Paediatrics Flashcards
What is the classification system of supracondylar humerus fractures in paediatrics?
Gartland Classification:
Type I: Nondisplaced
Type II: Displaced, posterior cortex intact
Type III: Completely displaced
Type IV: Complete periosteal disruption with instability in flexion & extension
What is the order of ossification of the ossification centres of the elbow?
Mnemonic: CRITOE
- Capitellum (1 year)
- Radius (4 years)
- Medial (internal) epicondyle (6 years)
- Trochlea (8 years)
- Olecranon (10 years)
- Lateral Epicondyle (12 years)
What is the indication for non-operative management of supracondylar humerus fractures?
Gartland Type 1
Gartland Type 2 with the following criteria:
- Anterior humeral line intersects capitellum
- Minimal swelling
- No medial comminution
What do you have to be careful of in Gartland type 1 supracondylar humerus fractures?
That there is no medial comminution
What can medial comminution of a supracondylar humerus fracture lead to?
Cubitus varus (so look at the AP)
What is the most common nerve injury associated with supracondylar humerus fractures? The second most common?
Most common: AIN neurapraxia
Second: Radial nerve palsy
What is the risk of using medial pins to fix a supracondylar humerus fracture?
Iatrogenic ulnar nerve injury (1-5%)
When do you see a non-iatrogenic ulnar nerve palsy in supracondylar humerus fractures?
Flexion-type supracondylar humerus fractures
What is the usual outcome for non-iatrogenic nerve injuries associated with supracondylar humerus fractures?
They resolve spontaneously
- So don’t need any acute studies
What is the most biomechanically stable construct for percutaneous pinning of supracondylar humerus fractures?
Kontio et al:
2 laterally based pins in a divergent pattern, the first parallel to the lateral epicondyle and the second crossing the medial border of the coronoid fossa
What is the difference between a greenstick and a torus fracture?
Both are types of buckle fractures.
Greenstick: buckle fracture with a cortical break on one side
Torus: purely buckle fracture with no obvious cortical break
What is a tardy ulnar nerve palsy? What is its common cause?
Nerve palsy that develops late after the initial insult.
The common cause is the development of cubitus valgus deformity
Name the classification systems of lateral epicondylar fractures?
- Milch classification
2. Fracture displacement classification
Describe the Milch classification for lateral epicondyle fractures
Milch: depends on where the fracture exits:
Milch type 1: fracture line is lateral to the trochlear groove (consider SH IV #)
Milch type 2: fracture line is into the trochlear groove (consider SH II #)
Describe the Fracture Displacement classifiation for lateral epicondyle fractures
Type I: Displacement 4mm, joint displaced and rotated
What is the management of lateral epicondyle fractures?
Type I (2mm displaced): OR and percutaneous pinning
What are the complications of lateral epicondyle fractures?
Non/malunion
–> cubitus valgus +/- tardy ulnar nerve palsy
Lateral overgrowth bump
AVN if posterior dissection during surgery
What are 2 concerns of lateral epicondyle fractures that have historically led to worse outcomes than supracondylar humerus fractures?
Articular nature
Missed/delayed diagnosis –> mal/nonunion
Name the single greatest risk factor for Slipped capital femoral epiphysis:
Obesity
Name 5 risk factors for slipped capital femoral epiphysis (SCFE):
Obesity (single greatest risk factor) Male (3:2 M:F) African american Pacific islander Occurs during a period of rapid growth (puberty) Femoral retroversion Left hip (L>R)
What is the average age of SCFE in girls/boys?
Girls: 12
Boys: 13
Name 2 endocrine disorders associated with SCFE
Hypothyroidism
Renal osteodystrophy
Growth hormone treatment
Define SCFE:
Disorder of the proximal femoral physis that leads to slippage of the epiphysis relative to the femoral neck.
The epiphysis stays in the acetabulum while the neck displaces anteriorly and externally rotates (epiphysis is posterior)
Which zone of the physis does SCFE occur?
