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Paediatrics > Pediatric Orthopedic Conditions > Flashcards

Pediatric Orthopedic Conditions Flashcards

1
Q

What are clinical guidelines ?

A

Evidence based recommandations by expert committees on the diagnosis and treatment of clinical conditions.

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2
Q

What are the goals of clinical guidelines ?

A
  • reduction of misdiagnosis
  • reduction of patient mismanagement
  • improvement of patient outcomes
  • improvement of value for money
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3
Q

What are the elements assessed in AGREE II

A
  • Process of Development
  • Presentation style
  • Completeness of reporting
  • Clinical validity
  • Overall quality
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4
Q

What are Salter Harris fractures ?

A

Fractures affecting the physis of bone.

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5
Q

What is a Salter-Harris fracture type I ?

A

Extra articular fracture through the physis with no bone involvement (may be undetectable on X-rays).

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6
Q

What is a Salter-Harris fracture type II ?

A

Extra-articular fracture through the physis and metaphysis.

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7
Q

What is a Salter-Harris fracture type III ?

A

Intra-articular fracture through the physis and epiphysis.

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8
Q

What is a Salter-Harris fracture type IV ?

A

Intra-articular fracture through the physis, metaphysis and epiphysis.

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9
Q

What is a Salter-Harris fracture type V?

A

Crush fracture though the physis, metaphysis and epiphysis.

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10
Q

Name a subtype of type I Salter Harris fracture (involving femur).

A

Slipped upper femoral epiphysis.

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11
Q

What is the medical management of stable Slipped upper femoral epiphysis?

A

Hip spica cast until check X-ray shows union.

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12
Q

What is the medical management for unstable slipped upper femoral epiphysis?

A

Open reduction and internal fixation with screw.

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13
Q

In slipped upper femoral epiphysis, what are the outcomes relevant to PT ?

A
  • pain
  • hip ROM
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14
Q

What are the red flags of a slipped upper femoral epiphysis ?

A

On 1st contact with patient (child), the child is limping with no physical sign of trauma but has pain in the hip, groin, thigh or knee. Exclude lymphadenopathy first. Start strict non weight bearing immediately and refer to orthopedic specialist in emergency.

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15
Q

What are the recommandations for stable SCFE with hip pica cast ?

A

Continue non-weight bearing until X-ray shows union.

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16
Q

What are the recommandations for unstable SCFE, post ORIF?

A

Start partial weight bearing crutch walking and hip passive movement within days, as soon as it is comfortable for patient.

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17
Q

When can we have full weight bearing post ORIF ?

A

Only if:
1- six weeks minimum post ORIF
2- zero pain
3- full hip ROM

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18
Q

What are the general guidelines for fracture rehabilitation ?

A

Phase 1: protect healing tissue. Manage pain and swelling. Restrict weight bearing.
Phases 2: allow weight bearing, improve ROM, proprioception, balance and mobility.
Phase 3: Strengthening and ROM activities.
Phase 4: Advance strengthening and specific sporting activities.

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19
Q

What is a Galeazzi fracture ?

A

Fracture of the distal 1/3 of the radius with dislocation of the distal radio ulnar joint. The ulnar styloïde process may also be fractured.

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20
Q

What are the complications of Galeazzi fracture ?

A
  • non-union
    -mal-union
    -compartment syndrome
    -radio-ulnar synostosis
    -ulno-humeral osteoarthritis
    -radial nerve injury
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21
Q

What is the type I classification of Galeazzi fracture?

A

Dorsal displacement

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22
Q

What is type II Galeazzi fracture?

A

Palmar displacement

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23
Q

What is the Rettig and Raskin classification of Galeazzi fracture?

A

Classification according to the distance from distal radio-ulnar joint). Type I means that the fracture is less stable because it is located distal to a mark 7,5cm from the DRUJ.
Type II means the fracture is more stable because it is located proximal to a mark 7,5cm from the DRUJ.

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24
Q

What is the most common medical management of Galeazzi fracture ?

A

Closed reduction with supination cast.

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25
Q

What are the indication for PT Tx in case of Galeazzi fracture post ORIF (with cast in supination)?

A

ROM activity of wrist and elbow can only start after 6 weeks and after X-ray confirms DRUJ alignement. If immobilized in any other position than supination, ask surgeon why or confirm from medical records that treatment was by ORIF.

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26
Q

What can the PT do if an angular deformity remains after ORIF in any forearm fracture ?

A

Check with surgeon ! It’s a source of concern.

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27
Q

What are the red flags for septic arthritis ?

