Pediatric MSK Flashcards
what is the most common salter Harris fracture?
type 2 (75%)
Which SH fractures are ass w/ complications. What are they and mx?
- Type 3-Growth arrest. Require surgery
- Type 4: growth arrest, focal fusion. Require anatomic reduction (often sx)
- type 5-poor prognosis.
“bony bridge across physics”
type 5 SH
A physeal bar or partial premature physeal arrest is a result of injury or infection to an unfused physis. It consists of a bony bridge crossing the growth plate that results in growth disturbance and/or deformity.
These bars form when the cartilage barrier is breached as a result of infection or trauma, this abnormal connection of metaphysis and epiphysis can be fibrous or osseous.
physeal bar
early bony bridge crossing growth plate
-inf or trauma
how long for periosteal rxn to appear on xray?
7-10 d
toddler fx
oblique fracture; 9 mo-3 yr
-if spiral, question child abuse
Wimberger sign
destruction of medial portion proximal metaphysis of tibia ass w/ syphilis. Pathogmonic.
torch infections w/ osseous change
-rubella (50%, appears ~wks) & syphilis (95%, appears ~6-8 wks)
syphilis osseous change
95%
- app 6-8 wks
- metaphyseal lucent bands, periosteal rxn
- “wimberger sgx”-destruction of medial portion proximal tibial metaphysis
*Treponema pallidum
rubella osseous change
50%
- ~wks
- “celery stall”-generalized lucency of metaphysics
Caffey dx
aka infantile cortical hyperostosis
- ST swelling, periosteal rx, irritability ~6 mo’s life
- HOT MANDIBLE –> clavicle –> ulna
- self-limiting
Effects of PgE 1 & 2
periosteal rxn
-look for sternotomy wires
neonatal periosteal rxn
- cong rubella, syphilis
- caffey
- PgE 1 & 2
- NB mets
- physiologic (NOT newborns, ~3 mo)
- abuse
physiologic periostitis of newborn-rules
NOT newborns (~3mo’s)
- first involves femur THEN tibia
- always involves DIAPHYSIS
3 classic appearances LCH
- beveled edge (uneven destruction inner and out tables)
- ribs-mult lucent lesions, expanded appearance
- spine-pancake/vertebra plant
“septic tank”
crossing vess close and infection cannot escape
when does OM bony change appear?
day 10
Define:
-brachy-, poly-, syn-, camp-, clino-, arachnodactyly
- short
- too many
- fused
- contracture
- radially angulated (usually 5th)
- spider like
a-, mero-, acro-, meso-, rhizo-, micromelia
- limb absent
- mostly absent
- hands/feet (distal limbs) are short
- forearm/lower leg (middle limb) short
- femur/humerus (prox lims) short
- short all over
Dwarfism-subtypes to know
- achondroplasia=mc
- thanatophoric=mc lethal
- asphyxiating thoracic dystrophy (Jeune)-usually fatal
- ellis-van crevald
- pseudoachondroplasia
- pyknodysostosis
achondroplasia-moa, RF, classic findings
- mc skel dysplasia
- fibroblast GF rec problem. FGFR3–> abN cartilate formation. Affects bones formed by endochondra oss, not mesenchymal
- RF-advanced paternal age
- Symmetric shortening of all bones, rhizomelia=most prom.
- tomb stone iliac crest, narrowing interpedicular distance, trident hands (3rd/4th long fingers), rhizomelia, flat acetabula w/ short femoral necks
thanatophoric dysplasia
- mc lethal dwarfism
- rhizomelia-“telephone receiver”
- very short ribs w/ long thorax
- small/squared iliac bones
- cloverleaf skull
- flat vertebral bones (platyspondyly)
asphyxiating thoracic dystrophy (jeune)
- usually fatal
- “bell shaped thorax” w/ short ribs that are bulbous anterior
- high-riding handlebar clavicle
- trident acetabulum
- vs thenatophoric dysplasia: Jeune has normal vb’s
- chronic nephritis if survive
Gorlin syndrome
bifid ribs
falx calcifications
basal cell cancers
odontogenic keratocysts
cleidocranial dysostosis
- complete or partial absence of clavicles
- delayed ossification of the skull, worming bones
- widened pubic symph (seen later)
pyknodysostosis
osteoporosis + worming bones + acro-osteolysis
-“wide or obtuse angled mandible”
Acro-osteolysis (plural: acro-osteolyses) refers to resorption of the distal phalanx. The terminal tuft is most commonly affected. It is associated with a heterogeneous group of pathological entities and, some of which can be remembered by using the mnemonic PINCH FO.
