Ped Ortho - Exam 3 Flashcards
A true groin pull is actually an _____. Always rule out a ____
adductor strain
slipped capital femoral epiphysis
____ is the test of choice for an osteochondral fx. What should you do next?
MRI
refer to pediatric ortho
What are 2 common “groin pain” injuries in young adults?
Avulsion fractures of the pelvis are common in young adults
Stress fractures of the femoral neck is a common injury
What are the 3 “groin pain” red flags?
Refusal to bear weight at all
Refusal to move hip
Pain more than 24-48 hours
What are the 7 red flag symptoms for knee pain?
Deformity
“Kneecap Slipped out of place”
Large lacerations
Unable to flex knee , walk
Immediate edema (not gradual)
Intolerable pain
May be a disguiser of HIP PAIN
_____ is the MC fx of the knee. _____ is another one that presents as knee pain
Tibial spine or osteochondral Fx
Patellar sleeve fx
What does the Ballotment test test for? How do you perform it?
effusion in the knee
Knee straight - pressure applied at top of patella toward femur. Spongy feeling suggests effusion
_____ is an important bony prominence that anchors the attachment of the ____
Tibial spine
ACL
Mechanically speaking, an avulsion fracture of the ____ is the equivalent of an _____ in adults
tibial spine
ACL rupture
What is the MOI for a tibial spine fx?
Hyperextension of knee with concurrent rotation of femur on tibia
Hemarthrosis
joint pain
markedly decreased ROM in the knee
sudden pain
What am I?
What is the tx based on?
tibial spine fx
nondisplaced vs displaced
What is the tx for a nondisplaced tibial spine fx?
Nondisplaced fractures may be managed conservatively with immobilization in extension and ortho f/u
Diagnosis by radiographs, repeat in 2 weeks to check healing
What is the tx for a displaced tibial spine fx?
Displaced fractures need reduction and immediate ortho consult
What am I?
tibial spine fx
Osteochondral fractures to the intra-articular portions of the femoral condyles or tibial plateau frequently accompany _____, ____, or _____
patellar dislocation
ligament tears
meniscal injuries
osteochondral _____ may arise from osteochondral fracture. What age range? What is a common presenting symptom?
fragments
think 12-18 years old
“locking knee”
What am I?
osteochondral knee fx
_______ is caused by an indirect force applied to the patella through sudden, forceful contraction of quadriceps to a flexed knee. What are 2 common MOIs?
Patellar Sleeve Avulsion Fracture
Occurs when someone lands on feet after jumping from moderate height
Or comes to sudden stop from full sprint
______ happens if the force generated by the quadriceps exceed the strength of the patella. What is a common PE finding? What imaging is needed?
Patellar Sleeve Avulsion Fracture
May not be able to extend knee against gravity
MRI may be needed
What is the tx for a Patellar Sleeve Avulsion Fracture?
immobilize knee and refer to ortho
for a patellar sleeve fx, _______ and _____ are more predictive than xray evidence. What do you need to have in this specific injury?
hemarthrosis
physical exam
there is a high morbidity with this injury so a LOW index of suspicion should be held
What am I? ____ is a super common exam finding
patellar sleeve fracture
hemarthrosis
What is Osteochondritis dissecans? What is it due to?
Bone beneath the cartilage of the knee joint dies due to lack of blood flow an the necrotic bone is replaced by subchondral trabeculae or cartilage
aka a piece of bone in the middle of the joint
Osteonecrosis of subchondral bone due to overuse (think avascular necrosis)
What happens in osteochondritis dissecans as the lesion progresses?
What is the tx?
focal areas of demineralization and repeated shear forces cause detachment of bone and overlying cartilage
immobilization for 3-6 mos vs surgery
_____ is used first in Osteochondritis Dissecans but _____ is diagnostic of choice
xray is used first
MRI is diagnostic of choice
What does knee popping usually indicate? What is the tx?
meniscal tear
meniscal tear = refer to ortho
What is the MC ankle sprain? What is the tx?
Calcaneofibular ligament and anterior talofibular ligament most common sprain
Brace, support, NSAIDS
Still need controlled ROM
What are the different grades of an ankle sprain?
What is the MC reason a child may limp?
injury/inflammation or infection
_____ is the most common reason for inflammatory childhood limp. What is the underlying cause? What does it usually occur after?
