Pediatric Orthopedic Conditions & Ortho Surgical Procedures Flashcards
Define foot progression angle (gait angle)
- The angle made by the foot with respect to a straight line plotted in the direction the child is walking
Define thigh-foot angle
- The angle between axis of the foot & axis of thigh measured with child prone & knees at 90º
- Describes the degrees of tibial torsion
Toeing in/Pigeon toed is caused by 3 types of deformities depending on age of the child including
- Metatarsus adductus
- Internal tibial torsion
- Increased femoral anteversion
Pathology of metatarsus adductus
- Most common congenital foot deformity
- More common in females
- Rigid form: medial subluxation of tarsometatarsal joints; hind foot in slight valgus with navicular lateral to head of talus
- Flexible form: adduction of all 5 metatarsals at the tarsometatarsal joints
Internal tibial torsion is associated with
- Associated with W sitting
- Most common cause of in-toeing
- High complication rate of osteotomy
Which muscle is released for surgical intervention of metatarsus adductus
- Abductor hallucis tendon
Common causes of toeing-out
- Femoral retroversion
- External tibial torsion
- Flat feet
Pathology of talipes equinovarus (Clubfoot)
- Abnormal development of the head & neck of talus, due to hereditary or neuromuscular disorders
- Observed deformity: PF, adducted, & inverted foot
Characteristics of the affected foot with talipes equinovarus (Clubfoot)
- Affected foot is a half size smaller than& less mobile
- Calf muscles will be smaller
- 50% can be affected bilaterally
Treatment of postural talipes equinovarus
- Manipulation followed by casting or splinting (Ponseti method)
- Following casting, stretching is important
- Orthoses (Denis-Browne splints) throughout the day for up to 3 months & then at night for up to 3 yrs
Age norms for genu valgum/varum
- Varum normal in newborns/infants
- Max varum present at 6-12 mo
- Zero tibiofemoral angle by 18-24 mo
- Max valgus around 3-4 yrs with avg. tibofemoral angle of 12º
- Valgum spontaneously corrects by age 7
- Normal adult tibofemoral angle is 7º for males & 8º for females
Etiology of hip dysplasia
- Abnormality in the size, shape, orientation, or organization of the femoral head, acetabulum, or both
- Can result in subluxations/dislocations
Risk factors for hip dysplasia
- Females > males
- Breech position
- Family history
- Low levels of amniotic fluid
- Swaddling an infant too tightly
What is the gold standard treatment for hip dysplasia
- Pavlik harness
Special tests for hip dysplasia
- Barlow test
- Ortolani test
- Limited hip abduction
- Galeazzi sign
- Klisic sign
Pathology of transient synovitis in children
- Acute onset of sudden hip pain in children age 3-10
- Transient inflammation of the synovium of the hip
- Decreased hip abduction & IR
Signs and symptoms of transient synovitis in children
- Unilateral hip/groin pain
- Less common medial tightness or knee pain
- Crying at night
- Antalgic limp
- Pain not common
- Recent history of upper respiratory tract infection
Pathology of Legg-Calve-Perthes disease
- Blood supply interrupted to the femoral head
- Age of onset its 2-13 yrs
- 4x more common in males than females
What MRI finding is indicative of Legg-Calve-Perthes disease
- Positive bony crescent sign
Signs/symptoms of Legg-Calve-Perthes disease
- Psoatic limp due to weakness of psoas major
- Moves in ER, flexion, and adduction
- Gradual onset of achey pain at hip, thigh, & knee
- Limited AROM in abduction and extension
Pathology of slipped capital femoral epiphysis (SCFE)
- Femoral head is displaced posteriorly & inferiorly in relation to the femoral neck & within the confines of the acetabulum
- Onset is 10-17 yrs for males & 8-15 yrs for females
- 2x more common in males
Clinical findings of SCFE
- AROM restricted in abduction, IR, and flexion
- Vague pain at knee, thigh, and hip
- Chronic condition may see Trendelenburg gait
Etiology of Osgood-Schlatter disease
- Mechanical dysfunction resulting in traction apophysitis of the tibial tubercle at the patellar tendon insertion
Etiology of Sever’s disease (calcanea apophysitis)
- Most common cause of heal pain in growing children, occurs before or during peak growth spurt
- Caused by repetitive micro trauma due to increased traction by the Achilles tendon on its insertion site
- Bilateral involvement in 60% of cases
Etiology of Sinding-Larsen Johannson’s disease
- Traction apophysitis at the patella-patellar tendon junction, overuse injury due to repeated stresses
- Can occur after significant growth spurt and/or increase activity
Etiology of growing pains (Benign nocturnal pains of childhood)
- Etiology unknown but could be due to muscular fatigue, poor posture, stress, etc.
