Pediatric Ortho Flashcards
Evaluation of the Limping Child
- when is the normal “adult” gait developed
- antalgic v non-antalgic gait
Normal Gait
- should be developed in kids that are older than 7
more than 70% of limping is due to some sort of pain
Antalgic Gait
- a gait which attempts to avoid pain
- reduced weight bearing on 1 side; shortened stance phase relative to swing phase
Non-antalgic Gait
- a gait which has NO PAIN ; but “abnormal”
- toe walking
- circumduction
- steppage: drapping (cannot dorsiflex)
- trendelenburg: pelvic tilt
History Pearls
- include the nature of pain: morning, evening, nighttime pain
- systemic symptoms?
- join appearance? ROM, point tenderness, masses?
Child with a Limp
- specific tests on PE and Labs to obtain
PE testing
- FABER (patrick) : flexion, abduction external rotation =SI joint
- Pelvic Compression: SI joint
- Straigh leg raise: never compression
- FADIR: flexion, adduction, internal rotation = intraarticualr hip pathology
- Ober test: for ITband syndrome
- Trendelenburg Test: inability to maintain even hips on 1 leg standing: weakness of contralateral hip abductors
Lab Tesing
- malignancy: CBC, ESR,CRP
- inflammatory arthritis: ANA
- rash/tick: do lyme testing
- septic artitirs: joint aspiration and cultures
- osteomyleitis: prcalcitonin, cultures
Child with a Limp
when do you image?
Imaging : for those under 5 with a limp
no concern for infection, nonlocalized symptoms = bilateral xray
point tenderness, but no infection concern = xray of area
concern for infection, not localized = MRI with/without contrast of bilateral LE looking for edema or abcesses
concern for infection, localized to the hip = US of the hip/pelvis (with/without contrast)
concern for infection, symptoms in LE but not hip/pelvis = MRI with/without contrast
Child with a Limp
inflammation v infection
JIA v Leukemia
inflammation
- history sus for lyme arthritis
- recent URI
- history of conjunctivitis, gastroenteritis = think reactive arthritis
- AM stiffness better with moving = rheumatologic
Infection
- toxic looking, fever
- Kocher Criteria
- flexed and externally rotated hip:think Septic arthritis infants
- high ESR/CRP and WBC > 12,000
Leukemia
- diffuse abd. tenderess & organomeg.
- leukopenia, low/normal platelets
- blasts on smear
JIA
- Asymmetrical arthritis knees & ankles
- ANA +
- RF and HLA-B27
Septic Arthritis
Etiology
Bugs that can get there
symptoms: &specific postion of infants and kids
Etiology
- infection of the joint and synovial space
- from hematogenous seeding (most common)
- contiguous spread fro ajacent msteomyleitis
- direct innoculation: surgery, trauma, needle
Bugs
- Staph aureus is most commonly the bug
- neonates: GBS, gram negs (from mom)
- kids: strap aureus, groupA,kingella
- sexually active: gonrrhea!!! (not reative arthritis)
Symptoms
-joint pain, redness and swelling
- specific to hip: will be in a flexed, abducted and external rotation position (lease pressure within the joint capsule)
- infants: psudoparalysis and crying with diaper changes
- younger kids; refuse to bear weight
Septic Arthritis
Lab Workup & Imaging
differnitate from transient synovitis
management
- emperic
- neonates specifically
- immuncomp.
- gonorrhea coverage
Labs
- CBC, ESR, CRP
- procalcitonin
- synovial fluid analysis via aspiration: looking at WBC > 60,000 & 90% neutrophils ; glucose low to normal
- blood cultures/joint aspiration cultures
Imaging
- likely normal
- US: is needed for hip spetic arthritis because aspiration of the hip is tricky!!
Treatment
Emperic Coverage
- naficillin or oxacillin (mssa coverage) OR first gen. ceph.
- clinda or vanco. can be used if MRSA risk
super ill looking: vancoy in addition to whatever else youre using
Neonates (need to get to CSF because risk of meningitis)
- anti-staph (nafcillin, oxicillin)
AND
- ceftazidime, cefipime, AGT (to cover gram neg. enterics)
immunocomp.
- cover MRSA and Pseudomon.
Gonococcal
- cover staph and gonococcal until cultures back
Osteomyelitis
Etiology
How does it spread
- specific in infants
- specific in kids over 1
Etiology
- bone infection
- most commonly hematogenous spread
- open fractures
- iatrogeneic: after surgery
- direct extension from soft tissue infection
Spread in Infants
- rapidly spread to joints: the hip MC
- due to spread from the metaphysis throug epiphysis (epiphysis is always distal to the growth plate: smaller piece)
- penitrating vessesl cross the epiphysis
Spread in Children over 1
- infection spread into the diaphysis
- can spread to be spetic arthriris: once it spreads beyond joint capsule
Osteomyleitis
Bugs
MC overall
Neonates
NICU
under 2
older kiddso
those with hemoglobinopathies
puncture via sneaker
Bugs
- STAPH AUREUS IS THE MOST COMMON BUG OVERALL OF OSTEOMYLEITIS
neonates
- staph
- GBS
- e. coli
NICU & indwelling
- candidia
Under 2
- strep. penumo (not vax.)