Toxic synovitis
is actually an inflammation of the joint- hips and knee affected the most
It occurs after a recent URI usually!!! think recent cold
What are the different Kosher criteria for septic arthritis? Give level 1-4
**What are the Kosher criteria for septic arthritis?
Fever over 101.3
ESR > 40
WBC >12 K
NO weight bearing
What should be included in your work up of a pt when trying to determine if it is transient synovitis or a septic hip?
consider the hx
xrays:
AP pelvis with frog leg views
labs: CBC, ESR, CRP, BMP
What is the tx for a septic hip?
I&D of hip if warranted - aspiration of joint fluid
Antibiotics- cover staph aureus
**____ is the MC cause of Intoeing in infants birth to 12 months old. Describe the presentation. Will it involve the ankle? How would a non-medical person describe it?
**Metatarsus Adductus
Inward deviation of the forefoot in relation to the hind foot
does NOT involve the ankle
“C”-shaped foot or “kidney bean” shape
If you draw a line from the middle of the heel to the toes, where will the line intersect in a normal foot?
intersect between toes 2 and 3
What is metatarsus adductus linked to? What sex?
Linked to intrauterine molding and position in the womb
equal boys and girls
_____ is the MC congenital foot deformity in children < 1 year old
Metatarsus Adductus
What are the risk factors for Metatarsus Adductus?
Risk factors:
breech presentation
family history of MA
hip dysplasia
decreased amniotic fluid
first born
twins
In metatarsus adductus, ____ resolve by 1st birthday and the rest by ____ old without intervention
90%
5-6 years
What dx testing should you order in metatarsus adductus?
NONE!! no testing or xrays needed
_____ MA examiner can passively over-correct the deformity into abduction with little effort. What is the tx?
Mild
Treatment - stretching, observation
____ MA examiner can passively correct the deformity only into middle position. What is the tx?
moderate
stretching observation
____ MA examiner is unable to correct the deformity to midline. What is the tx?
severe
corrective casting before 8 months of age or surgery in severe cases
_____ is when the foot points downward and inward and soles of feet face each other - foot appears internally rotated at ankle. What sex? How common is it?
Clubfoot (Talipes Equinovarus)
males > females
1 in every 1,000 babies born
What is the underlying cause of clubfoot?
Shortening of Achilles tendon, tendons of medial lower leg, as well as unusual shape to talus bone
calf muscles are also underdeveloped
What are the 3 features of clubfoot?
Plantar flexion of the foot and ankle
Inversion of the heel
Medial deviation of the forefoot
What are the risk factors for clubfoot?
decreased amniotic fluid
genetic factors
familial history
twins
spina bifida
SMOKING during preg
infection during preg
illicit drug use while preg
What is the chance that if one child born with a clubfoot, the next will be also?
1/30 chance
What are the 3 different types of clubfoot? Which one is MC?
congenital - MC type
syndromic
positional
What is syndromic clubfoot associated with?
spina bifida
What is positional clubfoot associated with?
Intrauterine crowding – example: twins
Breech
Low amniotic fluid
What are the 3 different tx options for clubfoot?
ponseti method
surgery
french functional method
What is the ponseti method for tx of clubfoot? What is the associated timing?
Specialist manipulates foot with hands to correct bend in foot
Plaster cast applied from toes to thigh to hold in position
Process occurs weekly and may last 4-10 applications
What is the sx tx for club foot? For how long?
Achilles tendon release
Boots and braces after surgery to hold feet in position for 2-3 months worn 23 hours per day
Braces continued during night and naps until 2-4 years of age
What is the french functional method for clubfoot? For how long?
Daily stretching and exercise
Massage
Immobilization and taping foot in position
PT until child is 2 years old
What is the difference between in-toeing and out-toeing?
What are the 2 different version of tibial torsion? What is the slang terms?
internal vs external
“Knock-knees” or “Pigeon-toes”
What is the MC cause of intoeing and outtoeing in older kiddos?
tibial torsion
____ is the MC cause of intoeing in kiddos 1-3 years old. When is it noticed? Is it normally uni or bilateral?
internal tibial torsion
Usually noticed when toddlers start to walk
Bilateral in 2/3 of cases
Describe internal tibial torsion in medical words
Medially deviated foot with patella facing forward
What type of bone deformity do the fastest runners usually have?