“wide or obtuse angled mandible”
pyknodysostosis
klippel feil
congenital fusion of cervical spine, tall & skinny
- +sprengel deformity (high riding scap)
- omovertebral bone-big VB (fibrous, cartilaginous or by), superomedial angle of scap to SP, lam or TP (may be primary cause of limited ROM); present in 1/3
- short webbed neck & low ahirline
hunters/hurlers/morquio
- mucopolysaccharidoses
- oval shaped VBs w/ ant beak (Mid in Morquio, Inf in Hurlers)
- canoe-paddle clavicles, ribs (thick and narrowed more medially)
- tall, flared iliac wings
- classic: wide metacarpal bones w/ proximal tapering
- findings progress 1st yr of life
mc lysosomal storage dx
gauchers
gaucher img findings
SMG, HMG
- avn femoral heads
- h shaped vert
- bone infarct
- erlenmeyer flask shaped flasks
skull markings
- convolutional-pst gyral markings
- copper beaten-gyral markings associated with raised intracranial pressure in children.
- luckenschadel/lacunar (resolves in 6 mo)- dysplasia of the membranous skull vault and is associated with Chiari II malformations (seen in up to 80% of such cases). The inner table is more affected than the outer, with regions of apparent thinning (corresponding to unossified fibrous bone) of the skull vault. abnormal collagen development and ossification
wimburger’s sign
- scurvy
- small epiphysis sharply marginated by sclerotic rim with central portion more radiolucent
- decreased cartilage proliferation and unimpaired mineralization
NF 1
- -kypho/scoliosis, scalloped vertebra, hypoplastic pedicles/pst elements-dysplasia of vert bodies, meningocele formation or enlarging neurofibroma.
- enlarging NF can cause spindling and deform of TPs and adj rib if intercostal nerve is affected
- osseous mesodermal dysplasia
- anterior tibial bowing, pseudoarthrosis
- ribbon ribs
- sphenoid wing dysplasia
idiopathic scoliosis configuration
S shaped
CoArc rib change
- BL
- T4-T8
- inf aspect ribs
rib change s/p post thoracotomy s/p PDA ligation
IP side of AA
congenital lobar overinflation/hyperinflation/emphysema-moa
one way valve
MOA rickets bony change
- provisional zone of calcification not formed –> cartilage proliferation not inhibited –> physis quite wide.
- never present at birth (mom’s vitD still doing its thing)
moa leukemia bone change
bone pain –> decreased weight bearing–> demineralization prox metaph just beyond zone of Ca, provisional zone persists but may be thinned
spinning top urethra
urethra dilated to size > bladder neck (should be about the same)
- detrusor sphincter dysinergy
- bladder instability-detrusor contrast and pt vol close ext sphincter
- vesicourinary reflux (bc of relative BOO)
- mx: biofeedback mechs
- vaginal reflux = mimic
MCC anterior wall “mass”
bifid rib-usually 1 (4th), if multiple think Gorlin
Gorlin syndrome
- bifid ribs (1+)
- Falx Ca
- BCC
- odontogenic keratocysts
OI relationship btw tib/fib
fib longer
OI mc subtype
infantile
Osteopetrosis MOA
- diminished OC act
- bone in bone of VB or carpals
- picture frame
- diffuse sclerosis, loss of CM diff
pyknodysostosis
osteopetrosis + worming bones + acro-osteolysis
-wide/obtuse angled mandible
klippel feil
- fused cervical spine, VBs tall and skinny
- sprengel defomoty
- omovertebral bone
MCC death mucopolysaccharidosis
C2 myelopathy
scoliosis causes
- idiopathic (girls), S shaped
- vertebral anomolies
- NF
radial dysplasia causes
- VACTERL
- Hold-oram
- Franconi Anemia
- Thrombocytopenia Absent Radius (TAR)-have a thumb
Hand foot syndrome-who/where/img
- SCD
- foot/hand ischemia –> dacylitis (swelling, pain)
- self resolving
- rgx: periostitis 2 wks after pain goes away
blounts-aka, patho, who, types, management, angle on plain film
- tibia vara
- prox tibia medial metaphysis downward slope –> disease progress depressed –> osseous outgrowth with epiph/metaph fusion