Hypertrophic zone of the physis
What are the zones of the physis?
Spongiosa
Hypertrophic
Proliferative
Reserve
What is the classification of slipped capital femoral epiphysis?
Loder classification
Slippage classification
Describe the Loder classification of SCFE:
Stable:
- Able to weight bear with or without crutches
- Minimal (<10%) risk of osteonecrosis
Unstable:
- Unable to weight bear (not even with crutches)
- Associated with high risk of osteonecrosis (~50%)
What are the grades for the Slippage classification of SCFE?
Grade 1: 0-33% slip
Grade 2: 33-50% slip
Grade 3: >50% slip
What are some suggestive signs on clinical exam of SCFE?
- May present as knee pain
- Obligatory ER with passive hip flexion
- Loss of hip internal rotation, abduction, and flexion
- Externally rotated foot progression angle
- Prefer to sit in a chair with affected leg cross over the other (b/c it’s ER)
What is the management of SCFE?
Percutaneous fixation +/- open (stable & unstable)
+/- bilateral fixation (controversial)
+/- reduction of epiphysis (controversial)
Proximal femoral osteotomy for chronic slips with functionally debilitating deformity
How many screws should be used to fix a SCFE?
One: a single cannulated screw sufficient and decreases risk of osteonecrosis (compared to multiple pins) in unstable SCFE
Where should the pin for SCFE fixation start?
On the anterior surface of the neck
- In order to cross perpendicular to the physis enter into the central portion of the femoral head (which has slipped posteriorly) on both the AP and lateral views
Where should the screw for a SCFE fixation end?
In the center of the femoral head, 5mm from the subchondral bone on all views
How many threads of the screw should pass the epiphysis for SCFE fixation?
At least 4 threads
Name 3 complications of SCFE:
Osteonecrosis of femoral head (Most common) Chondrolysis Residual proximal femoral deformity & limb length discrepancy Symptomatic impingement Slip progression Hip stiffness Degenerative arthritis Pin associated proximal femur fracture
Name 2 radiographic features of SCFE:
Kline’s line: doesn’t intersect epiphysis
Epiphysiolysis
Blanch sign of Steele: blurring of proximal femoral metaphysis
What is Kline’s line? What does it suggest?
Line draw on the superior border of femoral neck that NORMALLY DOES intersect the femoral head.
In SCFE, it will NOT intersect the femoral head (b/c the epiphysis has slipped)
What is the Blanche Sign of Steele?
Blurring of the proximal femoral metaphysis seen on AP due to the overlapping of the metaphysis and the posteriorly displaced epiphysis
What is Barlow’s test?
Test for DDH.
Dislocates a dislocatable hip by adduction and posteriorly directed force on a flexed femur
What is Ortolani’s test?
Test for DDH
Reduces a dislocated hip by elevation/anterior force and abduction of a flexed femur
What is Galeazzi’s test for the hip?
Test for DDH
There is an apparent limb length discrepancy due to a unilateral dislocated hip with the hip and knee flexed at 90 deg
Femur looks short on the affected (dislocated) side
When do Barlow and Ortolani’s test stop becoming positive, even in DDH?
After 3 months, because of soft tissue contractures of the hip
When is the use of Barlow and Ortolani’s test effective for the detection of DDH?
< 3 months
What is the most sensitive physical test for DDH in a child >3 months old?
Limitation in hip abduction - there will be asymmetry
Name 3 physical indications of DDH in a patient >1 year old?
Pelvic obliquity
Lumbar lordosis
Trendelenburg gait
Toe walking
Name 3 radiographic signs of hip dislocation in pediatrics?
