Paediatrics Flashcards
Rhizomelic
Mesomelic
Acromelic
Rhizo = "root", so more proximal than distal shortening Meso = "middle", so middle segment shortening Acro = "tip", so distal segment shortening
Achondroplasia features
Rhizomelic shortening Frontal bossing Button nose Cervical stenosis Radial head dislocation Trident hands Lumbar lordosis Short pedicles Champagne glass pelvis Genu varum
Diastrophic dysplasia features
Short-limbed dwarfism Cleft palate Clubfoot Hip dysplasia Cauliflower ears Hitchhiker thumb
Multiple Epiphyseal dysplasia
Proportionate dwarfism (no spinal involvement)
Shortened metacarpals
Double-layer patella
Spondyloepyphyseal dysplasia
Proportionate dwarfism
Spinal involvement
Barrel chest
Cervical instability (common)
McCune-Albright syndrome triad
Polyostotic Fibrous dyslplasia
Cafe-au-lait spots
Endocrine dysfunction
What investigations to order in Non-accidental Injury with:
- Children less than 2 years old
- Children less than 1 year old
- Neurological findings
- Shaking is suspected
- Skeletal survey (Skull, CXR, extremities)
- Lateral thoracolumbar x-ray
- Head CT
- Ophthalmologic exam
Age at Appearance (ossification) of ossification centers of the elbow
CRITOE
Capitellum = 1 Radial head = 4 Inner epicondyle = 6 Trochlea = 8 Olecranon = 10 External epicondyle = 12
Age at Fusion of ossification centers of the elbow
CET OR I
Capitellum, External epicondyle, Trochlea = 12
Olecranon, Radial head = 15
Inner epicondyle = 17
Indications for fixation in Supracondylar fractures
Medial comminution Type IIb Type III Type IV Flexion type
Urgent: Pulseless Neuro deficit Floating elbow Brachialis sign "subcutaneous bone" Swelling (if excessive)
Baumann’s angle
Humeral shaft
Lateral condylar physis on AP
Normal = 70-75 degrees
Deviation of 5-10 degrees should not be accepted
Indications for ORIF in medial epicondyle fractures in Paeds
Fracture entrapped in the joint Extension of the fracture to the articular surface Displaced >5 mm Elbow dislocation Open fracture > 2 mm displacement in athletes
Note: 9x higher rate of radiographic union with surgery
Indications for ORIF of radial head fractures in Paeds
> 30 degrees residual angulation (after reduction)
3 mm residual translation
< 45 degrees pronation / supination ROM
Patterson maneuver for closed reduction of Paediatric radial head fracture
Extension Traction Supination Varus Direct pressure
Israeli technique for closed reduction of Paediatric radial head fracture
Supination
Flex to 90
Direct pressure
Pronate while maintaining pressure
Metaizeau technique for reduction of Paediatric radial head fracture
Sharpen end of TENs nail a bit Insert TENs nail Guide it into radial head Rotate TENs nail Check on II Rotate the other way if no improvement
Indications for reduction of both bone forearm fracture in Paeds
If less then 9 yo then:
> 15 degrees angulation
If more than 9 yo then:
> 10 degrees angulation
Bayonetting > 1cm
Don’t accept malrotation (doesn’t remodel)
What is a Morscher osteotomy
Femoral neck lengthening osteotomy for residual Perthes. Take GT off, osteotomy in line with inferior neck, reattach GT more lateral and distal.
Cast Index in Distal radius fractures
Lateral x-ray inner cast diameter (excluding padding)
Divided by
AP x-ray inner cast diameter (excluding padding)
(measured at the fracture site)
Ideal is 0.8 or less. This is associated with a lower chance of fracture redisplacement (5.6% vs 26%).
