pedi ortho Flashcards
gower’s sign
- weakness of proximal hip muscles
- limited ability to rise from sitting to standing
- uses hand and arms to “climb” up body
- think muscular dystrophy
which fractures are more likely to require internal fixation?
- displaced epiphyseal fx
- displaced intra-articular fx
- fx in child with multiple injuries
- open or unstable fx
bone remodeling
- occurs through periosteal resoprtion and new bone formation
- dont need perfect alignment
- younger= better potential for remodeling
- cant accept rotated fx and deformity not in plane of motion
fracture complications
- overgrowth
- neruovascular injury- especially distal humerus and knee
- compartment syndrome
what fx are most likely to result in overgrowth
- femoral fx in kids < 10 y/o
- can have 1-3 cm of overgrowth
- generally occur more often in long bones d/t increased BF after fx
salter harris fx
- fx involves growth plate -> premature closure
- partial closure= angular deformity
- complete closure= limb shortening
common sites for salter harris fx
- distal radius
- distal tibia
- distal fibula
salter harris type I
- through growth plate
salter harris type II
- through metaphysis and growth plate
- most common
- good prognosis
salter harris type III
- through epiphysis and growth plate
- into joint- poorer prognosis
salter harris type IV
- through metaphysis and epiphysis
salter harris type V
- crushed through growth plate
- doesn’t displace growth plate but damages it by compression
- worst prognosis
green stick fx
- bending force perpendicular to shaft
- bone doesnt cause complete fx
- usu in forearm of young kids
toddlers fx
- minimally or non-displaced oblique fx of tibia
- pts 1-3
- limping pain with WB
- minimal welling and pain
- initial xray doesnt always show fx- can repeat
what is another name for a buckle fx
- torus fx
buckle fx
- occurs after compression of bone
- boney cortex doesn’t truly break
- occurs in metaphysis
- stable fx
- commonly d/t foosh -> buckle of distal radius
bowing fx
- no fx line on xray
- bone is bent, not a true fx
- will heal with periosteal reaction
- reductrion requires a lot of force, do under anesthesia
- may consider comparison views on xray
supracondylar fx
- extra-articular fx above joint line
- fx of distal humerus at elbow
- usu in kids 5-9
- most often from foosh from moderate hight onto extended elbow
- posterior displacement of distal compartment
conservative treatment for supracondylar fx
- used if non-displaced
- long arm cast
- serial xrays q 1-2 weeks
- analgesics
surgical tx for supracondylar fx
- ORIF
- 2 lateral pins for stable fixation, medial pin
- be sure to correct medial pin placement to avoid ulnar n damage
nusemaid’s elbow
- subluxation of radial head under annular l
- common in infants/ small children
- d/t pulling/ lifting of hand
- present with elbow pronated and painful
tx of nursemaid’s elbow
- pressure on radial head
- gentle supination while flexing elbow
galeazzi fx dislocation
- fx of distal radius
- dislocation of distal radioulnar joint
- usu in kids 9-12
- typically d/t foosh with flexed elbow
monteggia fx dislocation
- fx of ulnar shaft
- dislocation of radial head anteriorly
- usu secondary to foosh
tx for galeazzi and monteggia fx
- ORIF
developmental dysplasia of the hip (DDH)
- hip that is dislocated and irreversible
- hip that us dislocated and reducible
- dysplastic but within acetabulum (most common)
risk factors for DDH
- first born- smaller uterus
- females > males
- breech position in utero
- family hx of DDH or early hip replacement
possibly signs of DH
- toe walking, may be unilat
- limb length inequality
- waddling gait
- hyperlordosis (sway back)
- usually assess for DDH at newborn visits
barlow test
- used for DDH
- adduct hip with thumb and dislocate it
ortolani test
- used for DDH
- abduct hip to reduce it
galeazzi test
- used for DDH
- difference in knee height when knees are bent and feet are in the same position
tx of DDH
- pavlik harness
- abduction orthosis if pavlik harness fails
- closed reduction first surgical option
- open reduction if closed fails
- spica cast to hold hips after reduction
legg calve perthes (LCP)
- idiopathic osteonecrosis of capital femoral epiphysis
- vascular interruption into subchondral bone
who gets LCP
- ages 5-8
- more commonly boys
- usu the hyperactive boy who plays several sports, complains of vague hip pain
clinical presentation of LCP
- small for age
- delayed bone age
- very active or hyperactive, usu male
- nonspecific pain in ant hip, thigh, knee
- mild limp
- insidious onset, no trauma
stages of LCP
- necrosis
- fragmentation
- re-ossification
- remodeling
necrosis stage in LCP
- initial ischemia to femoral head
fragmentation stage of LCP
- re-absorption of bone with femoral head collapse
re-ossification stage of LCP
- new bone re-grows to reshape the femoral head
remodeling stage of LCP
- femoral head reshapes itself into spherical shape
PE findings for LCP
- limp
- limited ROM: abduction and internal rotation
- quad atrophy
- leg length inequality
dx of LCP
- AP pelvis and frog lateral
- early changes: smaller epiphysis, radiodense, crescent sign, mild flattening
- metaphyseal radiolucency
prognosis of LCP
- self healing 2-4 weeks
- not all pts end up with spherical head
- permanent femoral head deformity -> early OA
