Pediatric Orthopedics Flashcards
Metatarsus Adductus presentation
- Usually flexible, inward, congenital,
medial deviation of the forefoot - vertical crease in the medial aspect
of the arch, when more rigid - 10–15% also have hip dysplasia
Metatarsus Adductus Epidemiology
- Congenital flexible deformities
- usually 2° to intrauterine
crowding - Etiology of rigid deformities
- unknown
Metatarsus Adductus management
- Flexible deformities usually resolve spontaneously
- If the deformity is rigid & cannot be manipulated
past the midline: - Serial casting to correct the deformity
- Cast changes q1–2-weeks
- Corrective shoes thereafter
- maintainence
3 Classic Features of Clubfoot (Talipes Equinovarus)
- Metatarsus adductus
* Toeing in - Inversion deformity of the heel
* Varus - Plantar flexion of the ankle
* Short Achilles tendon
Clubfoot (Talipes Equinovarus) etiology
- Idiopathic
- May be hereditary
- Neurogenic
- Possible innervation changes during
intrauterine life 2°neurologic event (stroke?)
→ mild hemi/para-paresis - 35% incidence of varus & equinovarus
deformity in spina bifida
Clubfoot (Talipes Equinovarus) Diagnosis
- Clinical
- Imaging studies generally are not needed for diagnosis
- Baseline studies before & after surgical correction of the feet
Clubfoot (Talipes Equinovarus) Management
- Ponseti technique at birth
- Stretch contracted posteromedial tissues
- Cast to hold the correction
- Serial castings Q wk x 6-8 weeks
- Correction is rapid
- Treatment delay → foot can become more rigid in days
- After full correction → night brace for long-term maintenance
1st Ponseti cast
Note the positioning of the forefoot
to align with the heel, with the outer
edge of the foot tilted even further
downward due to Achilles tendon
tightness.
What is different after the first ponsetti cast?
- The foot is straight & the cavus
& crease are no longer evident.
What is a cavus deformity?
Characterized by a visible crease in
the midsection of the foot.
How is the 2nd ponsetti cast applied?
- applied with the outer edge of the
foot still tilted downward & the
forefoot moved slightly outward.
How is the 3rd ponsetti cast applied?
- The Achilles tendon is stretched,
bringing the outer edge of the foot
into a more normal position as the
forefoot is turned further outward.
How long is the ponseti technique done for?
- Infant is placed into an orthosis, or brace, which maintains the foot in its
corrected position. - The brace is worn 23 hours/day for the 3 months following casting, then
while sleeping usually until around age three or four.
Tibial Torsion
- Pediatric “toeing in” a common parental concern
- Tibial torsion: Rotation of the leg between the knee & ankle
How does tibial torsion occur?
- Normal internal rotation ~20 degrees at birth
- ↓ to neutral rotation by age 16 months
- May be accentuated by laxity of the knee ligaments
- allows excessive internal rotation of the leg
Etiology of Tibial Torsion
Intrauterine crowding
Tibial Torsion Diagnosis
- Clinical
- Confirmed by measuring thigh-foot angle
- negative angle indicates internal tibial torsion
- Imaging rarely needed
- CT used to assess extent of rotation in children
with severe torsion requiring surgical correction
Tibial Torsion Management
- Usually self-limiting
- Resolves spontaneously
- Educate families to the benign
nature of the condition
Surgical treatment for Tibial torsion
Tibial Derotational Osteotomy
Osgood-Schlatter Disease
- Chronic anteroinferior knee pain
- Adolescent actively participating in
sports
Osgood-Schlatter Disease Etiology
- Traction apophysitis theory
- Repetitive distraction force on developing
tibial tuberosity - As the tibial apophysis matures, tibial tuberosity
unable to withstand repetitive strain exerted by quadriceps via
patellar tendon - Micro-avulsions occur with 2° ossification
- Osteocyte hypertrophy results in enlarged tibial tuberosity
