Pediatric ortho

Question 1

Development of dysplasia of the hip

Answer 1

ball and socket doesn’t interact properly in utero

Risk factors:
female
first born (small uterus)
breach presentation

H and P:
hip clicks on ortolani (open) an barlow (back)
look for symmetry in skin folds

Galeazzi sign- unequal leg length when knees are flexed

Without early intervention, patient develops Trendelenberg gait

Diagnosis:
Hip ultrasound
not enough bone mineralization in the first 4 months of life to make an xray worthwhile

US screening if:
female breech, or family history of hip dysplasia
male breech

Treatment: Pavlik harness until about 6 mos, when infants are starting to crawl
This positions the femur onto the acetabulum so that it can develop correctly

After 6mos, open fixation with spica casting for 6mos to a year

After 8 years, reduced benefit, so reduction may not be attempted

Question 2

Slipped capital femoral epiphysis

Answer 2

early adolescance
RF:
overweight
male

H and P:
thigh, hip, knee pain, limp
limited internal rotation and abduction of the hip
hip flexion produces obligatory external hip rotation

Treatment:
mild, chronic, stable: bedrest
avoid weight-bearing, crutches, and/or wheelchair until surgically repaired

Prompt surgical pinning of the head of the femur

• if acute/unstable- admit to hospital for surfical treatment
• if chronic/stable- urgent outpatient evaluation

Closed reduction of acute slips prior to pinning is controversial

Complications:
avascular necrosis
osteoarthritis if treatment is not performed early

Question 3

Legg-Calve-Perthes disease

Answer 3

ages 3-8yo
avascular necrosis of capital femoral epiphysis
common cause of limp

gradual progression of limp
insiduous onset of pain
decreased range of motion

The ice cream is melting, not falling off of the cone

Treatment:
non-weightbearing on the affected side for an extended time

If limited femoral head involvement and full ROM, just observe

If extensive femoral head involvement or limited ROM,
bracing
hip abduction with a Petrie cast
osteotomy

So, unlike SCFE, you don’t need urgent surgical intervention

50% of untreated cases recover fully
increased risk of hip complications in adulthood (avascular necrosis etc)

Question 4

Osgood-Schlatter

Answer 4

inflammation at insertion of patellar tendon at tibial tuberosity

most common in young, especially in the rapid phase of growth

caused by microtrauma
microavulsions

H and P:
MC symptom is anterior knee pain that increases over time and is worsened by quadriceps contraction (running, jumping)

signs at the tibial tuberosity may include soft tissue swelling, a palpable bony mass, and/or pain upon quadriceps flexion

RICE
can continue sports depite pain

Rehabilitation:
stretching hamstrings and quadriceps
strengthening the quads

Osgood-Schlatter pad- protective pad over tibial tuberosity

Ice affected area after activities

NSAIDs for pain

knee immobilizers are contraindicated

Question 5

Club foot

Answer 5

inversion of foot
plantar flexion of ankle
adduction of forefoot

not difficult to identify

serial casting of foot in the correct position is treatment, followed by surgery to release contracture and modify bone alignment in severe or long-standing cases

if untreated, slow to walk and may limp

Question 6

Duchenne muscular dystrophy

Answer 6

MC lethal muscular dystrophy
affects lower extremities and ability to stand and walk

sx onset 2-6yo

H and P:
progressive clumsiness
easy fatigability
difficulty standing up with walking
proximal muscle weakness greater than distal muscle weakness

H and P:
pseudohypertrophy of calf mucles (fibrofatty infiltrate)
Gower maneuver

Diagnostic testing
increased creatinine kinase
muscle biopsy
EMG

Treatment:
PT
pulmonary support
Cardiac support

Complications:
contractures
scoliosis
death by 20yo due to pulmonary or cardiac failure

Becker is similar but more slowly and less severe

Question 7

Treatment for Osgood Schlatter disease

Answer 7

NSAIDs

ice stretching

Question 8

xray reveals femoral head sclerosis

Answer 8

Legg- Calve Perthes avascular necrosis

Question 9

ice cream scoop (femoral head) falling off cone (femur

Answer 9

SCFE

Question 10

obese male adulescent with dull hip pain and inability to bear weight

Answer 10

SCFE

Question 11

acute onset of tibial pain, fever, malaise, elevated ESR, no joint pain

Answer 11

ewing sarcoma

Question 12

Acute onset of knee pain, fever, elevated ESR, leukocytosis

Answer 12

septic arthritis

Question 13

7yo with growth delay and inner thigh pain

Answer 13

legg- calve-perthes

Question 14

13yo boy with pain and swelling at tibial tuberosity

Answer 14

osgood-schlatter

Question 15

follow up surveillance for a male post adenocarcinoma resection

Answer 15

CEA q3mos x 3 years
CT of chest, abdomen, pelvis qyear

Colonoscopy at 1, 3, 5 years

Question 16

Gold standard for diagnosis of bladder cancer

Answer 16

cystoscopy with biopsy

Question 17

What is Barrett esophagus?