Indications and treatment of Femoral Shaft fractures in Paeds
< 6 months old = Pavlik harness
0-5 years old + no shortening = Spica casting
0-5 years old + shortening = Traction, then delayed Spica
5-11 years old + <49kg + Length stable = TENS nails
>5 years old + >49kg = Submuscular plate
>11 years old or >49kg = Antegrade nail (trochanteric)
Cozen’s Phenomenon
Late valgus deformity after proximal tibial metaphyseal fracture in Paeds (3 to 6 year old)
Occurs in 50-90% of cases
Develops 5-15 months post injury
Maximal deformity at 12-18 months
Prevent by casting in extension and Varus mold. However, deformity occurs regardless of treatment.
Valgus deformity usually resolves spontaneously.
Blocks to open reduction of hip DDH
Capsule (lax, can be constricted by psoas) Psoas (tight) Labrum (inverted) Ligamentum teres (thickened) Transverse ligament (hipertrophied) Pulvinar (thickened)
Extrinsic: adductor tightness
Packaging conditions / disorders
Neck (Torticollis)
Hip (DDH)
Knee (Dislocation)
Foot (Metatarsus adductus)
Acetabular index in DDH
Line between:
Hilgenreiner’s line
A line formed by: point on the lateral margin of triradiate cartilage and point on the lateral margin of the acetabulum
Should be less than 25 degrees after 6 months of age.
Center-edge angle of Wiberg in DDH
Line between:
Perkin’s line
A line formed by: Center of femoral head to a poin on the lateral margin of the acetabulum
Should be more than 20 degrees after 5 years old (can’t seen bone very well until then)
Basic DDH treatment by age
< 6 weeks - Observe or Pavlik
< 6 months - Pavlik
< 18 months - Closed reduction and Spica
> 2 years - Open reduction + Femoral osteotomy
> 4 years - Open reduction + Acetabular osteotomy
> 14 years - Periacetabular ostotomy or Shelf
What is Pavlik Harness disease
Erosion of the Posterior Superior Acetabulum due to persistent dislocated position
Discontinue Pavlik if fails after 3-4 weeks
If hip is reducible (ortalani positive), go into a semi-rigid brace
Conditions affecting the Hypertrophic Zone of the Physis
SCFE Rickets Multiple Epiphyseal Dyslplasia Spondyloepiphyseal dysplasia Fractures (Zone of provisional calcification)
Conditions affecting the Proliferative Zone of the Physis
Achondroplasia
Multiple Hereditary Exostoses
Conditions affecting the Reserve Zone of the physis
Gaucher’s
Diastrophic dysplasia
Pseudoachondroplasia
Indication for physeal bar resection
< 50% of physis involved
2+ years of growth remaining
Indication for physeal bar resection
< 50% of physis involved
2+ yearsof growth remaining
What is the angle of Drennan and what is its significance
Metaphyseal - Diaphyseal angle of the proximal tibia in Infantile Blount’s disease
< 10 = 95% chance of spontaneous recovery without bracing
> 16 = 95% chance of progression
What conditions are associated with congenital vertical talus
Spinal muscular atrophy Cerebral palsy Arthrogryposis Myelomeningocele Diastematomyelia Congenital hip dislocation
At what age does the navicular bone ossify
Age 3
This is relevant in Congenital vertical talus, where the 1st metatarsal is used as a surrogate for the navicular on x-rays.
What is the physiological varus / valgus ages and alignment in Paeds
1 year = Varus 15 deg
2 yo = Neutral
3 yo = Valgus 10 deg
6 yo = 6 degrees valgus
Saleneus chart / curve
15 degree variation each way at each age
Pathologic causes of Varus legs in paeds
Fibrous dysplasia Infection Rickets Skeletal dysplasias (OI, FGFR3) Trauma JRA AnteroLateral bowing Blount's
FIRST JAB
from bone school
Important steps / points in Blounts correction osteotomy
Osteotomy distal to TT
Must correct Internal rotation as well as Varus
If doing acute correction, must do an ANTERIOR COMPARTMENT FASCIOTOMY!