Osgood-Schlatter Disease Diagnosis
- Clinical diagnosis
- X-ray may help r/o
other causes
Osgood-Schlatter Disease Staging
- Stage 1 = Pain after physical activity
- Stage 2 = Pain during physical activity
- Does not affecting function
- Sports participation can be continued
- Stage 3 = Pain during physical activity
affecting function & lasts all day - Sports activities are ↓ or stopped
- Stage 4 = Pain during all physical activities
Lateral x-ray view of the knee with Osgood-Schlatter Disease shows:
- Thickened patellar tendon
- Irregular ossification of the
tibial tuberosity- Localized soft tissue swelling
at this region
Osgood-Schlatter Disease Management
- Rest, Ice, Compression, Elevation,
Stabilization (R.I.C.E.S.) - Physical Therapy
- NSAIDS
- Prophylactic strapping
- Refer to ortho for refractory cases
Patellofemoral Syndrome & presentation
- Anterior knee pain described as being behind, around, or underneath patella
- Usually gradual onset (could be acute, if associated with trauma)
- Worse with prolonged sitting (+ Theater sign) or going down stairs
- May be exacerbated by running, jumping, or climbing stairs
Patellofemoral Syndrome Epidemiology
- young women > men
- Most common cause of anterior
knee pain - 16-25% of all injuries in runners
Patellofemoral Syndrome Diagnosis
- History + Clinical exam
- Anterior knee pain worse with long periods of sitting or descending stairs
- Painful resisted knee extension
- Painful squatting
- X-ray may be helpful to r/o other conditions
- MRI (usually not necessary)
Patellofemoral Syndrome Management
- R.I.C.E.S.
- NSAIDS
- Corticosteroid injection
- Prolotherapy or Platlet-Rich plasma injection
- Induce inflammatory process
- Surgery for severe refractory cases
Developmental Dysplasia of the Hip (DDH) presentation 0-3 months
- 0 – 3 months
- Difficulty putting on diapers
- Limited hip abduction or difference in leg length
Developmental Dysplasia of the Hip (DDH) presentation 4-11 months
- Leg dragging or trouble crawling
- Difficulty straddling adult’s leg
Developmental Dysplasia of the Hip (DDH) presentation Toddlers (1-3 years)
- Limping or toe walking on affected side
- Waddling gait
- ↑ lumbar lordosis
- Prominent buttocks
- Difficulty pedaling a tricycle
Developmental Dysplasia of the Hip (DDH) presentation in older children & adolescents
- Asymptomatic to slight discomfort with weight-bearing activities
- Associated with labral tear
- May experience catching, locking, or popping sensations in hip joint
- In older teenagers, continued pain may indicate osteoarthritis
Developmental Dysplasia of the Hip (DDH) Etiology
- Intrauterine abnormal positioning
- Extreme hip flexion
- Final trimester of pregnancy
- Laxity of hip ligaments & capsule may
promote femoral head subluxation
or dislocation - Leads to shortening & contracture of
iliopsoas muscle
Developmental Dysplasia of the Hip (DDH) Diagnosis
- Clinical diagnosis
- Instability of the joint demonstrated by
placing the supine & relaxed - Subtle signs (crying or upset infant, easily missed)
- Barlow test (dislocating the hip)
- Ortolani (relocating the hip)
- Restricted hip abduction
Imaging for confirmation - US < 4 months old
- X-ray > 4 months old
*Most sensitive sign associated with DDH in older infant
Restricted abduction of hips* < 60 degrees
Developmental Dysplasia of the Hip (DDH) Management
- Splints are used initially for infants
≤ 3 months old unless hip is not
reducible or family/social situation
makes splinting unreliable - Spica CAST
- Orthopedic surgery referral is
commonly indicated for DDH
When is a Spica CAST indicated?
- Infant > 6 months old
- Reduction is not achieved after
2 weeks in Pavlik harness, other
splinting device, or if the patient
is not appropriate for splinting
T/F Dysplasia is progressive with growth,
unless corrected
T
What is a pavlik harness?
