Pediatric Big Ten - Injuries Flashcards
What is developmental hip dysplasia?
Happens in infants - can range from a totally dislocated hip to slightly subluxable joints or just a slightly abnormal socket
What are some risk factors for developing hip dysplasia?
breech presentation - and thus first borns
torticollis (short neck)
metatarsus adductus (foot deformity)
oligohydramnios
usually the left hip
happens in girls 80% of the time
Why has dysplasia historically been more common in native american populations?
they use swaddling more often, which leads to hip dysplasia
What two maneuvers do you do to diagnose hip dysplasia in an infant?
the Barlow and Ortolani
Barlow is the dislocation (can you feel it pop out)
Ortolani is the reduction (can you feel it click back in)
Late diagnosis of hip dysplasia will eventually be made with what two tests?
look for limited abduction of the leg
Galeazzi sign - apparent leg length discrepancy
THe difficult of reducing a dysplastic hip ____ with age.
increases
they have tighter adductor and liiopsoas muscles and other intraarticular obstacles develop like capsular construction ligamentum teres and labrum
What imaging is best for hip dysplasia?
ultrasound (but its only as good as your technician)
x-ray after 4-8 months
What is the treatment for hip dysplasia in a kiddo less than 6 months?
the Pavlik harness
super successful
full time 6-12 weeks on average
However, if the parents take it off and then put it back on when the hip is unreduced, it will make later treatment more difficult
What is the treatment for hip dysplasis in a kid months to 2 years?
closed reduction of the hip using arthrogram to be sure, followed by Spica casting
only use open reduction if closed fails and you continue to get persistent subluxation
What is the treatment for hi dysplasia in a kid older than 2?
open reduction, usually with femoral shortening and acetabular procedure
When should you refer if you’re concerned about hip dysplasia?
with an abnormal exam, abnormal ultrasound, or abnormal x-ray
What is Perthes Disease?
It’s a temporary vascular insult to the epiphysis- we’re not sure what causes it
the femoral head loses blood supply and it gets soft and can fragment to the point where it gets flat within the acetabulum
Who is at greatest risk for Perthes Disease?
grade school-aged boys with a positive family history
they usually have delayed bone age and are shorter
How do kids with Perthes disease usually present?
present with an insidious limb and mild to moderate pain in the hip, thigh or knee
What is the treatment for Perthes disease?
you can’t really stop it once it starts, but…
rest, NSAIDS for pain, physical therapy, casting
bracing doesn’t work actually
goal is to contain the femoral head within the acetabulum so that it won’t fragment so much and may stay as round as possible.
the petri cast is placed so that the hips are abducted and inwardly rotated so that the head stays in the acetabulum
What hip disorder can develop in adolescence? Usually in overweight males….
slipped capital femoral epiphysis
WHat happens in slipped capital femoral epiphysis syndrome?
it’s a mechanical problem where the growth plate slips a bit
can be related to renal osteodystrophy, radiation therapy, or hypothyroidism or GH deficiency
What will a patient with slipped capital femoral epithpysis syndrome?
THey’ll have pain in the thigh or knee
importantly, they’ll have a limp with externally rotated gait
on exam they’ll have limited internal rotation and flexion
What is the difference between stable slipped capital femoral epiphysis and unstable slipped cpaital femoral epiphysis?
stable you can still walk on
unstable is too painful to walk
What is the treatment for slipped capital femoral epiphysis?
in situ fixation
osteotomy for deformity
you put a pin thorugh the growth plate so that it won’t continue to grow
In what situations would you prophylactically pin the hip that isn’t affected in slipped capital femoral epiphysis/
if it’s a high risk patient
those with hypothryodisim, renal osteodystrophy, or endocrinopathis
of if they’re younger than 10 years old because otherwise they’ll grow lopsided
What is the difference between static and dynamic intoeing/outtoeing?
static happens at rest, dynamic is only with walking
How does one do a static exam for intoeing/outtoeing?
have the patient lay prone
plex the knee and look where the foot goes relative to the thigh.
If it is outward, it’s actually an internal rotation
if it’s inward, it’s an external rotation
Describe increased femoral anteversion
it’s an increased medial hip rotation- they will intoe
more common in girls
will increase until age 10 and then normalizes
Describe internal tibial torsion
it’s internal rotation of the tibia
this causes intoeing as well
it usually normalizes on its own but isn’t even that big of an issue if it doesn’t
How do you test the dynamic omponent of intoeing/outtoeing?
watch them walk and compre their foot angle to a straight line they walk on. measure the angulation
called the line or progression
note that more people externally rotate by about 15 degrees
What is genu varum?
bowed legs
Describe physiologic bowing
usually bilateral leg bowing seen in young toddlers - usually in early and agile walkers
Where is the bowing distributed in physiologic bowing?
usually between the femur and the tibia - so over the knee
What is the treatment for physiologic bowing?
spontaneous correction is the rule - it will fix itself in almost every case
bracing is not effective
Although physical bowing normalizes, what are some thing syou need to rule on on DD?
Blounts DIsease
skeletal dysplasia
neoplasm
metabolic bone disease like rickets (nutritional or hypophosphatemic)
What happens in Blounts dissease?
it’s an osteochondrosis defomity of the proximal medial tibia epiphysis
you get progressive fragmentaion of the medial tibial plateau and eventually physeal bar formation
It will NOT get better
different than physiologic bowing because the femur is straight but the tibia is bent - more focal
What is the treatment for Blounts disease?
les than 2 years old: brace treatment
over 2: valgus proximal tibial osteotomy with pinning
When should you refer someone with bow legs?
if the height is less than the 5%ile
positive family history
assymetry
progressive
localized varus deformity
WHat is genu valgum?
valGUM (knees stick together)
knock-knees
Genu valgum usually resolves by about age 7
if it doesn’t, what will happen to the patella?
patellar subluxation can be associated with it
What is metatarsus adductus?
medial deviation of the forefoot on the hind foot
there will be a medial crease and the forefot will be slightly supinated
they’ll have full dorsiflexion
What is the lay term for talipes equinovarus?
clubfoot
What happens in talipes equinovarus?
forefoot aductus and hindfoot equinus
shortening of the foot and atrophy of the calf
What is the treatment for clubfoot?
serial casts after birth
should be seen each week
bracing will be needed to prevent recurrence
usually requirs percutaneous achilles tenotomy too
