the unaffected eye).

Question 27

Brachial Plexus Injury Treatment

Answer 27

•ROM (passive and active)
•Electrical stimulation
**Somewhat controversial on infants
•Parental education
•Sensory input
•Increase awareness of extremity
•Positioning
•Splinting

Question 28

Talipes Equinovarus/Club Foot

Answer 28

• a congenital deformity seen in newborn children
• the feet to point down and inward
• does not cause pain in the newborn child

Question 29

What are some of the future concerns with Club Foot/ Talipes Equinovarus? What is the prognosis?

Answer 29

• can cause long-term abnormalities in gait
•may lead to complications such as chronic skin ulcers.
•If properly treated, the deformity can resolve in early childhood.
**however this will not correct for differences in foot and calf size

Question 30

How will an injury to the whole brachial plexus present?

Answer 30

Erb’s-Klumpke paralysis

Question 31

Torticollis prevalence

Answer 31

1/300 live births

Question 32

Torticollis cause

Answer 32

Intrauterine positioning
Extrauterine positioning
Trauma, structural (tumor)
Gastro esophageal reflux

Question 33

In torticollis, deformation of the infant’s skull due to:

Answer 33

normal brain growth combined with an asymmetric pre and postnatal resting position

Question 34

In torticollis, shortening of the SCM results in:

Answer 34

Lateral flexion of the cervical spine to one side
asymmetric pre and postnatal resting position
with cervical rotation toward the opposite side

Question 35

What are come of the things that may accompany torticollis depending on its severity and presentation?

Answer 35

○ Plagiocephaly (“oblique head”): describes
asymmetry of the head shape
○ Often, a flattening of the head on the
preferred side.
○ “Bald spot” may be present on the
latero-posterior aspect of the preferred side of rotation.
○ Facial asymmetry is often present (muscle bulk is usually smaller on the side of with shortened SCM. )
○ Palpable knot/cord may be present in the SCM

Question 36

What are some of the associated conditions that correlate with torticollis?

Answer 36

○ Changes in facial features 
○ Hip dislocation or dysplasia 
○ Equinovarus deformity (club
foot) 
○ Gastroesophageal reflux

Question 37

How does one even begin to treat torticollis?!

Answer 37

○ Stretching
● until you feel a pull or at baby’s discomfort
○ Massage
● SCM
○ Positioning
● Holding/Feeding (parents should switch sides)
● Presenting objects to the child during
interaction/play
● Environmental modifications
● Helmet therapy to reshape the infant’s skull
○ Typically started around 5-6 months, earlier in more severe cases
○ Surgery
○ Parent/Caregiver training