- A Pavlik harness holds the hip in a flexed &
abducted position - Safe treatment requires that the hips must be manually
reducible with only gentle manipulation - (ie Barlow & Ortolani)
- If a Pavlik treatment cannot be used, then a
closed reduction with arthrogram is appropriate
treatment, followed by a hip spica cast
Developmental Dysplasia of the Hip (DDH) Complications
- Acetabular blunting or dysplasia (Pavlik harness disease) from prolonged
inadequately reduced femoral head resting on posterior lip of acetabulum - Osteoarthritis
- Avascular necrosis (osteonecrosis) of femoral head
If a Pavlik treatment cannot be used, then what can be done?
a closed reduction with arthrogram is appropriate treatment, followed by a hip spica cast
Slipped Capital Femoral Epiphysis (SCFE)
- Most commonly seen in adolescent, obese males c/o pain in the groin, lateral
or posterior hip/thigh - Ipsilateral knee pain in some patients (15 - 50%)
Slipped Capital Femoral Epiphysis etiology
- Mechanical overloading of
proximal femoral physis causes
displacement of the proximal
femoral epiphysis - Head of the femur is usually
displaced medially & posteriorly
relative to the femoral neck
Slipped Capital Femoral Epiphysis (SCFE) Diagnosis
- Child or adolescent with
characteristic clinical presentation - Limp & pain in groin, hip, thigh, or
knee
X-ray: Confirms diagnosis - Used to grade severity
Slipped Capital Femoral Epiphysis (SCFE) Management
- Stabilize the femoral epiphysis to
prevent further displacement, deformity, & other complications - Place patient in wheelchair
immediately or on non-weight- bearing crutches & refer to orthopedist - Surgical fixation is definitive
treatment for SCFE
Legg-Calves-Perthes Disease presentation
- Brought in by parents worsening
limping with pain in anterior hip, or
referred to knee & medial thigh, with
antalgic gait - Usually unilateral, but can be
bilateral in 10-15% of cases
This can happen in children 3-12 years old but is Most common in children aged 4-8 years
Legg-Calves-Perthes Disease
Legg-Calves-Perthes Disease etiology
- Cause unknown
- Theory → Disruption of blood supply to the femoral head
- Results = Disruption of the bone formation of the femoral head
Legg-Calves-Perthes Disease diagnosis
- Suspected in children with mild hip
pain (or referred to knee or thigh),
limp, &/or limited hip motion - X-ray may help to confirm diagnosis,
assess severity/stage, & detect
severe forms early - Bone scintigraphy
- Magnetic resonance imaging
- Greatest sensitivity
- Labs: R/O septic arthritis &
transient synovitis of the hip - CBC, ESR, CRP
What will you see on imaging for Legg-Calves-Perthes Disease
- Flattening & sclerosis of right
femoral epiphysis, suggests
osteonecrosis - Mild soft tissue swelling around
right hip with mild lateral
displacement of femoral head - No abnormal finding in left hip
- Legg-Calve-Perthes disease could
be considered if no other detectable
cause from history
Legg-Calves-Perthes Disease management
- Conservative management 3-12
years old - Pain medication
- Physical therapy
- Acetabular rotational osteotomy
(Salter osteotomy)
Nursemaid’s Elbow presentation
- Brought in by parents c/o elbow pain
- History of the child’s arm having been
pulled - Generalized pain in the arm,
exacerbated by movement
Most common elbow injury in children
Nursemaid’s Elbow
Nursemaid’s Elbow diagnosis
- Clinical exam
- Infant/child refuses to use injured
arm - Arm held in pronation with the
elbow mildly flexed &
adducted (self-splinted) - Tenderness over the radial head
- Elbow x-rays (AP & lateral) are
usually unnecessary - Useful if concerned for fractures
or after unsuccessful closed
reduction
Nursemaid’s Elbow Management
- Treatment involves closed reduction of the subluxation
- Splinting & immobilization are unnecessary after reduction
- Pain medications prn
Nursemaid’s Elbow Reduction: Hyperpronation method
- Position the patient’s elbow at 90°
- Use your contralateral hand to cup patient’s elbow with your thumb
stabilizing the radial head - Using your other hand, grasp the patient’s hand or wrist (as if you are
about to shake hands) & rapidly hyperpronate the patient’s wrist - If subluxation still not reduced, flex the elbow
Nursemaid’s Elbow Reduction: Supination method
- Position the patient’s elbow in slight extension beyond 90°
- Use your contralateral hand to cup patient’s elbow with your thumb
stabilizing the radial head - Using your other hand, grasp the patient’s hand or wrist (as if you are
about to shake hands) & supinate the patient’s wrist while also flexing at
the patient’s elbow
Adolescent Idiopathic Scoliosis Presentation
- Most patients with scoliosis present because of a perceived deformity
- Perceived by patient, family member, or medical provider
- Asymmetry of the shoulders, waist, breasts, or rib cage
- 25% report pain
Adolescent Idiopathic Scoliosis Diagnosis
- Adam’s forward bend test, inclinometer, & visual inspection to assess for
asymmetrical chest, back, pelvis, waist, &/or shoulders
What is Adam’s forward bend test used to check for?