older kids
- staph aureus
- group A strep
- H. flu
Hemoglonipathies
- salmonella
Puncture via sneaker
- pseudomonas
Osteomyleitis: Acute
Symptoms
labs & imaging
Symptoms
at location
- tender/painful
- red, swollern
- not using it
systemically
- fever
- irritable
- tired
Labs
- CBC, ESR, CRP
- procalcitonin
- needle aspiration of site & blood culutres
- TB test via blood for at risk
Imaging
- alwasy get xray first : rule out a fracture
- see : blurred soft-tissue planes and bone cahnges “periosteal elevation”
- gold standard for dx. : MRI to see the bone, soft tissue and the abcesses
Osteomyleitis: Acute
Treatment
- emepric
- newborn emperic
- dirty wound
- pseudomonas
Emperic Treatment : IV to PO over 4-6 weeks
- nafcillin/oxacillin +/- vanco./clinda (mrsa)
- cefazolin +/- vanco./clinda (mrsa)
surgically drain the abcess
Newborns - Emperic
- nafcillin/oxacillin AND cefotaxime/gentamycin (mrsa + gram neg.)
- e. coli found or GBS = cefotaxime Or gent Or ampucillin
- any other gram neg: cefotaxime AND gent or ampu.
Dirty wound: pip-taz AND AGT
Pseudomonas
- pip taz
- ceftazidime and AGT
Complications of acute osteomylesis
DVT
pathologic fractures
later on…
limb length discrepencies (because growth plate issues)
avscualr necrosis (hip)
Chronic Osteomyelitis
clinical manifestations
labs & imaging
Chronic: usually months of the infection
Clinically
- simialr to the acute; but more indolent, less obvious
- can see formations of sinus tracking
Labs & Imaging
- labs can be similar to acute, but often are normal
- imaging:
- XRAY: periosteal eleveation and lytic lesions
- MRI: see sinus tracking and abcesses
Chronic Osteomyleitis
treatment
Treatment
Surgical
- drain and debriedment
- somtimes removal of bone to isolate infection
emperic antibiotics: 3-6months
- cephalexin or dicolxacillin
- mrsa risk: clindamycine or linezolid
Transient Synovitis
etiology
symptoms
differentitate between this and septic art.
Etiology
- a benign and self limiting ; post viral infection
- usually after viral gastroenteritis
- commonly going to the hip, kids age 3-6
Symptoms
- abrupt onset unilateral hip pain
- nontoxic appearing, no systemic findings
- restricted hip movement; held in abducted external rot.
- full passive ROM
Transient SYnovitis
labs and imaging
treatment
Labs and Imaging
- ESR,CRP, CBC will be significantly lower than septic arthritis but this CANNOT be used to differentiate the two
- procal: negative (since viral)
- synovical fluid analysis will differentatite
Xray
- can show effusion but no bone changes
US
better for effusions
Treatment
- rest until pain resolves on its own
- NSAIDS for the pain
Developmental Dysplasia of the Hip
etiology and pathology
risk factors
Etiology
- the acetabulum is more shallow: so the femoral head doesnt sit nicely inside: slips out
- can dislocate, pop in and out (barlow/ortaloni) & sublux (partial disloc.)
- check at every well baby visit until 1year old
Risk Factors
- female, first born, breech
- fam. hx.
- oligohydroamniosis
Developmental Dysplasis of the HIp
symptoms
signs on PE
Symptoms
- younger infants usually asymptomatic (not walking yet)
- limited abduction of the hip, lateral posture if prone
- trendelenburg gait and waddling
PE findings
- limited abduction : < 45 degrees
- barlow and ortalani test: show instability
- barlow: flex, posterior pressure to pop out the hip
- ortaloni: ABDUCt hip with pressure to pop back in
- Galeazzi sign: the knees arent equal (disloacted lower)
- asymmetric leg creases
Developmental Dysplasis of the Hip
imaging
treatment
Imaging
asymptomatic screening: US of all breech infants older than 34 weeks
- + finding : warrent US under 6 months or xray for those over 6 months
Treatment
Pavlik Harness: for infants under 6 months
Surgical treatment
- joint reduction or reconstruction : after 6wk.-3mo. of harness
can abduct brace up to 2 years
ClubFood (talipes equinovarus)
etiology
causes
Etiology
- a congential deformit of the foot, often due to intrauterine postioning and decreased amniotic fluid
- often due to contraction of tendons; CANNOT BE PLACED into normal positioning
foot is
- plantarflexed
- adducted (varus of the heel)
- high arch
- adducted forefoot
Causes
- most are idopathic
- can be trisomy 18
- can be spina bifida
- or congenital constriction band syndrome
Treatment
- initally: manipulation and cating to straight over time
- afte 3-4 months if fialure: surgical correction needed
