Pediatric Ortho Flashcards
Definition of torticollis
- Unilateral contraction of neck muscles causing head to be tilted to one side
- Chin rotates to opposite side of contraction
- 80% are congenital (rest are trauma/disease)
When does congenital torticollis MC occur?
Following breech deliveries
What can congenital torticollis be associated with?
- Hip dysplasia
- Clubfoot
What happens to the SCM in congenital torticollis?
Fibrosis of SCM causes a palpable “mass”
When does the SCM mass resolve in congenital torticollis?
- A few weeks after birth
- SCM is shortened and contracted after
What happens if congenital torticollis is left untreated?
- Plagiocephaly (facial asymmetry/skull deformity)
- Changes in cervical vertebrae
How is congenital torticollis diagnosed?
- Clinically (based on PE and palpable mass of SCM)
- Xray of cervical spine is recommended
Conservative treatment of congenital torticollis
- Stretching exercises
- Doc band to help improve secondary plagiocephaly
Surgical treatment of congenital torticollis
- For pts who fail conservative tx or are diagnosed late
- Release of SCM (traction/casting and exercises)
Define plagiocephaly
Skull deformity from external forces (either in utero or infancy)
Risk factors for plagiocephaly
- Position in womb
- Multiple births
- Premature
- Torticollis
- Sleeping on the back
Treatment of plagiocephaly
- Encourage belly time
- Reposition often
- Stretching for torticollis
- Doc Band (4-6 months)
Define scoliosis
Lateral curvature with rotation of the spine in upright position
MC cause of scoliosis?
Idiopathic (80%)
Classifications of scoliosis
Structural: fixed, nonflexible, does NOT correct w/side bending
Non-structural: Flexible and corrects w/side bending
Who is most affected by scoliosis?
Adolescent girls (including serious curvatures)
What is the MC type of curvature in scoliosis?
Right thoracic
How large does curve have to be in scoliosis?
Greater than 10 degrees
What is the most serious complication of scoliosis?
Cardiopulmonary dysfunction
Clinical presentation of scoliosis
Usually asymptomatic
Pain is RARE and if present is a red flag
What is the Cobb angle?
Angle of spinal curvature in scoliosis (identified on x-ray)
What is the Risser sign?
Sensitive indicator of skeletal maturity
Ossification progression from lateral to medial (SI joint)
When do respiratory symptoms occur in scoliosis?
Spinal curvature over 60 degrees
General treatment of scoliosis
- Early detection is key to preventing progression
- Referral is mandatory for all patients
Non-surgical treatment of scoliosis
Will NOT fully correct curve, but will prevent progression and maintain flexibility
Surgical treatment of scoliosis
Will correct the curve BUT reduces flexibility
Deformity correction AND spinal fusion
When is spinal bracing indicated in scoliosis?
- In curves less than 20 degrees IF they are progressing
- In curves 20-40 degrees (esp skeletally immature pt)
- 23 hrs/day for 2 years or longer
When is surgical treatment indicated in scoliosis?
Curves over 45 degrees
Define nursemaid’s elbow
“Pulled elbow”
Head of radius subluxes distally through annular ligament
Who is MC affected by nursemaid’s elbow?
Children 1-3 yo
Rare after 6 yo
Treatment of nursemaid’s elbow
- Reduction
- Immobilization NOT recommended except for recurrent cases
Define little league elbow
- Traction injury to medial epicondylar physis
- Caused by repetitive throwing
Pathophys of little league elbow
Repetitive valgus stress
What would an x-ray of little league elbow show?
Widening of apophysis
Treatment of little league elbow
Complete rest from throwing
PT is helpful
Prevention is key
Define development dysplasia of hip (DDH)
- Spectrum of hip disorders in young children
- 98% reversible
- MSK abnormalities increase the risk
When is the hip fully formed?
11th week of gestation
Prognosis of DDH
Early diagnosis and intervention!
Hallmark sign of DDH
Restricted hip abduction
What is the Barlow Maneuver?
- To examine for DDH in infants
- Hip is purposefully dislocated and then reduced (via Ortolani maneuver)
What is the Ortolani maneuver?
Gentle reduction of dislocated hip (used w/Barlow maneuver in infants)
Imaging in DDH
- Not reliable in children under 6 wks old
- US is 1st line in 6 wks to 4 mo children
- X-ray is 1st line in children over 6 mos
When is the most opportune time to treat DDH?
