Pediatric Ortho Flashcards
Pediatric Orthopedic Conditions
Torticollis Scoliosis Nursemaid’s elbow Transient Synovitis Little league elbow Club Foot Rotational/Angular deformities of the legs Legg-Calves-Perthes Disease SCFE Developmental dysplasia of hip Osgood Schlatter’s Disease Sever’s disease Osteogenesis Imperfecta
Torticollis
contraction or contracture of the muscles of the neck that occurs and causes the head to be tilted to one side
Rotation of the chin to the opposite side of the contraction
>80% are congenital in nature the rest is trauma/disease
Congenital Torticollis
More common following breech deliveries
Can be associated w/ hip dysplasia and clubfoot
Unilateral contracture of SCM muscle
Fibrosis of SCM occurs w/ a resultant palpable “mass” in the SCM muscle
Mass resolves w/in a few weeks after birth, but it results in a shortened and contracted SCM
If untreated, facial asymmetry/skull deformity (plagiocephally) can occur as well as changes in the cervical vertebrae
Diagnosis for Congenital Torticollis
Clinical diagnosis based on physical examination and palpable “mass” of SCM muscle
X-ray of cervical spine recommended
Treatment for Congenital Torticollis
Conservative: stretching exercises several times/day to regain full ROM
May need Doc-band to help improve secondary plagiocephaly
Surgery: for patients who fail conservative treatment or those who are diagnosed late
Release of SCM muscle traction/casting and exercises
Plagiocephaly
Skull deformity that occurs secondary to external forces on the skull either in utero or during infancy
Scoliosis
Lateral curvature of the spine in the upright position
Usually accompanied by rotation as well as an increase in the normal kyphosis (thoracic) or lordosis (lumbar) of the spine
-occurs in 1-3% of population
Structural Classification of Scoliosis
Fixed, nonflexible, does not correct w/ side bending
Etiology:
Idiopathic (mechanism unknown, appears hereditary)- 80%
Congenital abnormalities
Neuromuscular (ex. Cerebral palsy, muscular dystrophy)
Dysmorphic syndromes (Neurofibromatosis, Marfan’s, osteogenesis imperfecta)
Non Structural Classification of Scoliosis
Flexible and corrects w/ side bending
Etiology:
Compensation d/t leg length discrepencies, local inflammation, muscle spasms
Idiopathic Scoliosis
4-5 times more common in girls
Serious curvatures are more frequent in fm
Progresses during rapid skeletal growth
Curve must be greater than 10 degrees
Right thoracic curvature is most common
Left thoracic curvature likely indicates a spinal disorder
Complications of Idiopathic Scoliosis
Cardiopulmonary dysfunction (most serious)
Progressive deformity
Pain with aging
Disability
Classification by age of idiopathic scoliosis
Infantile Occurs by age 3 M>Fm Usually resolves spontaneously Juvenile Occurs b/w ages 4-10 years Adolescent- MOST COMMON Occurs b/w age 10 until skeletal maturity Most significant and prevalent form Fm>M (girls age 10-12y and boys 14-16y)
Signs and Symptoms of Idiopathic Scoliosis
Usually asymptomatic
Pain is rare and if present is a red flag (look for secondary cause)
Diagnosis of Idiopathic Scoliosis
Confirmed with a standing (AP and lateral) X-ray of entire spine
Determine Cobb angle
Angle of spinal curvature
Identify the upper and lower end vertebrae of curve
Draw a line parallel to the end plate of each vertebrae
The angle at which they intersect is the Cobb angle
Risser Sign (skeletal maturity)
Sensitive indicator of skeletal maturity
Ossification progresses from lateral to medial (SI joint)
MRI for Idiopathic Scoliosis
Indicated if a secondary cause is suspected:
Significant pain
Abnormal neurological symptoms
Left thoracic curve (associated w/ spinal disorder)
Rapid progression
Progressive Facts for idiopathic scoliosis
Curves >20 degrees tend to progress in the young
Curves < 30 degrees at maturity have minimal progression as adults
Respiratory symptoms rarely develop in curves < 60 degrees
The greater the curve and the younger the patient, the more likely the curve will progress
Progression is more common in young children who are beginning their growth spurt
Curves in adolescent females are more likely to progress
Treatment for idiopathic scoliosis
Early detection is key to prevent progression
Referral to a specialist is mandatory for all patients
Depends on the age of the patient and the angle of the curve
Non-surgical treatment methods will not fully correct the curve (it may improve the curve in some cases), but will prevent progression of the curve and maintain flexibility
Surgical treatment will correct the curve, but it also reduces flexibility
Immature and Older children idiopathic scoliosis treatment
Immature patients:
Observation every 6-12 months till the curve reaches 20 degrees
Curves >20-25 degrees will require treatment
Older child (growth has slowed)
Observation if a small curve is present b/c it is less likely to progress
Non surgical treatment for idiopathic scoliosis
Spinal Bracing
Indicated in curves <20 degrees if they are progressing
Indicated in curves between 20-40 degrees, particularly in a skeletally immature patient