A
  • joint pain
  • joint swelling
  • pyrexie > 39° (not in all cases)
  • Erythema
  • reduced ROM
  • Loss of function
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28
Q

What to do if you suspect septic arthritis ?

A

Refer to emergency. Can be fatal in up to 15% of cases.

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29
Q

What is the course of PT treatment in case of septic arthritis ?

A
  • do not treat during acute phase : refer to emergencies
  • pain relief
  • when infection is controlled: early mobilisation
  • as soon as possible: aggressive ROM to prevent intractable stiffness
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30
Q

What are the scales used to assess congenital talipes equinovarus ?

A

DiMeglio scale, Pirani scale.

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31
Q

What are the stages of treatment in the Ponseti technique ?

A

To treat congenital talipes equinovarus:
Manipulation
Serial casting
Achilles tenotomy
Bracing (Denis Brown splint).

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32
Q

Describe the sequence of events in the Ponseti method to treat congenital talipes equinovarus.

A

1- manipulation and weekly cast changes for 5-6 weeks
2- Achilles tenotomy
3- cast reapplied for 3 weeks
4- Boots and bar fitted and worn for 23h per day from 3 months
5- Boots and bar for 14-16h per day until four years

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33
Q

What are the types of congenital torticolis ?

A

Sternocleidomastoid mass > muscular > postural

34
Q

What is the prognosis for congenial torticolis ?

A

98% of babies achieve full symmetry of neck posture and movement if PT starts before 1 month of age.

35
Q

How to assess congenital torticolis ?

A

Muscle function scale version II
Arthrodial goniometer assessment of passive cervical side flexion and rotation

36
Q

State action statement 6 of CPG for CMT (by Kaplan et al).

A

Referral to physician if:
1- Non-muscular causes of asymmetry (e.g: poor visual tracking)-
2- Associated conditions such as cranial deformity
3- Asymmetries inconsistent with CMT
4- If > 12 mo with facial asymmetry and/or 10° to 15° of difference in passive or active Cx rotation or lateral flexion.
5- If > 5 mo with SCM mass
6- If the side of torticolis changes
7- If the size and location of mass increases

37
Q

State action statement 8 of CPG for CMT by Kaplan et al.

A

Examine body structures:
1- infant posture and tolerance to supine, prone, sitting and standing positions for body symmetry, with or without support, as appropriate for age.
2- Bilateral PROM of Cx lateral flexion and rotation.
3- Bilateral AROM of Cx lateral flexion and rotation.
4- PROM of trunk, upper and lower extremities including screening for possible developmental dysplasia of the hip.
5- pain at rest and during AROM and PROM
6- skin integrity, symmetry of neck and hip skin folds, presence and location of a SCM.
7- Craniofacial asymmetries and head/skull shape.

38
Q

State action statement 11 of CPG for CMT (by Kaplan et al)

A

Document the parent/caregiver responses regarding:
1- positioning when awake/asleep
2- infant time spent in the prone position
3- whether the parent is alternating sides when breastfeeding
4- infant time spent in equipment/positionning devices

39
Q

State action statement 13 of CPG for CMT by Kaplan et al.

A

First choice of intervention:
1- Neck PROM
2- Neck and trunk AROM
3- Development of symmetrical movement
4- Environment adaptations
5- Parent/caregiver education.

40
Q

What is idiopathic scoliosis ?

A

An angular deformity of the spine without a known cause. The minimum angular deformity for diagnosis is 10° (Cobb angle).

41
Q

When to refer for an X-ray if we suspect idiopathic scoliosis ?

A

Use a scoliometer, if the angle reads 5° or more, refer.

42
Q

What test can be done to assess idiopathic scoliosis ?

A

Adam’s forward bend test.

43
Q

What is the chronological classification for idiopathic scoliosis ?

A

Infantile: from 0 to 2 yo
Juvenile: from 3 to 9 yo
Adolescent: from 10 to 17
Adult: at 18+

44
Q

What is the angular classification of idiopathic scoliosis ?

A

Based on angle of Cobb
Mild: from 10° to 20°
Moderate: from 21° to 35°
Moderate to severe: from 36° to 40°
Severe: from 41° to 50°
Severe to very severe: 51° to 55°
Very severe: 56° or more.

45
Q

What is the topographic classification of idiopathic scoliosis ?

A

Cervical: apex curve from discs C6 to C7
Cervico-thoracic: apex curve from discs C7 to T1
Thoracic: apex curve from discs T1 to T12
Thoracico-lumbar: apex curve from discs T12 to L1
Lumbar: apex curve from discs L1 to L2.

46
Q

How to test trunk extensors endurance?