Birth to 6 wks old
What is the gold standard treatment for DDH?
Pavlik harness
- Maintains hip flexion of 100 degrees, prevents adduction
- Worn several weeks
Define Legg Calve Perthes Disease (LCPD)
Disruption of blood supply to femoral head resulting in AVN
Who is MC affected by LCPD?
4-10 yo
Males 4:1
Bilateral in 15% cases
Stages of LCPD
- Early (6 months)
- Regenerative/fragmentation (1-2 years)
- Reossification
Gold standard for diagnosing LCPD?
AP and lateral frog X-ray
Treatment of LCPD
Based on age
- Less than 6 yo w/mild disease: symptomatic care
- Over 6 yo: abduction brace to keep femoral head w/in acetabulum (worn continuously for up to 2 years)
Define slipped capital femoral epiphysis (SCFE)
- Displacement of proximal femoral epiphysis due to disruption of the growth plate
- Results in upward and anterior displacement of femoral neck
Clinical features of SCFE
- Bilat in up to 25% cases
- Primarily gradual onset
- Trauma or hormonal
Who is MC affected by SCFE?
Boys 10-17 yo
African Americans
Hypothyroid
Obese or tall/thin
Imaging of SCFE
AP and lateral x-ray of BOTH HIPS
- Klein’s line
- Ice cream scoop slipping off cone
Treatment of SCFE
- Refer immediately to ortho surgeon
- Non wt bearing w/crutches
Prophylaxis of SCFE
- Pinning of contralateral hip
- Controversial, not recommended
Define transient synovitis of hip
Self limited, nonspecific synovial inflammation of hip joint Results in joint effusion Cause unknown (viral infection maybe)
What is the MC cause of hip pain in children under 10 yo?
Transient synovitis of hip
Who is MC affected by transient synovitis of hip?
Males
Peak age 5-6 yo
What is the MC angular/rotational deformity of the legs?
In toeing
Define genu varum
Bow leg (tibial rotation toward midline)
Define Blount’s disease
- Pathologic, developmental bow legs
- Caused by disrupted growth of upper medial tibial epiphysis
- MC in obese early walkers, African Americans, fam hx
Define genu valgum
Knock knee (tibial rotation away from midline)
3-8 yo
May be caused by skeletal dysplasia and rickets
Out-toeing
Etiologies of toeing in
Metatarsus adductus/varus of foot in infants
Internal tibial torsion in toddler
Increased femoral torsion in child over 10 yo
Define Osgood-Schlatter’s disease
- Inflammation of patella tendon attachment to tibial tubercle apophysis
- Potentially partial avulsion
- 20% occur bilaterally
Who is MC affected by Osgood-Schlatter’s disease?
Early adolescent males (especially athletic)
What is a common cause of knee pain in adolescents?
Osgood-Schlatter’s disease
Treatment of Osgood-Schlatter’s disease
Conservative - rest, ice, NSAIDs
What is Sever’s disease?
Calcaneal apophysitis - similar to Osgood-Schlatter’s
- Low grade inflammation at insertion of Achilles tendon
- Often bilateral
Who is MC affected by Sever’s disease?
Boys 8-14 yo
High impact sports, activities
Treatment of Sever’s disease
Conservative - ice, rest, NSAIDs, heel cups
What is talipes equinovarus?
Club foot
MC in males
3 categories: idiopathic, neurogenic, a/w abnormal syndromes
What features must be present to diagnose club foot?
- Plantar flexion of foot at ankle joint (equinus)
- Inversion deformity of heel (varus)
- Medial deviation of forefoot (varus)
Treatment of club foot
Stretch contracted tissues followed by casting to hold correction
Define osteogenesis imperfecta
- Rare genetic CT disorder characterized by multiple and recurrent fractures
- Type 1 MC
- Type 2 results in fetal death
- Can look similar to child abuse
Clinical presentation and diagnosis of osteogenesis imperfecta
Blue sclera, hyperextensibility of ligaments, Wormian bones (accessory skull bones)
Genetic testing and x-ray findings
Treatment of osteogenesis imperfecta
Bisphophonates to decrease fractures
Surgery to correct deformities
Preventive measures