Answer 17

distal esophageal change 2/2 chronic inflammation from GERD

metaplastic change from squamous (nml) to columnar epithelium

this can lead to adenocarcinoma of the esophagus

Question 18

calvicular fractures

Answer 18

0.2-0.5% of spontaneous vaginal deliveries

or, fall on posterior shoulder, with force transmitted medially

no treatment needed for clavicular fracture in a newbord, do not need to immobilize

evaluate for brachial plexus injury

In non-neonates who are more active, gentle immobilization can be helpful.

mid-third clavicle fracture-

Figure 8 strap and/or arm sling until fracture site and ROM are painless (usually 4-8 weeks)

Follow up in 1-2 weeks, then every 2-3 weeks until asx

(adults: usually 6-12 weeks, children usually 3-6 weeks)

at 6 weeks: repeat xray
rehab with strength training

Question 19

Physeal fractures: Salter Harris

Answer 19

I: physeal separation without extension into adjacent bone
-focal tenderness
-normal xray
good prog

II: partial fracture through the physis that extends into the metaphasis
good prog

III: fracture extends through the physis and then tracks through epiphsysis
alignment is key for prognosis
surgical fixation may be necessary for stability

IV: fracture extends through the physis, metaphysis, and epiphysis
-perfect reduction must be achieved to maintain joint stability
guarded prognosis

V: crush injury with damage to plate, partial growth arrest is possible

SALTER (with long bone (diaphysis) pointing up)
separation through physis
above
lower
through
erase the physis

Question 20

Nursemaid’s elbow

Answer 20

subluxation of radial head out of the annular ligament

MOI: pulling or traction on arm
H and P: child refuses to use arm
Tx: closed reduction- passively supinate the forearm and then flex the elbow

or, hyperpronate the forearm

pop
instant repair

Question 21

Rickets

Answer 21

impaired bone mineralization
most often caused in childhood by vitamin D deficiency and subsequent calcium

RF:
exclusively breast fed
dark skin and pigmentation
living in the extreme north or North/South

H and P:
bone pain
delayed walking 
bowing of the legs
kyphoscoliosis
limb weakness
decreased height
softened skull bones
fractures from minimal trauma

Labs:
elevated alk phos
decreased phosphorus
variable calcium and PTH

Radiology:
widened physis
bowed long bones
translucent lines in bones
flattened skull
large costal cartilage (rickettic rosary)

Tx: Vit D supplementation

Question 22

What is the recommended amount of Vit D to supplement for infants

Answer 22

all children (Especially breastfed infants) should receive vitamin D supplementation of

400 IU daily starting within the first few days of life

Question 23

Scoliosis

Answer 23

more common in females
lateral curve of spine
asymmetry of back musculature

Tx: observation
bracing
severe
depending on severity

Question 24

Spondylolisthesis

Answer 24

anterior slippage of vertebra resulting in palpable step off. Usually L5 over S2 , also visible on xray

exacerbated by hyperextension of the spine

typical knee-flexed hip-flexed gait

neurologic dysfunction would be very rare

Question 25

Juvenile idiopathic arthritis

Answer 25

late childhood, early teens
nonmigratory arthropathy affecting more than 1 joint for more than 3 months

H and P:
persistent joint swelling due to thickened synovium and accumulation of synovial fluid

Three subtypes:
Pauciarticular JIA: a few joints, maybe with uveitis

Polyarticular JIA: lots of joints involved, severe symmetrical arthritis with deformities of the hands and some dactylitis

Systemic onset JIA Still’s disease- systemic symptoms precede arthritis: fever, maculopapular rash, hepatosplenomegaly, lymphadenopathy

Labs: elevated WBC and anemia
Still’s disease starts out looking a lot like leukemia

How to treat JIA?
NSAIDs
if NSAIDs don't work, then try 
methotrexate, 
corticosteroids
immune modulators (annikinra, interleukin receptor antagonist)