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
Congenital Muscular Torticollis
cuases
symptoms
Causes
- injury to teh SCM during birth
- cerival vertebral abnormalities
Symptoms
- the chin is rotated to the opposite side of teh affected muscle: head tilted towards contracture
- a “mass” in the SCM can be felt: fiberous stissue
Diagnosis
- cervical xray
Treatment
- gentle stretching and PT
- do not need to remove mass
COmplications if not fixed
- asymmetricla face
- plagiocephaly: due to postioning of head
- vision issues
Acquired Torticollis
causes (life threatening and common)
Causes
remember, this is acquired therefore not just infants!!
Life Threatening Causes
- retropharygeal abcess
- jugualr thrombophelbitisis
- c-spine injury
- spinal hematoma
- CNS tumor
- leukemia
Common Casues
- muscel injury
- ENT infection
- atlanot-occipital sublux (JIA and Trisom21)
MAnagement
- treat underlying causes
- MSK realted: NSAIDS (diazepam if not helping)
Subluxation of the Radial Head (Nursemaids Elbow)
Etiology
PE findings
Imaging
Etiology
- usually taller person forcefully pulls (or they fall/twist)
- causes the radius to pull through the annular ligament and sublux
- results in : sudden pain/loss of function
PE findings
- arm held in slightly flexed and pronated postion
- refused to move
- tender with pronate/supnate
Imaging
- XRAY : often when they move into position: it goes back into place
- can see sublux. and rule out other injuries
- often history and PE so good the xray is not needed
Subluxation of the Radial Head (Nursemaids Elbow)
reduction techniques
how to tell if they worked
Reduction
- supnate & flex to reduce
- hyperpronate to reduce
Eval after reduction
-if they can Reach overhead = they’re good
- unsuccessful, can reduce again and get ortho
Throwing Injuries: little leaguars elbow
etiology
imaging
Etiology
- traction of the apophysitis of the medial epicondyle
- due to repeated throwing
- joint will lock or cathc: because fragemetns of split bone have splintered the joint space
- chronic pain at elbow
Imaging
- Xray: rule out stress fracture & see osteochondritis dissecans
Treatment
- Rest for 3-6 weeks: no throwing
- PT for mobilization after
- limit amount of pitching !
Colle’s Fracture
Colle’s Fracture
- FOOSH injury: distal radius fractures with the displaced protion (closer to the hand) displaced upwards (dorally toward back of hand)
treatment
- sugar tong cast/splint
Slipped Captial Femoral Epiphysis
etiology
Etiology
- displaced of the femoral head through the physis (growth plate): sudden or gradual (head through the palte)
- considered a Salter-Harris 1: through the physis
- happens during teenage years: growth spurts
Risk Factors
- male
- obese
- AA
- atheltics involvment
- endocrine disorders
Symptoms
- pain worsened with activity
- pain: located in the anterior proximal thigh/hip
- rarely, to knee and ankle
PE
- lost internal rotation is the most sensitive and specific
- reduced abduction and extension
- gait : abnormal ex. rot. of the hip and limb length issue
SKIFFY
diagnosis & Imaging
treatment
Diagnosis
- Frog-Legged View XRAY
- mild : < 30degree angle
- moderate 30-50 degree
- severe 50+ degree
Findings on XRAY
- doube density at metaphasis (slips off the top and malaligned in back)
- widened physis
- decreased epiphsyeal height
Klines Lines
- when drawing a line from femoral neck to the hip, should have some overlap over the epiphysis
- if the line does not cross over the epiphysis,slipped cap
Treatment
- NON WEIGHT BEARING untile surgery
- risks if not: ostenoencrosis, chdrolysis premature growth plate closure
- treatment: surgical stabilization and reduction with screws
Legg Calve Perthes Disase
etiology
Etiology
- idopathic osteonecrosis (avscualr necrosis) of the femoral head
- males, white
Symptoms
- painful limp, worse in the evening and after activity
- pain can be anywhere in the thigh, groin or knee
PE
- restricted hip motion: cannot ABDUCT or INTERNAL ROTATE
Diagnosis
- XRAY: AP and frog leg
- increased density of femoral head
- femoral head flattened
Treatment
- refer to ortho: bedrest and traction
- observe if low risk
- older kids = increased risk of dislocation, may need stabilization
Intoeing
what is it
causes
What
- a pigeon toeing: foot turns inward more thant expected during walking
- by age2: kids usually have some outtoesing
Causes
- femoral antiversion: femur internally rotating
- tibial torsion: inward twisintg
- foot deformitiy
- neuromsuc. dz.
