PC Peds Flashcards
Treatment of patellar sleeve fx
Open reduciton and suture repair or tension band
Treatment of proximal tibia fx
nonop
Complicatoin of proximal tibial fx
Late valgus deformity; corrects over 12-24 mos
Accpetable alignment of tibial shaft fxs
< 5 deg posterior
5-10 deg varus/valgus
Distal tibial physeal fx at highest risk of growth arrest
Post reduction gap of >3mm
Workup tillaux fx
CT to assess displacement (2mm)
Order of closure of distal tibial physis
Central –> medial –> lateral
Treatment of tillaux fxs
ORPP if > 2mm displacement; otherwise, cast
Halo for peds c spine — _____ pins at ______in-lbs
6-8 pins at 2-4 inlbs
Age at dentocentral syndchondrosis fuses
6
Treatment of odontoid fxs in peds
CR + halo
Association of TL spine injuries
50% intraabdominal
15% paraplegia
Most common mechanism of osteo in peds
hematogenous
metaphysis
Most common organisms for osteo in peds
Staph aureus
What type of culture is needed for kingella kingae
Blood culture medium
Pediatric osteomyelitis with delayed presentation
Kingella kingae — blood culture medium
Sequestrum
necrotic bone that is avascular and can be nidus for chronic infxn
What lab peaks fastestand and normalies more quickly in osteo
CRP
Complications of osteomyelitis
– Can be fatal if untreated – Growth arrest and LLD – Deformity – Chronic infection – DVT (MRSA with PVL gene)
Kocher criteria
– NWB
– ESR > 40
– Fever > 38.5
– WBC > 12K
4 = 99%, 3 = 93%, 2 = 40%, 1 = 3%
Best predictor of septic hip
Fever followed by CRP
Treatment of lyme disease (>8)
Doxycylcine
Treatment of lyme disease (<8)
Amoxicillin
Treatment of diskitis in peds
Abx
if fail –> look for TB
Treatment of chronic recurrent multifocal osteomyelitis
NSAIDs
Most common cause of sepitc hip in sickle cell pt
Staph aureus
MRI brain in CP
periventricular leukomalacia
Hemiplegic CP
one side
Diplegic
Lower > upper body involvment
GMFCS classification of CP
I – Speed, balance, coordination impaired
II – Hold railing, trouble with uneven surface
III – Rolling walker, self propelled wheelchair
IV – Operate powered wheelchair
V – Completely dependent
Botox mechanicsm
Inhibits presynaptic release of Acetylcholine
Treatment of stif kneed gait
hamstring lengthening and rectus transfer
Indications for scoliosis surgery in CP
– Progressive deformity with
– Sitting imbalance
– AND manageable comorbidities
Indication to treat dysplastic hips in CP
Early: adductor and IP release
Late: VDRO & pelvic osteotomy
Late dislocaiton: leave untreated
Treatment of equinovalgus foot in CP
Cause: spastic peroneals
TAL, PB Length, Lat Column Length, Calc osteotomy
Treatment of equinovarus foot in CP
Cause: spastic PT +/- AT
- SPTT to peroneals – flexible varus with weak peroneals
- SATT to cuboid – flexible varus with overactive tib ant
- Rancho Procedure – combined with Post Tib length
Etiology of arthrogryposis
decreased anterior horn cells
Risk factors for spinal bifida
– Low Folic Acid – Valproic Acid – Carbamazepine – Maternal hyperthermia – Maternal IDDM
Level of spina bifida needed for walking
L4
Type of allergy in spina bifida to latex
IgE
Functional status change in spina bifida
Need to get brain/spine MRI to eval for shunt malformation, hydrocephalus, arnold chiari, tethered cord
Associatoin in sacral agenesis
Maternal diabetes
Duchenne’s protein
Dystrophin
Duchenne’s inheritance
XLR
Indications to fuse scoliosis in Duchenne’s
Fuse > 20 deg
Fascioscapulohumeral muscular dystrophy - inheritance
Autosomal dominant
Fascioscapulohumeral muscular dystrophy - exam
– Scapular winging
– Weakness involving muscles of facial expression and proximal UE
– Inability to whistle
Treamtent of polymyosistis/dermatomyositis
Anti-TNF
AIS MRI indications
Left thoracic curves Pain Apical Kyphosis Rapid curve progression Neurologic signs Congenital anomalies
Peak growth velocity timeing
Occurs prior to menarche
Occurs prior to Risser1
AIS progression after maturity
Thoracic curves >50°
Lumbar curves >30°
Typically 1-2 degrees per year
This data guides treatment!!