Fastest runners are typically in-toed (sprinters and athletes)
How should you evaluate a pt’s normal leg anatomy?
kneecaps needs to be symmetric and straight up
When does tibial torsion tend to resolve? What is the tx?
Typically resolves by age 5 when tibia rotates laterally
Observation only at yearly WCC
When would you need to tx tibial torsion? What should you do next? What is an INEFFECTIVE method of tx?
treat if feet still turn inward by > 15 degrees at age 5 because spontaneous correction unlikely at that point
Refer to orthopedics if > 8 years old and activity is limited due to in-toeing or cosmetic reasons
Treatment with orthotics is ineffective
____ is the MC cause of out-toeing in toddlers and young children. Describe it in medical terms. When is it usually discovered?
External Tibial Torsion
Medial malleolus is anterior to the lateral malleolus
Can be discovered later at 4-7 years old or even early adolescence
_____ is the increased angle of rotation of femoral neck in relation to transcondylar axis of femur
Femoral Anteversion
____ is the MC cause of intoeing AFTER 3 years old. Describe it in medical terms
femoral anteversion
Inward facing feet and patella
What am I? What does it cause? What is the pattern of walking?
Prefer sitting in “W” position
Femoral Anteversion
Egg-beater” or “Windmill” pattern of walking and swimming
When should you refer for femoral anteversion?
Refer if persists past 11 years of age
What is the MC cause of intoeing if the kiddo is less than 12 months old?
Metatarsus Adductus
What is the MC cause of intoeing if the kiddo is between 12 months and 3 years old?
Tibial Torsion most common cause
What is the MC cause of intoeing if the kiddo is older than 3 years old?
Femoral Anteversion
What are the different terminology for hip dysplasia?
unstable
subluxation
dislocation
dysplasia
_____ hip loose in socket with abnormal movement
unstable
_____ partial dislocation (hip partly out of socket)
subluxation
____ hip completely out of socket
dislocation
_____ wide spectrum term ranging from unstable to dysplastic to malformed
dysplasia
What is the preferred term if the hip is noted to enter and exit the socket? What is it?
Newborn hip instability
Normally formed hip that becomes displaced in utero or at ≤ 1 yr of age in otherwise healthy child
Developmental Dysplasia of Hip (DDH) is bilateral in __% of cases. What sex?
20% of cases and has a genetic component
Girls > Boys (75%)
What are the risk factors for DDH? Left or right hip?
Breech
Twins
First born
may have swaddling link
left > right
Asymmetrical buttock or thigh hip creases / skin folds
may have hip clicks
Painless, but exaggerated waddling limp after learning to walk
Swayback
Limited abduction of the hip
What am I?
What PE finding?
DDH
Trendelenburg sign
What is Trendelenburg sign?
painless limp and lurch to one side with a dip in pelvis on opposite side when child stands on affected leg (secondary to weakness of gluteal muscle)
_____ Thigh grasped loosely with examiner’s index and middle finger along the greater trochanter and thumb along inner thigh. Hip adducted and posteriorly directed pressure applied
Barlow maneuver
______ Thigh grasped loosely.
From an adducted position – the hip is abducted while lifting the trochanter anteriorly
ortolani maneuver
Is Barlow or ortolani the more important test? Why?
Ortolani
relocates dislocated hip - more important test
What are the different types of DDH? What is the most severe form?
subluxated
dislocatable
dislocated- most severe form
______ DDH types: Head of femur loose in socket. Bone moved during physical exam but won’t dislocate
Subluxated
____ DDH types: Head of femur is in acetabulum but easily pushed out during physical examination
Dislocatable
_____ DDH types: Head of femur completely out of socket
dislocated
_____ is used for the standard dx of DDH. When should a newborn be screened?
US
Any male or female born breech > 34 weeks gestation should be screened
and/or
Family history of DDH
if a kiddo is 4 - 6 months of age and older with instability or any child with a limp or unstable gait when able to walk, what should you order next?
X-ray evaluation :A-P pelvis, bilateral hips and frog leg views
Under what circumstances may DDH resolve spontaneously? **When should you refer to a specialist?