A

Biering-Sorensen test.
Time elapsed while in static back extension.
Normal values are age and gender specific.
Healthy adults= 77 to 198 seconds.

47
Q

How to test trunk flexors endurance ?

A

Flexion rotation of the trunk test.
Maximum number of repetitions within 90s.
Normal values are age and gender specific.
Healthy adults= 55 to 118 reps.

48
Q

What are the general treatment strategies for idiopathic scoliosis according to SOSORT ?

A

SOSORT: international scientific society on scoliosis orthopedic and rehabilitation treatment.
SOSORT PSSE (physiotherapy scoliosis specific exercises) summary:
1- auto-correction in 3D
2- Training in activities of daily living
3- stabilizing the corrected posture
4- patient’s education

PSSE are individualized according to patient’s needs, curve pattern and treatment phase.

49
Q

What are the SOSORT CPG on PSSE during brace treatment and surgical therapy ?

A

1- PSSE are performed during brace treatment.
2- While performing PSSE, therapist should work to increase compliance to the brace treatment
3- Spinal mobilisation PSSE are used in preparation for bracing
4- Stabilization PSSE in autocorrection are used during brace weaning period.
5- PSSE in painful operated patients are used to reduce pain and increase function.
6- Aerobic physiotherapy training can be used prior to surgery.

50
Q

Name PSSE schools in Europe.

A
  • Lyon approach (France)
  • Schroth method (Germany)
  • Scientific exercise approach to scoliosis (Italy)
  • Barcelona scoliosis physical therapy school (Spain)
  • Dobomed method (Poland)
  • Side shift (UK)
  • Functional individual therapy of scoliosis (Poland).
51
Q

What is a normal variant ?

A

An unusual anatomical or physiological feature found in a proportion of the population with no clinical significance and considered to be within the spectrum of normal findings.

52
Q

Give examples of normal anatomical variants.

A
  • Dextrocardia
  • Pectus excavatum
  • Bipartite patella
  • Os acromiale
53
Q

Why are normal variants in pediatrics lower limbs important ?

A

1- they are very common
2- they cause undue parental anxiety
3- parents may be worried that it will cause degenerative MSK problems
4-some parents will expect treatment for normal variant and are difficult to convince otherwise
5-they are a major cause for referral to GP and PT
6-some MSK diseases have the same presentation
7-value for money

54
Q

What implies the concept of value for money ?

A
  • the collective health gain of the population
  • the best healthcare at the lowest cost possible
55
Q

Are parents right to worry about normal variants ?

A

Yes: in most cases normal variants are asymptomatic but sometimes they may lead to pathological conditions.
No: 85% of complaints due to variants do not require monitoring or treatment.

56
Q

What are the PT practical steps when dealing with possible anatomical variant ?

A
  • show parents that you take their concerns seriously
  • inform parents about clinical course and spontaneous resolution
  • be aware of pathological condition mimicking normal variant
  • asymmetry of the limbs requires further assessment
  • pain is always a cause for concern which must be further investigated.
57
Q

How to assess hyper mobility (generalized ligament outs laxity) ?

A

Beighton score.

58
Q

Which syndromes have generalized joint laxity as part of their clinical presentation ?

A

Ehlers-Danlos syndrome
Marfan syndrome

59
Q

Describe metatarsus adductus

A

Medial angulation of forefoot on a flexible or rigid hind foot with convex lateral border of the foot.
Commonest congenital foot deformity.
90% do not require treatment because asymptomatic or spontaneously resolve by 6-9mo.
Treatment: serial casting if not resolved at 9mo. Surgery if resistance to serial casting.

60
Q

Describe femoral anteversion (as an anatomical normal variant)

A

Medial rotation of the femur.
Normal femoral anteversion angle is between 30°q and 40° at birth and gradually reduces to as low as 8° in adults. Otherwise it is pathological and can lead to in-going, squinting patella and eggbeater running patter.
Rarely de-rotation osteotomy is performed.

61
Q

Describe medial tibial torsion.

A

It is a thigh foot angle of about 5° of medial tibial torsion at birth which gradually increases to 15° of lateral tibial torsion in adulthood.
Main features is in-toeing.
Will require treatment only if the child is > 10yo and the thigh foot angle is > 5° of medial tibial torsion plus other symptoms such as pain and frequent tripping and falling.
Treatment: De-rotation osteotomy followed by PT (orthotics and conservative treatments alone are not effective).

62
Q

How to know if Genu Valgum is a normal variant or not ?

A

Normal intermalleolar distance is less than 8cm.

63
Q

Which pathologies can mimic genu valgum normal variant ?