Bracing number hours per day needed
14
AIS < 25 deg and skeletally immature
Observe
AIS < 40 and skeletally mature
Observe
AIS 25-40 and skeletally immature
Brace
AIS > 50 and skeletally immature
Surgery
AIS > 50 and skeletally mature
Surgery
Bracing for AIS with apex T7 or higher
CTLSO or Milwaukee brace
Bracing for AIS with apex T78 or lower
TLSO
Indication for ASF and PSF in AIS
Skeletal immaturity (crankshaft)
less than 10 y.o.
Severe curves ( over 75 degrees)
Early onset scoliosis - curve type
Usually left thoracic
Early onset scoliosis - RVAD — who prorgresses
RVAD= (concave –convex) at apical vertebra
RVAD > 20 = high risk of progression
Treatement of early onset scoliosis
< 25°; RVAD < 20°= observation
25-45°; RVAD > 20°= cast / brace/MRI
> 50°= MRI, +/-surgery
Surgical treatment of congenital scoliosis
ASF/PSF without instrumentation
Most sensitive test for spondylolysis
SPECT scan
First line treatment for spondylolysis
Antilordotic bracing, PT, activiy restriction for 3 mos
Treatment L5 spondylolysis that failed nonop
l5/S1 fusion
Treatment of L3 spondy that has failed nonop
Repair
Indication for surgical treatment of spondylolisthesis
Grade III or higher (>50%)
Progression of deformity
Failure of nonop tx
Bracing indications for Scheuermann’s
65-80 deg
Surgical indications for Scheuermann’s
> 80 deg
Who to consider atlantoaxial instability
Down’s syndrome (fuse if ADI > 10)
Juvenile rheumatoid arthritis
Skeletal dysplasias
Treatment C1-C2 rotatory subluxation that fails traction
C1-C2 fusion
Position of elbow during CRPP of flexion type SCH fx
extensoin
Associated anomalies with Klippel-Feil
Screen for:
- Sprengel
- deafness
- GU abnls
- CV abnls
Indications to keep a child out from contact sports with Klippel Feil
- Massive fusion of cervical spine
- any involvement of C2
- Limited cervical motion
Factors most associated with nonaccidental trauma
- nonambulatory pts
- suspicious histories
- associated injuries
- metaphyseal fxs
Study of choice for workup of suspected talocalcaneal coalition
CT scan
If nondiagnostic then MRI
Initial treatment of congenital dislocation of the knee
Casting with the knee in flexion if able to achieve 30 degrees flexion (GI or GII)
If not able to achieve 30 degrees flexion (GIII) or recurrent case –> then need to do a quadricepsplasty of some sort
Incidence of multilevel spine injury when there is ONE pediatric spine fx identified
30-55%
Therefore, entire spine should be imaged in these cases
Treatment of 5 yo with vertcial shear pelvic ring injury displaced 2 cm and symphysis widening
Closed reduction and spica cast for 2 months
Cause of Poland syndrome
Interruptoin of embryonic sublavian blood supply
Cause of Sprengel deformity
Interruption of embryonic subclavian, internal thoracic, or suprascapular artery
Cause of fibular hemimelia
No known genetic or environmental factor
Cause of distal arthrogryposis
MYH3 gene mutation encoding for myosin heavy chain 3
Cause of NF1
NF1 gene on chromosome 17 coding for neuofibromin (a tumor suppressor)
Cause of Beckwith-Wiedemann syndomre
Chromosome 11 mutation near the IGF gene
Characterized by: major criteria: -- overgrowth -- abdominal wall defects, incl. omphalocele -- macroglossia or large tongue minor criteria -- hemihypertrophy (10-20%) -- ear anomalies -- neonatal hypoglycemia -- nephromegaly
Genetic defect of the _____ protein in marfan syndrome
Fibrillin-1
FBN-1
Genetic defect of the _____ protein in Ehlers-Danlos
Type III collagen
Trewatment of adolescent Blount’s with open physes
Lateral tibial epiphysiodesis
Treatment of adolescent Blount’s near/after skeletal maturity
Proximal tibial osteotomies
DVT association in peds
Osteomyelitis caused by MRSA
Bacterial gene that predisposes to DVT