Ex. Milwaukee Brace and Thoracolumbosacral orthotic (TLSO)
23 hours/day for 2 years or longer
Exercises while in the brace to improve appearance and decrease the curve
Surgical Treatment for idiopathic scoliosis
Indicated for curves >45 degrees
2 components:
Deformity correction with intraoperative instrumentation
Spinal fusion
Success rates are high
Results in decreased spine motion which can be quite limiting
Nursemaids/ pulled elbow
Head of the radius subluxes distally through the annular ligament
Etiology of Nursemaids/ pulled elbow
Children age 1-3 are most affected, rare after age 6
Etiology
Toddler being pulled or swung by an extended arm (longitudinal traction w/ elbow extended and forearm pronated)
Trauma
Clinical Signs and Symptoms of Nursemaid elbow
May hear a snap when the radial head subluxes
Immediate elbow pain that increase w/ movement
Arm is held with the elbow flexed and the forearm pronated
Tenderness to radial head
Diagnosis and imaging for nursemaid elbow
Clinical diagnosis based on history and PE
Imaging
Typically not indicated unless the history suggests trauma or an unusual mechanism
Usually appear normal
Presumably d/t spontaneous reduction before or during the X-ray with radiographic positioning
Treatment for Nursemaids elbow
Reduction
Start w/ the elbow extended and the forearm pronated
Supinate the forearm and flex the elbow simultaneously while applying manual pressure over the radial head
A palpable click can be palpated when reduction occurs
Pain resolves immediately and the toddler will start using the arm
Immobilization is not recommended following the injury except for recurrent subluxations
Little League Elbow
A traction injury to the medial epicondylar physis related to repetitive throwing
Pathophysiology
Repetitive valgus stress results in shearing, inflammation, traction and abnormal bone development
Symptoms of Little League Elbow
Acute or gradual Acute suggests avulsion injury Pain to medial epicondyle Swelling Stiffness Decrease in performance Weakness
Signs of Little League Elbow
Tenderness to medial epicondyle
Pain worsened by valgus stress
May have decreased range of motion (ROM)
Wrist flexion and forearm pronation may bring on pain
Diagnosis of Little League Elbow
Imaging is not required but an X-raymay show widening of the apophysis
Treatment of Little League Elbow
Complete rest from throwing activities
Stretching and strengthening (PT) is helpful
Prevention is key (proper throwing mechanics, proper conditioning, limiting # of pitches and 3-4 days of rest b/w games pitched)
Dysplasia
abnormal growth or development
Dislocated Hip
Femoral head is not in contact with the acetabulum
Subluxation of hip
Femoral head is w/in the acetabulum but can partially come out of the socket w/ a provocative maneuver
Development of dysplasia of the hip
Term used to describe a spectrum of hip disorders in young children
Congenital hip dysplasia is the most common
Others include conditions associated with neuromuscular abnormalities
98% of the cases are reversible
2% are severe and irreversible
Epidemiology for dysplasia of the hip
Incidence: 1-2 cases per 1,000 live births in the US
Frequently bilateral
Females > Males
Left hip > Right hip
RF for dysplasia of the hip
First born child Female born in breech position musculoskeletal abnormalities (metatarsus adductus, clubfoot and torticollis) Certain syndromes (Trisomy 21) FH of DDH
congenital dysplasia of the hip
Hip is fully formed by 11th weeks of gestation
Proper growth of the acetabulum requires a round femoral head
In congenital dysplasia, the hip forms normally but dislocates around the time of birth
Once the normal articulation is disrupted, the acetabulum and femoral head grow abnormally and this will progress if not treated early
Acetabulum shallower, saucerlike
Femoral head flattened and anteverted
Joint capsule loose/lax
prognosis for dysplasia of the hip
If untreated, leads to deformity, disability and painful arthritis in adults
Early diagnosis and early intervention is KEY
Signs/symptoms for dysplasia of the hip
Very subtle and can be easily missed
In infants, you can’t see any abnormality, you can only feel it
In children 3-12 months (not walking)
Restricted hip abduction is the hallmark sign
Shortening of thigh compared to contralateral side
Abnormal skin folds
Unilateral Signs/symptoms of dysplasia of the hip in an older child
Unilateral
Painless limp and a lurch to the affected side
Leg length discrepency
Positive Trendelenburg sign (weakness of gluteus medius)
Bilateral Signs/symptoms of dysplasia of the hip in an older child
Loss of hip abduction
Waddling gait
Flexion contracture of the hips with secondary hyperlordosis of lumbar spine
Infant hip exam with 2 special tests
Examine one hip at a time
Examine supine on exam table
Examine the patient when they are calm and comfortable
2 tests should be performed:
Barlow Maneuver- hip is purposefully dislocated and then reduced by doing the Ortolani Maneuver
Ortolani Maneuver- Gentle reduction of the dislocated hip