“Rab” oblique osteotomy (banana osteotomy) vs corticotomy and frame vs closing wedge (shortening)
Fibula osteotomy required in most cases
What are the predictors of Walking in Cerebral Palsy
Hemiplegic - 100% walk Diplegic - 75% walk Quadriplegic - 25% walk Sit by 2 Stand by 4
Coxa Vara in Paeds indications for surgery
Epiphyseal angle (vs Hilgenreiner’s line)
< 45 - no operation
45-60 and stable - observe
45-60 and progressing - Valgising osteotomy
> 60 - Valgising osteotomy
Aim is to get angle to < 40
Use 150 degree plate
Add 20 degrees anteversion (usually retroverted)
What are the three types of Tibial Bowing
Antero - Lateral = Neurofibromatosis
Antero - Medial = Fibular hemimelia
Postero - Medial = Physiologic
Fibular Hemimelia associated conditions
Ankle instability DDH Absent lateral rays PFFD Tibial Bowing (anteromedial) Talipes equinoVALGUS Tarsal coalition Cruciate ligament deficiency Genu VALGUM LLD
Differentials for hemihypertrophy
Beckwith-Weidermann syndrome
Neurofibromatosis
Klippel-Trenaunay-Weber syndrome
Proteus syndrome
Malignant tumors Ollier's Fibrous dysplasia Poliomyelitis Spastic hemiplegia Russell-Silver syndrome (hemiartrophy, short, cafe-au-lait, clinidactyly) Haemophilia Xray therapy Condrodysplasia punctata
Perthes disease good prognostic factors
Male gender (longer remodeling time) Involvement of head low (Caterall or Herring) Containment of head good Range of Movement Age < 6 at onset
Herring low
Stuhlberg low
What are the three types of osteochondroses (and give an example of each)
Crushing
Pulling
Splitting
Crushing = Kohler's, Friedberg's, Panner's, Kienbock's Pulling = Osgood-Schlatter, Sever's, Sinding-Larsen-Johansson, Menelaus-Batten Splitting = OCD (knee, ankle, hip)
What is Kohler’s Disease
AVN of the navicular
4-6 yo boys
Resolves in 18+ months
What is Panner’s Disease
AVN of the capitellum
4-10 yo boys
Non-op mgmt if no OCD
If OCD, then treat as required
Indications for amputation in Fibular Hemimelia
Less than 2 rays of the foot
> 16cm LLD at maturity (some texts say 20)
Unstable ankle (relative)
Associated severe PFFD (relative)
4 things to examine for in a Juvenile Hallux Valgus case
Ligamentous laxity
Achilles tightness
TMTJ hypermobility
Neurological exam
Infications for contralateral SUFE pinning
PRE SLYPT
Portly
Remote
Endocrine
Severe slip Late presentation Young age (<10 yo) Posterior sloping angle (>14 degrees) Triradiates open
Physeal / Metaphyseal dysplasias
Multiple hereditary exostoses Achondroplasia Hypochondroplasia Metaphyseal chondrodysplasia Dyschomdrodysplasia (Olliers and Maffuci)
Epiphyseal dysplasias
Multiple epiphyseal dysplasia
Spondyloepiphyseal dysplasia
Dysplasia epiphysealis hemimelica
Chondrodysplasia punctata
Diaphyseal (/metaphyseal) dysplasias
Metaphyseal dysplasia Craniodiaphyseal dysplasia Diaphyseal dysplasia Craniometaphyseal dysplasia Osteopetrosis Pyknodysostosis
Autosomal Recessive Conditions
FrOGS SHODM
Friedrich’s ataxia Osteogenesis imperfecta 2/3 Gauchers Sickle cell Spinal Muscular atrophy Hypophosphatasia Osteopetrosis Diastrophic dysplasia Mucopolysacharidpses (except Hunter, which is X)
What is the safe zone for the hip in closed reduction for DDH
Less than 60 abduction
Less than 90 flexion
“Ramsay” safe zone
Maximum abduction - Position of re-dislocation
If this zone is less than 20 degrees, then not safe.