Panton-Valentine leukocidin gene
PVL gene
Treatment of Ortolani positive hip that has failed to reduce in Pavlik for 3 wks (remains Ortolani positive)
Apply semi-rigid hip abduction orthosis
Fusion sequence of ossification centers of the elbow
CTE-R-O-I
Rate of motor recovery after total brachial plexus birth palsy with associated Horner’s
<10%
Disorders with COMP gene mutation
Multiple Epiphyseal Dysplasia
Pseudoachondroplasia
Normal femoral head coverage, alpha angle, and beta angle on ultrasound
50% coverage
alpha angle > 60
beta angle < 50
Comparison of treatment of both bone FA fxs with flexible IMN and ORIF
OR time, blood loss, radial bow magnitude, forearm rotation and union
IMN shorter surgical time and less blood loss
Similar union, radial bow magnitude and forearm rotation
Larsen’s syndrome
Multiple joint dislocations and abnl facial features
Additional workup needed in pt with multiple congenital joint dislocaoitns
Larsen’s syndrome
XR and/or MRI of the cervical spine prior to any sort of surgery or manipulation of the spine due to risk of cevial kyphosis and instability
Workup Toddler with genu varum > 20 degrees
Blood work, calcium, phosphorus, alk phos, vit D, and renal function tests
DDx: Blounts, skeletal dysplasias, rickets
Alpha angle on ultrasound measures what anatomic structure
Degree of horizontalization of the acetabular sourcil
Preferred position that patients with SCFE hold their hip in
external rotation
Treatment of osteoid osteoma of the spine
Excision if within 1 cm of neurovascular structures; otherwise RFA
Deficient protein in Larsen syndrome
Filamin B
First line treatment for pt with NF-1 with tibial fx
Long leg cast; if goes onto nonunion, can address with surgery
For a patient with achondroplasia, the thoracolumbar kyphosis seen in infancy will most likely
Resolve with independent walking
Consideration if not walking by 18 months of age
Evaluate for neurologic or developmental condition
Orthopaedic conditions should not delay amubulation
Treatment of 2 year old presenting with dislocated hip
Open reduction and +/- acetabular +/- femoral osteotomy
Key point is that you have to do an OPEN reduction; can’t get closed
MSK manisfestations associated with fibular deficiency
ACL deficiency
Ball and socked ankle joint
Tarsal coalition
Complication after tibial spine fx
Arthrofibrosis
Intraoperative neurophysiologic monitoring for pediatric spine surgery entails:
Motor cortex to the corticospinal tract –> spinal cord interneuron –> anterior horn cells –> peripheral nerve –> skeletal muscle in an efferent direction
Risk factors for spinal agenesis
Maternal diabetes
Genetic association with clubfoot
PITX1-TBX4 translocation
Weakest zone of the physis - and therein most susceptible to fracture:
Zone of hypertrophy
Genetic defect in fibrous dysplsia
GNAS1 on chromosome 20
Pediatric septic joint with delayed presentation
Kingella kingae — blood culture medium or PCR
What portends greatest risk of physeal arrest after fracture?
Amount of post-reduction displacement
Lowest possible FVC of a pulmonary function testin in a pt with Duchenne’s that you can reasonably expect to wean from vent
35%
Best method to reduce a native pediatric hip dislocatoin
Closed reduction under GENERAL anesthetic with fluoroscopy
Timing to act on “physiologic” genu valgum
8 yrs
Bacteria associated with increased risk of pathologic fx after subperiosteal abscess in kids
USA300-0114 pulsotype MRSA
Presurgical testing for pt with Morquio’s should include ________
cervical spine XR
intability common at C1/C2
Risk factor for arthrofibrosis after fixation of tibial spine fx
Surgical time > 120 min
Surgery > 7 days afer injury
Prolonged immobilization with delay of ROM rehab