PE
- ortho exam & eval for neuromsucle. issues
- assess tone, giat, clonus and motor milestones
femoral Anteversion
PE
- excessive internal rotation of the hip with limitied ability to externally rotate
kids
- will sit in a W position instead of criss-cross applesauce
- “kissing knees”
management
- most cases you can observe: will resolve
- discourage the W position
- refer to orther if its still there at age 7, or have difficulting waling/running
tibial torsion
results in intoeing
- inward turning of the tibia can be normal in infancy
- but commonyl as child grows, teh tiba will externally rotate
Measure thigh foot angle
- a neutral or internal angle signifies tibial torsion
managment
- corrects self at age 6
- surgeury delayed until 8-10
Outtoeing
examine the same as the intoeing
hip rotation: excessive external rotation can create this ; with limitied ability to internally rotate
- risk for SCFE
the thigh foot anlge will be more than 30 degrees
Normal growth and developemn of hte LE
genu varum
as a baby - genu varum (knees bowed out)
then by the age 3-4 =straightened up
Genu Varum
- bow legged: the tibia is adducted in comaprison to the femur
Causes
- rickettes
- dwarfism
- ostegen. imperfecta
- osteochrondritis
- neuromusc
- blount disease
- trauma
Workup
- measure height (if under 25th% = xray)
- measure ankle to knee distance
- measure degree of angulation with goniometer
Treatment
- refer to ortho
- < 36 months = brace
- older - ostotomy
Genu Valgum
Valgum: “knock knee”
- tibia is laterally displaced from femur
- assocaited with over pronation of the ankle
- overweight kids
causes
- ricketts
- renal osetodystrophy
- skeletak dysplasia
- unilateral: trauma, infection, tumor
Work up
- measure height
- measure tibiofemoral angle
- measure intermalleolar distance
treatment
- refer to orther if short or older thatn 3-4
- observe, often they resolve
Osgood Schlatter Disease
etiology
symptoms
diagnosis
Treatment
Etiology
- an overuse injury: in a growing child
- pain at the tibial tuberosity: due to “pulling” of the apophysis
- seen in : those at peak growth spirtis, sports related (run/jump)
Clinical Manifestation
- pain exacerbated by running, jumping or prolonged flexion of the knee
- TTP and swelling over tibial tuberosity
Xray
- not necessary but if its unilateral pain: can help to r/o tumor
Treatment
- ice, NSAIDS & rest
- taping/bracing
Sever Disease
Sever Etiology
- traction apophysitis at the calcaneous
risks
- athletes
- adolecents
symptoms
- pain at the achilles tendon
Xray
- diagnosis to see widened physis
Treatmnet
- rest ice nsaids
Scoliosis
etiology
causes
symptoms
Etiology
- a lateral curvature of the spine over 10 degrees
- thoracic, lumbar or both
- rotation of the vertebrae elicts this
- females > men
- adolscent is most common
- universial screening no longer recmmneded
Causes
- idopathic
- congential
- neuromusc.
- vertebral disease
- spinal cord tumor
- connective tissue issue
Symptoms
- asymptomatic: in general is does not cause pain
- pain = work up for tumor/infection
- can create respiratory symtoms if sever enough thoracic
Diagnosis
- 10+ degree curve
- ADAMS test : bend and look
Scoliosis
Diagnosis: adolescent idopathic
Diagnosis
- dx. of exclusion
- abnormal cutaneous fnidings
- asymmetry of illiac crest and scaular spine
- waist line asymmetry
- assess feet for asymmetry
- neruo exam
Xray: scoliosis survery: gets cervical, thoracic, lumbar spine and pelvis: measures Cobb Angle
mri/ct if neuro issue
Treatment
- depedns on degrees of curve
- mild/mod = observation
- bracing for moderate or progression curves
- curve beyon 50 in thoracic or 40-45 in thoracolumbar = posterior fusion
Growing Pains
benign noctural limb pain of kids
etiology
etiology
- cramping pains of thighs, shins and cafts that feel muscalr in nature
- assocaited with growth
Presentation
- pain in evenin or nighttime can awake them from sleep
- disappears in the morning
- no systemic sx. or limp
disgnosis
no tests needed
treatment
reassurace
Growth Plate Fracture Classificaitons
Salter Harris
Salter Harris: SALTR
Type 1 = “slipped”
- through the physis
- xray: widened physis or displaced epiphysis
type 2 = “above”
- above the physis: distal to the physis, away from the joint
- includes the metaphysis
- most common
Type 3 = “lower”
- invovles the epiphyssi: closer to the joint
- considered an intraarticualr fracutre
- risk of growth issues and altereed joint here
Type 4: “through”
- includes the epiphysis, pysis and metaphysis
- articualr cartilage impacted too
- impacts joint mechanics
Type 5 = “Rammed”
- crush/compression of the growht plate
- electrical shock injuries or frostbite/radiation
- worst prognosis
Greenstick Fracture
Torus Fracture
toddlets fracture
a fracutre of the diaphysis : bone is bendy so it just like bends a little
Torus Fx.
- buckle fracture : incomplete: creating a “bludge” of the bone cortex
- due to axial loading
toddelrs fracture
- Spiral fracture of the tibia
Juvenile Idopathic arthritis
etiology
Etiology
- uncommon group of syndromes: all are chronic artritis
- under 16, 1+ join arthritis for 6+ weeks & all other diseases excluded
JIA
oligoarthritis
Oligo
- less than 5 joints
- persistant oligo = 1-4 joints befor dx. and no more during disease
- extended olio = under 5 during first 6 months; added more than 4 during
cannot be RF+, or have first degree relative with psoriasis or enthesis related arthritis
RF postive/negative polyarthritis JIA
arthritis in 5+ joints
either RF+ or RF-
Systemic arthritis JIA
most severe
- arthritis in 1+ joints
- fever 2+ weeks daily for at least 3 days
at least 1+ of
- erythematous rash
- hepatomegaly
- splenomegaly
- lymph enlargement
- serositis (pericarditis)
Psoriatric arthritis JIA
child with psoriasis and arthritis OR
child with arthritis and
- psoriasis in 1st degree relative
- dactalysisi
- fingernail ab. (pitting or oncy)
cannot be RF+ or have enthestitis realted
Enthesistis-related arthritis
undifferentiated arthritis
Enthesistis related
- those with enthesitis and arthritis, or just enthesitsi or enthesitis with
- SI joint or lumbosacral pain
- HLAb27
- first degree relative with uveitis
- acute anterior uveitis
- arthritis in males > 6 years old
undiff.
- doesnt fit in a categorty or has mixed features
JIA overall how to treat
JIA
- needs to be treated: left untreated results in disability, growth issues, blindness
treatment
MTX in all subtypes is first line
poor response = dmards biologics