- BL and Bimodal (<2yo, >12 yo)
- infantile vs adolescent-infantile no syx. Adolescent UL & medial
- can brace but by adol yrs it doesn’t work
- metadiaphyseal angle of drennan: beasure btw medial and lat peaks (>11 degrees = blount)
foot vocab: talipes
congenital
foot vocab: pes
foot, acquired
foot vocab: equines vs calcaneus
- tibiocalcaneal angle. *calcaneus normally dorsiflexed
- equines- plantar flexed ankle: heel cord often tight, heel doesn’t touch floor. CT angle >90
- calcaneus- exaggerated DF; calcaneus angle up
foot vocab: varus vs valgus
forefoot in vs out
foot vocab: cavus vs planus
- cavus- high arch
- planus- flat foot
foot vocab: supination vs pronation
sole in vs sole out
hindfoot valgus vs varus
- AP talocalcaneal angle. Midtalar line passes through base of 1st MT and midcalcaneal line through base of 4th MT on AP view
- varus: talus outward, lat to 1st MT and angled down
- valgus: talus inward, medial to 1st MT and angled up/parallel to C
flat foot/pes planus subtypes
- defined by hindfoot valgus
1) adult
2) congenital-flexible or rigid
a) flexible (improves w/ stress on plantar flexion view)
b) rigid- i) tarsal coalitions & ii) vertical talus
tarsal coalitions
- talocalcaneus
- calcaneonavicular
talocalcaneus findings
-C shaped
-absent middle facet
talar beak (spur on ant talus, 25%)
calcaneonavicular
anteater (blood thirst. nose of ant eater)= elongated ant process of calcaneus
vertical talus (equines hindfoot valgus) (rocker bottom)-app, ass
- talus in extreme plantar flexion w/ dorsal dislocation of navicular –> talus locked in plantar flexion
- ass w/ myelomeningocele
clubfoot (talipes equino varus/congenital plantar flexed ankle forefoot)
- Boys, BL (50%)
- toes down (equines)
- hindfoot varus-talocalcaneal angle decr/acute
- elevated plantar arch
- dysplasia of ankle: tibial & fibula shortening, talus equinus (ext rotated, can be palp), navicular medially subluxed over talus, cuboid med subluxed over calc, forefoot adducted and supinated.
- leg m atrophy, esp peroneals-never grew to bg with
- contracted PTT, FDL, FHL
MC complication club foot surgical correction
-overcorrection –> rocker bottom foot
-DDH-who, BL, BWs
- female, breech, oligohydramnios
- BL 1/3
- “asymm skin/gluteal folds”, “leg length discrepancy”, “palpable clunk”, “delayed ambulation”
DDH alpha and b angles, acetabular angle
alpha <60
beta >60
<50% acetabular coverage
-acetabular angle: >30˚
Hilgenreiner’s, Perkin’s, Shenton’s, and Klein’s Line. Acetabular angle
- H=line drawn horizontally through the inferior aspect of both triradiate cartilages.
- P= line drawn perpendicular to Hilgenreiner line, intersecting the lateral most aspect of the acetabular roof.
- S=imaginary curved line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur.
- broken in ddh
- K= lateral edge femoral neck –> lateral superior femoral epiphysis
- acetabular angle: The angle is formed by Hilgenreiner line and Perkins. Should be 30–> 22˚ by 1 yo. Decrease with age as things solidify
Normal femoral head location in relation to Hilgenreiner’s and Perkin’s lines
inf to H and med to P
significance of acetabular angle >30˚
- DDH
- NM disorder
proximal focal femoral deficiency
absent/hypoplastic proximal femur + varus deformity
- DDH mimic but DDH has normal prox femur!
- tends to involve the intertrochanteric femur
- may be bilateral
slipped capital femoral epiphysis-fx type, what makes it unique, who, bilaterally, next step?
- Type I SH that must be fixed
- fat AA adolescent
- BL 1/3
- frog leg
Legg-calve-perthes-what, who, bilaterally, next step, findings
- 5-8 yr old Caucasian, B>G
- BL 10% (20-25?%)
- frog leg, MRI more sens
- Klein line messed up, subchondral lucency, flat collapsed FH
how will hip joint effusion present?
lateral displacement of FH
what radiographic test excludes int effusion?