A

Cozen’s fracture: valgus angulation of the tibia after a Salter Harris fracture in the proximal tibia.
Blunts disease: a genetic disorder of tibial growth.
Rickets: caused by vitamin D deficiency, even if the manifestations are mostly genu varum, genu valgum can also occur + pain in the extremities and frontal bossing.

64
Q

Which pathology can mimic femoral anteversion or medial tibial torsion ?

A

Perches disease: avascular necrosis of the head of the femur.

65
Q

How to determine if genu varum is a normal variant or not ?

A

Space between medial condyles of the knees must be less than 6cm.

66
Q

Describe physiological pes planus.

A

Most cases resolve spontaneously between 4 and 8 yo.
Present when Windlass test does not elicit a temporary medial longitudinal foot arch.
No pain.
There is foot pronation with hind foot or calcaneum valgus deformity.
No treatment required.

67
Q

Define serial casting.

A

The process of applying and removing a series of casts to a body part with the goal of improving anatomical alignment, providing a progressive increase in ROM and improving function.

68
Q

What is the EBP from NICE guidelines about serial casting ?

A

Spasticity improvement is better with Botox combined with serial casting than with Botox alone or serial casting alone.

69
Q

What is the clinical rationale for serial casting ?

A
  • non invasive
  • compliance at discretion of patient
  • provides circumferential pressure (even distribution)
  • provides stability to the joint
  • allows lower limb weight bearing
70
Q

What are the indications for serial casting ?

A
  • persistant limitation of ROM secondary to soft tissue contracture
  • spasticity
  • joint mal alignment
  • gait deviation secondary to all above
71
Q

What are the contraindications to serial casting?

A
  • ankylosis/ joint rigidity
  • pain in the joint
  • impaired peripheral circulation
  • peripheral oedema
  • skin sensitivity/ allergy to casting materials
72
Q

What are the precautions for serial casting?

A
  • impaired sensation
  • skin lesions/ abrasion
  • mild static oedema
  • patient’s cognitive/ communication ability
73
Q

What are the adverse effects of serial casting and how to overcome them ?

A

1- skin break down: do not pull tight when applying resin cast
2- muscle spasm caused by muscle/nerve overstretch: always cast in the patient’s tolerable joint position
3- peripheral neuropathy caused by nerve compression: educate patient to detect nerve compression and teach patient how to remove cast at home.
4-peripheral ischemia caused by blood vessel occlusion: educate patient on how to detect circulatory issues and on how to remove cast at home.
5- mild atrophy: will resolve when patient returns to usual activity after serial casting

74
Q

How to align forefoot and hind foot properly during serial casting ?

A

Simulate the balance between the pronation ground reaction force on the lateral mid and fore foot combined with the supination ground reaction force on the medial calcaneal tubercle.

75
Q

List the material required for serial casting.

A
  • Mackintosh
  • Stockinet and padding
  • plastic spacer
  • basin of water
  • casting gloves
  • soft and hard casts
  • adhesive bandage
76
Q

What are the signs of adrenal crisis ?

A

Postural hypotension
Dehydration
Hypovolemic shock and coma

77
Q

What is the emergency management of syncopal attack?

A
  • watch out for dizziness, cold hands and feet and excessive yawning
  • children at risk of orthostatique hypotension should be closely monitored while in assisted standing
  • in the event of syncope, quickly bring the child to supine position than follow local first aid
78
Q

What are the guidelines for PT management of DMD early and late ambulatory stages?

A
  • assess MSK functions every 6 monts
  • scoliosis monitoring as frequently as necessary
  • prevent joint contracture and deformity
  • prevent falls
  • provide orthosis and walking aids
  • provide strategy for managing fatigue
  • implement submaximal aerobic physical activity such as cycling and swimming
79
Q

What are the guidelines for PT management of DMD early and late non-ambulatory stages?

A
  • Assess MSK functions every 6 months
  • Scoliosis monitoring every 6 months
  • Implement submaximal aerobic physical activity such as cycling and swimming
  • provide orthosis
  • provide wheelchair mobility in collaboration with occupational therapy including custom seating
  • implement assisted standing
  • provide assistive devices to facilitate learning
  • physiotherapy management of respiratory dysfunction
80
Q

On which principle is based the Muscle Function Scale version II ?

A

Head righting reaction

81
Q

How to test for developmental hip dysplasia.

A

Asymmetrical skin folds.
Excessive looseness of hip and knee flexion.
Contractures of hip hip adductors, iliopsoas and hamstrings on the affected side.
Greater trochanter height difference.
Ortolani and Barlow tests are positive.

Paediatrics (4 decks)

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