- poorer outcomes in pts > 8 y/o
tx of LCP
- reduced activities, NWB
- NSAIDs
- refer to pedi ortho for surgery within 2-3 weeks
- surgery= osteotomy
slipped capital femoral epiphysis (SCFE)
- slippage of epiphysis relative to femoral neck
- neck and shaft displace anteriorly, rotate externally
- head slips posteriorly
- most common disorder affecting adolescent hips
- males > females
- obesity major risk factors
when do SCFEs occur
- during periods of rapid growth
- 13 in males
- 12 in females
clinical presentation of SCFE
- may be bilat
- groin/ thigh pain most common
- can have knee pain in up to 25% of cases
- ext rotated gait or trandelenburg gait
- decreased hip motion
dx of SCFE
- AP hip and frog leg lateral
tx of SCFE
- immed referral to pedi ortho
- nonweight bearing
- percutaneous in situ fixation tx of choice
- stabilize epiphysis from further slippage
- promote closure of proximal femoral physis
prognosis of SCFE
- abnormal gait and ext rotated leg position are permanent
- outcome depends on severity of slippage and if stable/ unstable
transient synovitis of the hip
- most common cause of hip pain in kids
- self limited
- usu undetermined etiology
- occasionally follows URI
clinical features of transient hip synovitis
- rapid onset limping
- refusal to walk/ weight bear
- ROM limited by pain and spasms
- hip held in flexion
dx of transient hip synovitis
- dx of exclusion*
- +/- mild elevation of WBC, ESR, CRP
- AP pelvis and frog leg lateral usu normal
- may see joint space widening
- US to eval for effusion
- MUST exclude septic arthritis
when do you aspirate the hip to dx transient hip synovitis
- ESR > 20
- temp > 37.5 (99.5)
treatment of transient hip synovitis
- bed rest until sx improve
- gradual increase to activity
- NSAIDs
- resolution of sx and return to ROM are characteristic
what disorders are included in apophysitis
- osgood- schlatter’s
- severe’s disease
- occurs during periods of rapid grwoth
osgood- schlatter’s
- traction at insertion of patella tendon into tibial tubercle
- pain usu relieved by rest
- prominent tibial tubercle
- +/- swelling or redness
tx of osgood- schlatter’s
- rest
- ice
- NSAIDs
severe’s disease
- aka calcanea aphophysitis
- common cause of heel pain in kids
- repetitive stress on growth plate -> inflammation and pain
when does severe’s disease occur
- beginning of new sports season
- usu new cleats or footwear
clinical presentation of severe’s disease
- child with heel pain -> limp
- usu first noticed after sports
- then pain during and after sports
- then pain before sports
tx of severe’s disease
- RICE
- gel heel pads for mild
- d/c sports if mod- severe
- achilles stretches
- modify activity
- good prognosis if compliant, may require casting if not
genu varum
- aka bow legged
- normal in ages 0-2
- usu benign and resolves without intervention
- normal growth plate on xray
when is genu varum worrisome
- lateral thrust during gait
- short stature
- ligament laxity
- abnormal location of deformity
- apparent enlargement of elbow, wrist, knees, ankles
when are xrays indicated for genu varum
- asymmetric
- atypical age
- worsening deformity
blount’s disease
- pathologic genu varum deformity
- progressive
- unilat
- early walking, obesity, family hx
- lateral thrust during gait
- refer if genu varum > 2 y/o
ricketts
- can cause pathologic genu varum
- short stature
- enlargement of elbows, wrists, knees,hands
genu valgus
- aka knock knees
- symmetric valgus normal at age 3-5
- improves with growth
- normal growth plate on xrays
toe walking
- common in early walkers
- eval any child > 3 who still toe walks
- most likely habit/ idiopathic
- consider neuromusc disorder, achilles contracture, leg length discrepancies
tx for idiopathic toe walking
- improves spont with maturity and weight
- heel cord stretching
- serial casting
- surgical heel cord lengthening (rarely needed)
club foot
- congenital abnormality
- equinus, adductus, varus, medial rotation
- dx should prompt search for other musculoskel problems
tx of club foot
- surgery- heel cord lengthening
- and/or serial casting
- PT guided stretching daily
scoliosis
- lateral spinal curvature with cobb angle > 10 degrees
- most common peds back deformity
- not painful
causes of scoliosis
- idiopathic: most common, usu females, adolescent growth spurt
- congenital vertebral abnormalities
- neuromuscular disorders
PE findings for scoliosis
- one shoulder higher than the other
- larger space from arm to side of body
- uneven waist creases
- uneven hip levels
- look at pts back while standing erect and bending forward
dx of scoliosis
- full length scoli series
- asses pelvic obliquity and limb length discrepancy
- measure cobb angle
what is the risser classification
- used to grade skel abnormalities based on level of ossification of iliac crest apophysis
risser 0
- no ossification at center of iliac crest apophysis
risser 1
- apophysis < 25% of iliac crest
risser 2
- apophysis 25-50% of iliac crest
risser 3
- apophysis 50-75% of iliac crest
risser 4
- apophysis > 75% of iliac crest
risser 5
- complete ossification and fusion of iliac crest apophysis
treatment of scoliosis
- observe if curve < 25 degrees
- orthosis/ brace if curve 25-40 degrees
- operate if curve > 40 degrees or rapidly progressive curve