Most resolve spontaneously by 2 – 6 weeks of age
**Positive Ortolani at any age - refer to specialis
What should you do if the Barlow test is positive? Give tx options for the following age ranges
0-6 months
6-18 months
18 months- 6 years
older than 6 years
observe and follow
0 – 6 months – Pavlik Harness
6 – 18 months – closed reduction and Spica casting for 2-3 months
18 months – 6 years – closed reduction vs. open reduction
> 6 years – no treatment
_____ is inflammation of the patellar tendon. What is it associated with? What sex? What age range is MC?
Osgood Schlatter Disease
Growth spurts during puberty
boys> girls
Affects 1 in 5 adolescent athletes
Pain and tenderness to tibial tubercle with or without edema
Worsens with activity / Improves with rest
Tightness in surrounding muscles
usually unilateral but can be bilateral
What am I?
What is the MOI?
Osgood Schlatter Disease
Overuse injury caused by repetitive strain and chronic avulsion of ossification center of tibial tubercle
______ Anterior knee pain increasing over time with activity and may limp but improves with rest. What dx test? Where is TTP?
Osgood Schlatter Disease
no xrays are needed!!
Tenderness to palpation over tibial tubercle
What is the tx for Osgood Schlatter Disease? Can they still play sports?
Treatment – Ice (20-30 min. twice daily), NSAIDS, Stretching (quadriceps), PT if needed
usually waxes and wanes over 16-18 months
YES!!! Complete avoidance of PE not recommended – playing IS permitted. No crutches or knee immobilizers
_____ is the MC chronic anterior knee pain in athletes? What is it due to? Why does it happen?
Patellofemoral Syndrome
Degeneration of cartilage due to poor alignment of kneecap
Abnormal tracking allows patella to grate over the femur causing chronic inflammation
What pt population is at the highest risk of patellofemoral syndrome? name 2 additional populations
teenage females highest risk
Knock-knee and flat footed pts
What makes patellofemoral syndrome worse? What is the sign called?
Aggravated by activity or prolonged sitting with bent knee
“theatre sign”
How do you dx patellofemoral syndrome? What is the tx?
Clinical, although may see on x-ray or MRI
Ice
NSAIDS
Discontinue activity causing the pain
Strengthening quadriceps and hamstrings
_____ happens when the ball of upper end of femur slips off in a backward direction secondary to weakness in the growth plate
Slipped Capital Femoral Epiphysis
_____ is one of the MC hip disorders in adolescents
Slipped Capital Femoral Epiphysis
What are the risk factors for Slipped Capital Femoral Epiphysis? What sex? When does it tend to occur? What hip?
OBESITY!!
Males > Females
aka chubby teanage boys
Occurs during periods of accelerated growth during puberty
Left hip > Right hip
Several weeks or months of hip or knee pain, intermittent limp. Pain during exam with limited internal hip rotation
What am I?
What are the 2 different options?
Slipped Capital Femoral Epiphysis
acute vs chronic
Define acute vs chronic and stable vs unstable Slipped Capital Femoral Epiphysis?
Acute – symptoms less than 3 weeks
Chronic – symptoms more than 3 weeks
Stable – can ambulate with assistance such as crutches; foot is gradually externally rotating
Unstable – cannot ambulate even with crutches. Non-weight bearing
aka stable can walk and unstable CANNOT walk
What dx should you order for SCFE?
X-ray, U/S, MRI
What is the tx for SCFE?
internal fixation with single cannulated screw placed in center of epiphysis
How is SCFE categorized?
Type 1 (mild) - <33% displaced (epiphysis <1/3 diameter of femoral head)
Type 2 (moderate) – 33 – 50% displaced
Type 3 (severe) - >50% displaced
What are the compications of SCFE? What is the major one? What are the post-op instructions?
Avascular necrosis of femoral head** major one
Chondrolysis at hip joint (loss of cartilage); osteoarthritis
Limited weight bearing and crutches
_____ happens when the blood supply temporarily interrupted to femoral head and the bone dies and easily breaks. What is another name for it?
Legg-Calve Perthes Disease
Idiopathic avascular necrosis of the hip
aka the femoral head flattens
What sex for Legg-Calve Perthes Disease? Ethnicity? Age range? How common is it to be in bilateral hips?
Boys > Girls
WHITE!!
3 – 12 years old, peak 5 – 7
Bilateral hips in 10 – 20%
How long will it take to see someone on xray for Legg-Calve Perthes Disease? What will it show? What should you order next?