- Can affect 20% of children most likely between the ages of 3-5 and 8-11
- Not related to redness, temperature, swelling, & tenderness
- Increase pain at night typically bilateral
Pathology of osteochondritis dissecans
- Occurs in adolescents b/w ages 12-15 yrs
- Most common is separation of articular cartilage from underlying bone usually involving the medial femoral condyle
- Can occur at humeral capitellum central/lateral aspect from repetitive compressive forces
Etiology of Panner’s disease
- Localized AVN of capitellum leading to loss of subchondral bone with fissuring & softening of articular surfaces of radiocapitellar joint
- Occurs in children 10 of younger
Describe structural versus nonstructural scoliosis
- Structural: irreversible lateral curvature of the spine with a rotational component
- Nonstructural: reversible lateral curvature of spine without a rotational component which straightens as individual flexes the spine
Treatment options of scoliosis
- Conservative: degree of curvature <25º
- Bracing: degree of curvature 25-45º
- Surgery with placement of Harrington rod instrumentation; curvature >45º
Pathology of pes planus
- Can be caused by genetic weakness, ligamentous laxity, paralysis, excessive pronation, trauma, or disease
- Normal arches develop around 2-3 yrs
- Reduction of the medial longitudinal arch
Etiology of plagiocephaly (flat head syndrome)
- Development of a flat spot on the back or side of the head as the skull is soft & malleable & can be misshapen easily
Etiology of arthogryposis multiplex congenita
- Congenital deformity of skeleton & soft tissues, characterized by limitation in joint motion & a sausage like appearance of limbs
- Nonprogressiive contractures
- Intelligence develops normally
Pathology of osteogenesis imperfect (OI)
- Inherited disorder transmitted by autosomal dominant gene
- Characterized by abnormal collagen synthesis leading to imbalance b/w bone deposition & reabsorption
- Cortical & cancellous bones become very thin leading to fx & deformity of weight bearing bones
Difference between spondylolysis and spondylolisthesis
- Spondylolysis: fracture of the pars interarticularis with positive “scotty dog” on oblique radiographic view of the spine
- Spondylolisthesis: actual anterior or posterior slippage of one vertebra on another following bilateral fracture of pars interarticularis
Grading of slippage for spondylolisthesis
- Grade 1: 25% slippage
- Grade 2: 50% slippage
- Grade 3: 75% slippage
- Grade 4: 100% slippage
What are the key issues with tendon surgery
- Are prevention of mobility impairments without overloading repair and preventing excessive atrophy
How long and in what position is the knee put in following a PCL repair
- Frequently immobilized in full extension for a period of 6 wks
How long and in what position is the knee put in following a flexor tendon repair of the hand
- Immobilized for 3-4 wks with wrist and digits flexed
What positions should be avoided early on following a repair of the knee meniscus
- Weight bearing with flexion
What positions should be avoided early on following a repair of the shoulder anterior-inferior labrum (Bankart)
- ER
What positions should be avoided early on following a repair of the hip labrum
- Passive unilateral hip extension, excessive hip flexion, abduction, & ER
Describe an osteochondral autograft transplantation (OAT)
- Transfers articular cartilage from areas of low-loading to areas of high-loading
Describe an autologous chondrocyte implantation (ACI)
- Healthy articular cartilage is harvested from the patient & injected under a periosteal flap closed with additional sutures & fibrin glue
Computer assisted navigation systems (CAS) or robotic surgery are new techniques, often associated with
- Minimally invasive surgery that improve surgeon precision, flexibility, and control with less soft tissue trauma
Difference between cemented and non cemented joint replacements
- Cemented joint replacements can tolerate full weight bearing immediately following surgery
- Noncemented joint replacements are more stressful on bones during surgeries
Difference between a total hip arthroplasty (THA) and a hemiarthroplasty
- THA: replacement of both femoral and acetabular articulator surfaces
- Hemiarthroplasty: replacement of the femoral head articular surface only
Difference between a total knee arthroplasty (TKA) and an unicompartmental knee arthroplasty (UKA)
- TKA: replacement of medal/lateral femoral condyle, tibial plateau. & patellar articular surfaces
- UKA: replacement of the articular surface either medially or laterally
Difference between a total shoulder arthroplasty (TSA) and a shoulder hemiarthroplasty
- TSA: replacement of humeral head & glenoid articular surfaces
- Shoulder hemiarthroplasty: replacement of only the humeral head articular surface
What are the hip precautions following a THA
- Avoid >90º hip flexion, adduction past midline, & IR for the first 6 wks post-op as these positions place the hip at risk for dislocation
PT protocol following a Harrington rod placement for idiopathic scoliosis
- Early mobilization in bed and effective coughing
- Begin ambulation b/w 4-7 day post-op
- Avoid heavy lifting & excessive twisting & bending
Precautions following a lumbar nonfusion procedure
- Avoid end range rotation & flexion
- No joint mobilization for 3 months
Lumbar precautions following a lumbar fusion procedure
- Avoid end range rotation & extension
- No intensive abdominals
- No impact loading for 3 months
Cervical precautions following a cervical fusion procedure
- No lifting >5-10 lbs for 4 wks
