Pediatric Big Ten - Injuries

Question 1

What is developmental hip dysplasia?

Answer 1

Happens in infants - can range from a totally dislocated hip to slightly subluxable joints or just a slightly abnormal socket

Question 2

What are some risk factors for developing hip dysplasia?

Answer 2

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

Question 3

Why has dysplasia historically been more common in native american populations?

Answer 3

they use swaddling more often, which leads to hip dysplasia

Question 4

What two maneuvers do you do to diagnose hip dysplasia in an infant?

Answer 4

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)

Question 5

Late diagnosis of hip dysplasia will eventually be made with what two tests?

Answer 5

look for limited abduction of the leg

Galeazzi sign - apparent leg length discrepancy

Question 6

THe difficult of reducing a dysplastic hip ____ with age.

Answer 6

increases

they have tighter adductor and liiopsoas muscles and other intraarticular obstacles develop like capsular construction ligamentum teres and labrum

Question 7

What imaging is best for hip dysplasia?

Answer 7

ultrasound (but its only as good as your technician)

x-ray after 4-8 months

Question 8

What is the treatment for hip dysplasia in a kiddo less than 6 months?

Answer 8

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

Question 9

What is the treatment for hip dysplasis in a kid months to 2 years?

Answer 9

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

Question 10

What is the treatment for hi dysplasia in a kid older than 2?

Answer 10

open reduction, usually with femoral shortening and acetabular procedure

Question 11

When should you refer if you’re concerned about hip dysplasia?

Answer 11

with an abnormal exam, abnormal ultrasound, or abnormal x-ray

Question 12

What is Perthes Disease?

Answer 12

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

Question 13

Who is at greatest risk for Perthes Disease?

Answer 13

grade school-aged boys with a positive family history

they usually have delayed bone age and are shorter

Question 14

How do kids with Perthes disease usually present?

Answer 14

present with an insidious limb and mild to moderate pain in the hip, thigh or knee

Question 15

What is the treatment for Perthes disease?

Answer 15

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

Question 16

What hip disorder can develop in adolescence? Usually in overweight males….

Answer 16

slipped capital femoral epiphysis

Question 17

WHat happens in slipped capital femoral epiphysis syndrome?

Answer 17

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

Question 18

What will a patient with slipped capital femoral epithpysis syndrome?

Answer 18

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

Question 19

What is the difference between stable slipped capital femoral epiphysis and unstable slipped cpaital femoral epiphysis?

Answer 19

stable you can still walk on

unstable is too painful to walk

Question 20

What is the treatment for slipped capital femoral epiphysis?

Answer 20

in situ fixation

osteotomy for deformity

you put a pin thorugh the growth plate so that it won’t continue to grow

Question 21

In what situations would you prophylactically pin the hip that isn’t affected in slipped capital femoral epiphysis/

Answer 21

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

Question 22

What is the difference between static and dynamic intoeing/outtoeing?

Answer 22

static happens at rest, dynamic is only with walking

Question 23

How does one do a static exam for intoeing/outtoeing?

Answer 23

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

Question 24

Describe increased femoral anteversion

Answer 24

it’s an increased medial hip rotation- they will intoe

more common in girls

will increase until age 10 and then normalizes

Question 25

Describe internal tibial torsion

Answer 25

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

Question 26

How do you test the dynamic omponent of intoeing/outtoeing?

Answer 26

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

Question 27

What is genu varum?

Answer 27

bowed legs

Question 28

Describe physiologic bowing

Answer 28

usually bilateral leg bowing seen in young toddlers - usually in early and agile walkers

Question 29

Where is the bowing distributed in physiologic bowing?

Answer 29

usually between the femur and the tibia - so over the knee

Question 30

What is the treatment for physiologic bowing?

Answer 30

spontaneous correction is the rule - it will fix itself in almost every case

bracing is not effective

Question 31

Although physical bowing normalizes, what are some thing syou need to rule on on DD?

Answer 31

Blounts DIsease

skeletal dysplasia

neoplasm

metabolic bone disease like rickets (nutritional or hypophosphatemic)

Question 32

What happens in Blounts dissease?

Answer 32

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

Question 33

What is the treatment for Blounts disease?

Answer 33

les than 2 years old: brace treatment

over 2: valgus proximal tibial osteotomy with pinning

Question 34

When should you refer someone with bow legs?

Answer 34

if the height is less than the 5%ile

positive family history

assymetry

progressive

localized varus deformity

Question 35

WHat is genu valgum?

Answer 35

valGUM (knees stick together)

knock-knees

Question 36

Genu valgum usually resolves by about age 7

if it doesn’t, what will happen to the patella?

Answer 36

patellar subluxation can be associated with it

Question 37

What is metatarsus adductus?

Answer 37

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

Question 38

What is the lay term for talipes equinovarus?

Answer 38

clubfoot

Question 39

What happens in talipes equinovarus?

Answer 39

forefoot aductus and hindfoot equinus

shortening of the foot and atrophy of the calf

Question 40

What is the treatment for clubfoot?

Answer 40

serial casts after birth

should be seen each week

bracing will be needed to prevent recurrence

usually requirs percutaneous achilles tenotomy too