Scoliosis
Adolescent Idiopathic Scoliosis imaging studies
- Scoliosis confirmed on
posteroanterior (PA) view with
Cobb angle ≥ 10°
Calculating the Cobb angle (PA view x-ray)
- Determine the vertebrae at the superior &
inferior ends of the curve (“end vertebrae”) - Draw straight lines along the superior end
of the superior vertebra & inferior end of
the inferior vertebra - Draw perpendicular lines to the 2 previous
lines (these lines would be vertical in a
straight spine) - Cobb angle is the angle between the
2 previous lines
Adolescent Idiopathic Scoliosis Management goal
- Prevent curve progression,
- Keep curve < 50o at maturity
Adolescent Idiopathic Scoliosis Management
- Consider bracing to prevent curve
progression in patients with curves 25-45
degrees - Most common brace = thoracolumbosacral
orthosis (TLSO) - Surgery (fusion of spine via instrumentation &
bone grafting) to stop curve progression &
improve spinal balance & alignment in
patients with curves > 50°
Salter-Harris Fractures
- Cartilage physeal plates
- Areas of relatively ↓ strength
compared to surrounding bone - Susceptible to fracture
- If displacement occurs in the physeal
substance, bone may grow across it
epiphyseal to metaphyseal bone, &
anchor it from further growth - Leads to progressive shortening
or worsening angulation
Salter-Harris classifications
S: slipped or straight (type I)
A: above (type II)
L: lower (type III)
T: through or transverse (type IV)
ER: erased or ruined or rammed (type V)
Most common type, making up approximately 75% of Salter-Harris fractures.
Type II
Type II salter-harris fracture
- Fracture extends through the physis & into a portion of the metaphysis
- 33-50% occur at the distal radius
- Other common fx: distal tibia, distal fibula &, phalanges
- Majority of fractures that involve the physis have at least a small
fragment of metaphysis associated with them & are type II injuries - Prognosis is generally favorable for healing without deformity
Salter-Harris I
- Epiphysis is separated from the end of the bone, or the metaphysis
- Vital portions of the growth plate remain attached to the epiphysis
- Rarely requires surgical reduction
- Type I injuries generally require a cast to keep the fracture in place as it heals
- Unless the blood supply is damaged, it is likely the bone will grow normally
Salter-Harris III
- Salter-Harris type III fractures pass through the epiphysis
extending and continuing to the edge of the physis. - Fracture through the epiphysis is vertical/oblique in orientation
- Fracture through the physis, horizontally oriented to the periphery
- No fracture of the metaphysis
- Angulation, displacement & rotation may occur
Salter-Harris IV
- The fracture line passes through the
epiphysis of the distal tibia, the growth
plate, the distal metaphysis & diaphysis
of the tibia, & the distal diaphysis of
the fibula - Salter-Harris type IV fractures demonstrate a
lucent fracture line extending through
metaphysis, across physis & into the epiphysis - Angulation, displacement & rotation may occur
Salter-Harris V
- Almost all Salter-Harris type V fractures are occult on initial imaging
- Usually retrospectively identified on follow up when there is
clinical deformity or radiographic evidence of growth arrest. - Though occult, narrowing of the physis may be noted
- History raises the index of suspicion