Air arthrogram sign
transient synovitis cause, peak age, mx
- viral (URI, GI)
- peak age 5
- self resolving
Kocher Criteria
fever, inability or walk, ESR/CRP +, WBC >12
- 3/4+ = SA
- CRP most imp
septic hip test progression
- xray-medial hip widening, lat displacement FH
- US-effusion
- Kocher criteria+ –> aspiration
- MRI only if hip aspiration can’t/hasn’t been performed
rickets bony change
- metaphyseal fraying/cupping
- rachitic rosa-expansion ANT rib at costochondral junction
hypophosphatasia
rickets in new born-frayed metaph/bowed long bones
- hypo ALP
- adult form more mild
scurvy
- wimberger’s sign
- spurs
- hemarthrosis
- scorbutic rosary- costochondral expansion (like rickets)
- never before 6 mo
Lucent metaphyseal bands=LINE
leukemia
Infection (torch)
NB met
Endocrine-rickets/scurvy
lead poisoning vs normal variant
lead poisoning does not spare fibular
dating fractures, exceptions
- periosteal reaction-<1 wk
- complete healing ~12wks
- exceptions: metaphyseal, skull, costochondral junction fx heal w/o periosteal rxn
flat foot (pes planus)
-hindfoot valgus
intramembranous ossification
mesenchyme –> bone
-skull/facial, mandible, central clavicle
enchondral ossification
cartilage –> bone
-skull base, spine, pelvis, extremities
tubulation
remodeling long bone shaft into normal configuration
overtubulation
- cylindrical portion of shaft is too long with short and narrowed metaphysis
- “gracile”
- MC: NM d.o. via decr weight bearing, ex: cerebral palsy
- ex: absent weight bearing, neuromuscular conditions, OI, JVA, Marfan, Homocystinuria, athrogryposis
undertubulation
cylindrical portion of shaft too short, wide and long metasphysis.
- short squat bones
- -Via decr osteoclast act.
- ex: OPet, FD, rickets, mulstiple osteochondromas, dwarfism, storage dx (gaucher’s)
zones of physis
- resting- adj to epiph, small clusters cartilage cells
- proliferative- cart cells div and enlarge
- maturation zone- enlarge
- hypertrophic zone-provisional Ca
- degenerative-degen, death of cart cells
- osteogenic-lateral margin physis, occasional Ca (small zpicule of bone ext distally from metaph)
growth recovery/parke/harris lines
-when, where
stress
- par to physes
- femur > tib (fmur faster growth)
causes of scoliosis
idiopathic (75%) leg-length discrepancy congenital NM d.o NF conn tissue d.o trauma tumors radiation rx
angle used to measure scoliosis
cobb angle
juvenile kyphosis
> 40 degrees from T3-T4
Scheurmann’s disease
thoracic kyphosis w/ vertebral body wedging, diskspace narrowing, pain and endplate irreg
harness for ddh
pavlik harness-hips held in flexion, mild abduction, mild external rotation
coxa vara
- congenital vs infantile vs acquired
- congenital= limb bud insult 1st TM, doesn’t worsen
- infantile- worsens, BL, sx
- acquired-trauma, SCFE, metabolic, tumors, skel dysplasia, FD, pagets
coxa valga
decr tone of m’s that cross hip –> decr ambulation
-NM d.o (cerebral palsy)
primary protrusio of acetabulum (otto pelvis)-line of reference
lateral margin pelvic inlet & obturator foramen
discoid meniscus
- abN growth of meniscus (circular shape rather than crescent)
- prev normal contact of articular surfs within knee
- high incidence of tear
- too many bow ties on sag view
rx: arthroscopic sculping, wrisberg, etc
madelung deformity
short radius, severe shortening medially, lateral bowing, dorsal sublucation of distal ulna
- elongated triangular fibrocartilage on mr
- vickers ligment-distal radius to lunate lig creation
congenital dislocation of radial heads
- abN growth of radial head and capitellum
- radial head dislocated
sprengel’s deformity
- sporadic
- scapula-cervical appendage ribs 4-6 that form wk 5 gestation
- MC ass = klippel feil
tibial bowing causes
1) NF 1
2) foot deformities
3) physiologic bowing
4) hypophosphatasia
5) rickets
6) blunts
7) OI
8) dwarfs
NF-1 tibial bowing dir, ass findings
anterolateral +/- hypopastic fibular w/ pseudoarthosis
tibial bowing w/ foot deformities-dif
pst
physiologic tibial bowing
- lateral
- BL
- 18mo-2 yr
hypophosphatasia tibial bowing/”rickets in a newborn”
lateral
rickets tibial bowing-dir, ass findings, where
- lateral
- fraying of metaph, widening of GP
- fast growing bones-knee, wrist
Blount tibial bowing
- asymm tibial vara
- early walking, fat, black
- prox tibia pstmed physical growth disturbance –> deformit
osteogenesis imperfecta-tibial bowing
involves all long bones
dwarfs tibial bowing
short limbs