May take 1-2 months to show on x-ray
Joint effusion with widening of joint space and periarticular swelling
MRI and bone scan
What is the tx for Legg-Calve Perthes Disease?
aka it will get better on its own
no WEIGHT BEARING is important
_____ is any degree of curvature of the spine as described by the _____
scoliosis
Cobb’s angle
When should you screen for scoliosis? What test? What is the mean age of dx?
Screened age 8 – 9 and older by Adam’s forward bend test (AFB)
14 years of age – mean
What is the MC section of the spine for scoliosis to occur in? What sex?
Right thoracic – most common
Girls > Boys
aka right as girls are going through puberty
How do you dx scoliosis? What is the tx?
scoliosis films and measurement of Cobb’s angle
**<20 degrees – follow for progression
**>20 degrees or progression of ≥5 degrees – refer for bracing or surgery
How is the Cobb’s angle measurement taken?
What is a Toddler’s fx? What is the MC age?
Distal ½ of tibia that happens as a result of a Trivial injury common: Fall from low height
Tripping
Twisting ankle
9 – 36 months most common age
What is a CAST fx? How will it present? What should you do next?
“CAST” – Childhood Accidental Spiral Tibial fracture
child will refuse to bear weight
screen for child abuse
_____ is a genetic CT disease that results in multiple and recurrent fx. **What are the 2 super highlighted points? What will they more than likely develop?
Osteogenesis Imperfecta
**BLUE sclera and hearing loss
may also have deformed teeth and super prone to develop osteoporosis
______ is the result of a genetic mutation causing short-limbed dwarfism. How is it inherited?
Achondroplasia
autosomal dominant w/ 80% cases from random mutation
How tall will a pt with achondroplasia usually get? What are some additional PE features?
Short stature – usually around 4 feet tall max
Average-sized trunk
Short arms and legs w/ bowing
Waddling gait
Macrocephaly with prominent forehead
Normal Intelligence and sexual function
What is the tx for achondroplasia?
Endocrine - growth hormone in some cases
Genetics
______ is a birth defect causing the early growing together of two or more bones of the skull. What does it result in?
craniosynostosis
Asymmetrical head shape or appearance, hydrocephalus from the sutures closing too early
What is plagiocephaly?
Craniosynostosis from how the baby is laid resulting in an aysmmetrical head shape
What is another name for Familial Hypophosphatemic Rickets? It encompasses ___% of all hypophosphatemia. Why does it occur?
Specifically referred to as X-linked hypophosphatemia (XLH)
80% of all hypophosphatemia
Mutation of the phosphate-regulating gene
Impaired growth and bowing of the femur/tibia which results in the short stature of the lower limbs
dental abnormalities
deafness
Chiari malformation of the brain
Calcification of tendons, ligaments and joints
Craniosynostosis
What am I?
How do you dx?
Familial Hypophosphatemic Rickets
xrays, severe hypophosphatemia (<2.5 mg/dL), elevated serum alk phos
What is the tx for Familial Hypophosphatemic Rickets?
Calcitriol with Amiloride and HCTZ
Growth Hormone is a possible option
What is nursemaid’s elbow? What age range? What is the MOI?
Subluxation of the radial head
1-4 years of age most common
Tug or pull injury
What is the tx for nursemaid’s elbow? What will the xrays reveal? How will the kiddo be holding their arm?
closed reduction – supinate hand and flex elbow – “pop” over radial head
xray will be normal
Holds arm by side - fully pronated, refuses to use
A 2 year old boy new to your office comes in with his parents who complain that their child is “pigeon toed”. You watch the child walk and notice that his toes are pointed inward and his knees are facing forward. The most common cause would be
A. Metatarsus Adductus
B. Internal Tibial Torsion
C. External Tibial Torsion
D. Femoral Anteversion
B Internal tibial torsion
A 2 month old infant presents to your office for a WCC. On examination of the hips, you can palpate a “clunk” on his left hip while performing the Barlow maneuver. The next most appropriate step would be:
A. Order hip films, including A-P pelvis and frog leg views
B. Order an Ultrasound of the hips
C. Observation only and recheck at next WCC in 2 months
D. All of the above
D. All of the above
should order US, xrays and observation in this kiddo because he is 2 months old