Hilgenreiner’s line: horizontal line through left and right triradiate cartilage
- Femoral head ossification center should be inferior to this line
Perkin’s line: line perpendicular to hilgenreiner’s line at a point on the lateral margin of the acetabulum
- Femoral head ossification should be medial to this line
Shenton’s line: Arc along inferior border of femoral neck and superior margin of obturator foramen
- Arc should be continuous
What are 3 radiographic signs/indices of hip dysplasia?
Acetabular index:
- Angle formed by a line drawn from a point on the lateral triradiate cartilage to a point on the lateral margin of the acetabulum and Hilgenreiner’s line
- Should be 6mos
Center-edge angle of Wiberg
- Angle formed by a vertical line from the center of the femoral head and a line from the center of the femoral head to the lateral edge of the acetabulum
- 5years`
What is the management of DDH by age range?
18 months: open reduction & spica casting
>18 months: open reduction +/- pelvic osteotomy +/- femoral osteotomy
What are the different types of pelvic osteotomies?
Redirectional (complete), Reshaping (incomplete), salvage
What is the difference between a Redirectional & Reshaping pelvic osteotomy?
Redirectional moves the acetabulum without changing the shape of it
Reshaping changes the shape of the acetabulum to provide better coverage
Name 3 redirectional pelvic osteotomies:
Salter
Steele
Ganz
Name 2 Reshaping pelvic osteotomies
Pemberton
Dega
Name 2 salvage pelvic osteotomies
Chiari
Shelf
When is the main advantage of a Dega osteotomy in neuromuscular hip dysplasia/dislocation?
It provides posterior coverage, which is usually deficient in neuromuscular patients (these patients require posterior coverage b/c they are usually sitting aka in a wheelchair for a long time)
What are does a salter osteotomy provide coverage for?
Anterolateral
What modality is primarily used for assessment of DDH in children <4-6 mos old?
Ultrasound - because this is before there is ossification of the femoral head
What is alpha angle?
Assessment for DDH on ultrasound, created by lines along the bony acetabulum and ilium
- Normal is >60 deg
What is the beta angle?
Angle created by lines along the labrum and ilium for assessment of DDH
Normal is <55 deg
Is ultrasound done on every baby for routine screening of DDH? Why or why not?
No, because it is not cost effective
What is Blount’s disease?
Pathological genu varum of knee onset before 10yrs
Name 5 risk factors for child abuse:
Child Factors: - Hyperactive - Precicious - Premature - Adopted/Step-child - Handicapped Parent Factors: - Age <20 - Lower education - Hx of psychiatric disease Social Factors: - Job loss - Family death - Unplanned births - High stress levels
At the earliest, when can elastic nails of the forearm be taken out?
4-6 months
At the earliest, when can elastic nails of the femur be taken out?
6-12 months
What type of fixation for femur fractures is associated with damage to the MFCA in pediatric and adolescent population?
Piriformis entry IM nails
What constitutes the highest proportion of fractures due to child abuse?
distal humerus physeal separation (Figure D) has the highest association with child abuse.
What is the classification of tibial hemimelia?
Jones classification: Type 1: complete absence of tibia Type 2: only proximal tibia Type 3: only distal tibia Type 4: divergence of proximal tibia & fibula with proximal displacement of the talus
What is the most common cause of anteromedial bowing of the tibia?
Fibular hemimelia
What gene is associated with fibular hemimelia?
Sonic hedge hog gene
What is the classification of fibular hemimelia?
Achterman and Kalamchi classification
Birch classification
- Birch is more useful because it gives management options
What is the Birch classification & treatment of fibular hemimeila?
Type I. Functional foot
Shortening 5% or less (none or epiphysiodesis)
Shortening 6–10% (epiphysiodesis or lengthening)
Shortening 11–30% (1–2 lengthenings)
Shortening >30% (multiple lengthening or amputation)
Type II. Non-functional foot
Upper extremities functional (amputation)
Foot needed for prehension (no treatment)
What is the Achterman & Kalamchi classification of fibular hemimelia?
- Type I has part of the fibula present
- Type II, the fibula is absent.
