Pediatric Orthopedics

Question 1

what are important history factors for orthopedic conditions?

Answer 1

• onset
• location
• frequency
• duration
• exacerbating factors
• relieving factors
• associated symptoms
• family, social and birth history

Question 2

• due to in-utero positioning
• associated with torticollis
• very common birth defect
• flexibility is the true measure of severity

Answer 2

Metatarsus Adductus

Question 3

treatment of metatarsus adductus?

Answer 3

• casting only for rigid deformity: no urgency on referral, may ultimately require surgery
• weekly long leg cast changes
• mainly observation

Question 4

• variable genetic penetrance; prenatal diagnosis (20 week u/s)
• nerve and vessels smaller, muscles smaller and more fibrotic
• leg lenth discrepency
• four types of deformity (Cavus= high arch, adductus, varus= heel curs towards midline, equinus= foot points downward
• treated with surgical correction; >40% severe OA
• ponseti casting: weekly casting (4-8 casts) start after leave hospital

Answer 4

Congenital talipes equinovarus (aka clubfoot)

Question 5

• In-toeing or out toeing
• exam: gait observation: prone, knees flexed 90 degrees: thigh-foot angle, hip internal/external rotation
• imaging: none
• treatment: none unless tripping/falling
• referal: tripping/falling not improved by physical therapy (nonurgent)

Answer 5

Tibal torsion

Question 6

• 1:100-1:1000
• breech presentation
• objective is detection of hip instability
• postive ortolani exam, abnormal gait
• imaging: screening ultrasound
• referral: ortolani positive, abnormal ultrasound (< 2 weeks)
• treatment: bracing (pavlik harness)

Answer 6

developmental dysplasia of the hip

Question 7

• Hip/groin/leg pain, limp, 3-10 years old
• acute onset pain, waxing/waning (if chronic); injury, fever, ability to bear weight
• exam: gait, hip range of motion
• imaging: AP/frog pelvis
• referral: Semi-urgent (< 1 month)
• treatment: activity modification, physical therapy, bracing/surgery

Answer 7

Legg-Calve Perthes Disease

Question 8

• Acute/chronic hip/groin/knee pain, > 10 years old
• Exam: BMI, hip motion
• imaging: AP/frog pelvis
• referral: emergent
• treatment: surgery

Answer 8

Slipped capital femoral epiphysis

Question 9

Types

Congenital

• abnormality in vertebral formation
• associated with CNS, renal/caridac abnormalities

Early onset

• < 10 y.o
• 20% have underlying cause

Adolescent; Presentation: Uneven shoulders or hips

Screening

• Adams forward bending test- spine curve, paraspinous process
• scoliosis is a 3 dimensional deformity so obtain PA and lateral images
• risk of progression increases with severity of curve and younger age

Answer 9

Scoliosis

Question 10

indications for bracing for scoliosis

Answer 10

• 20 -25 degree curve or greater
• less effective if > 30 degrees, obese, male
• goal- prevent progression > 50 degrees, maintain curve

Alternative treatments for bracing

• Dynamic bracing not helpful
• schroth PT
• Chiropractic

Question 11

• tibial tubercle apophysitis
• diagnosis is clinical; palpation of tubercle, gait
• resolves with physeal closure
• symptomatic treatment
• Presentation: insidious anterior knee pain, bump at tibial tubercle
• imaging typically not needed
• treatment: rest, activity modification

Answer 11

osgood- schlatter

Question 12

• irritation of retropatellar surface, insidious anterior knee pain with activity; clickin/ popping, limp exacerbants, relievers
• clinical diagnosis (pain around patella, atraumatic/ overuse, pain on underside of patella and or with compression of patella
• imaging to assess for osteochondritis dissecans (OCD) and or alignment
• treatment: Minimize alignment issues, physical therapy, shoes

Answer 12

patellofemoral pain

Question 13

• annular ligament subluxation
• produced by pull on arm with forearm pronated
• typically < 6 y.o
• treatment with reduction maneuver; if unable to reduce- consider occult fracture, X-ray before reduction

Answer 13

nursemaid elbow