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Pediatrics Exam 3 > Pediatric Orthopedics > Flashcards

Pediatric Orthopedics Flashcards

1
Q

Metatarsus Adductus presentation

A
  • 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
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2
Q

Metatarsus Adductus Epidemiology

A
  • Congenital flexible deformities
  • usually 2° to intrauterine
    crowding
  • Etiology of rigid deformities
  • unknown
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3
Q

Metatarsus Adductus management

A
  • 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
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4
Q

3 Classic Features of Clubfoot (Talipes Equinovarus)

A
  1. Metatarsus adductus
    * Toeing in
  2. Inversion deformity of the heel
    * Varus
  3. Plantar flexion of the ankle
    * Short Achilles tendon
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5
Q

Clubfoot (Talipes Equinovarus) etiology

A
  • 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
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6
Q

Clubfoot (Talipes Equinovarus) Diagnosis

A
  • Clinical
  • Imaging studies generally are not needed for diagnosis
  • Baseline studies before & after surgical correction of the feet
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7
Q

Clubfoot (Talipes Equinovarus) Management

A
  • 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
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8
Q

1st Ponseti cast

A

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.

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9
Q

What is different after the first ponsetti cast?

A
  • The foot is straight & the cavus
    & crease are no longer evident.
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10
Q

What is a cavus deformity?

A

Characterized by a visible crease in
the midsection of the foot.

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11
Q

How is the 2nd ponsetti cast applied?

A
  • applied with the outer edge of the
    foot still tilted downward & the
    forefoot moved slightly outward.
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12
Q

How is the 3rd ponsetti cast applied?

A
  • The Achilles tendon is stretched,
    bringing the outer edge of the foot
    into a more normal position as the
    forefoot is turned further outward.
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13
Q

How long is the ponseti technique done for?

A
  • 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.
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14
Q

Tibial Torsion

A
  • Pediatric “toeing in” a common parental concern
  • Tibial torsion: Rotation of the leg between the knee & ankle
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15
Q

How does tibial torsion occur?

A
  • 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
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16
Q

Etiology of Tibial Torsion

A

Intrauterine crowding

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17
Q

Tibial Torsion Diagnosis

A
  • 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
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18
Q

Tibial Torsion Management

A
  • Usually self-limiting
  • Resolves spontaneously
  • Educate families to the benign
    nature of the condition
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19
Q

Surgical treatment for Tibial torsion

A

Tibial Derotational Osteotomy

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20
Q

Osgood-Schlatter Disease

A
  • Chronic anteroinferior knee pain
  • Adolescent actively participating in
    sports
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21
Q

Osgood-Schlatter Disease Etiology

A
  • 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
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22
Q

Osgood-Schlatter Disease Diagnosis

A
  • Clinical diagnosis
  • X-ray may help r/o
    other causes
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23
Q

Osgood-Schlatter Disease Staging

A
  • 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
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24
Q

Lateral x-ray view of the knee with Osgood-Schlatter Disease shows:

A
  • Thickened patellar tendon
  • Irregular ossification of the
    tibial tuberosity- Localized soft tissue swelling
    at this region
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25
Q

Osgood-Schlatter Disease Management

A
  • Rest, Ice, Compression, Elevation,
    Stabilization (R.I.C.E.S.)
  • Physical Therapy
  • NSAIDS
  • Prophylactic strapping
  • Refer to ortho for refractory cases
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26
Q

Patellofemoral Syndrome & presentation

A
  • 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
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27
Q

Patellofemoral Syndrome Epidemiology

A
  • young women > men
  • Most common cause of anterior
    knee pain
  • 16-25% of all injuries in runners
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28
Q

Patellofemoral Syndrome Diagnosis

A
  • 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)
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29
Q

Patellofemoral Syndrome Management

A
  • R.I.C.E.S.
  • NSAIDS
  • Corticosteroid injection
  • Prolotherapy or Platlet-Rich plasma injection
  • Induce inflammatory process
  • Surgery for severe refractory cases
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30
Q

Developmental Dysplasia of the Hip (DDH) presentation 0-3 months

A
  • 0 – 3 months
  • Difficulty putting on diapers
  • Limited hip abduction or difference in leg length
31
Q

Developmental Dysplasia of the Hip (DDH) presentation 4-11 months

A
  • Leg dragging or trouble crawling
  • Difficulty straddling adult’s leg
32
Q

Developmental Dysplasia of the Hip (DDH) presentation Toddlers (1-3 years)

A
  • Limping or toe walking on affected side
  • Waddling gait
  • ↑ lumbar lordosis
  • Prominent buttocks
  • Difficulty pedaling a tricycle
33
Q

Developmental Dysplasia of the Hip (DDH) presentation in older children & adolescents

A
  • 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
34
Q

Developmental Dysplasia of the Hip (DDH) Etiology

A
  • 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
35
Q

Developmental Dysplasia of the Hip (DDH) Diagnosis

A
  • 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
36
Q

*Most sensitive sign associated with DDH in older infant

A

Restricted abduction of hips* < 60 degrees

37
Q

Developmental Dysplasia of the Hip (DDH) Management

A
  • 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
38
Q

When is a Spica CAST indicated?

A
  • 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
39
Q

T/F Dysplasia is progressive with growth,
unless corrected

A

T

40
Q

What is a pavlik harness?

A
  • 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
41
Q

Developmental Dysplasia of the Hip (DDH) Complications

A
  • 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
42
Q

If a Pavlik treatment cannot be used, then what can be done?

A

a closed reduction with arthrogram is appropriate treatment, followed by a hip spica cast

43
Q

Slipped Capital Femoral Epiphysis (SCFE)

A
  • 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%)
44
Q

Slipped Capital Femoral Epiphysis etiology

A
  • 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
45
Q

Slipped Capital Femoral Epiphysis (SCFE) Diagnosis

A
  • Child or adolescent with
    characteristic clinical presentation
  • Limp & pain in groin, hip, thigh, or
    knee
    X-ray: Confirms diagnosis
  • Used to grade severity
46
Q

Slipped Capital Femoral Epiphysis (SCFE) Management

A
  • 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
47
Q

Legg-Calves-Perthes Disease presentation

A
  • 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
48
Q

This can happen in children 3-12 years old but is Most common in children aged 4-8 years

A

Legg-Calves-Perthes Disease

49
Q

Legg-Calves-Perthes Disease etiology

A
  • Cause unknown
  • Theory → Disruption of blood supply to the femoral head
  • Results = Disruption of the bone formation of the femoral head
50
Q

Legg-Calves-Perthes Disease diagnosis

A
  • 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
51
Q

What will you see on imaging for Legg-Calves-Perthes Disease

A
  1. Flattening & sclerosis of right
    femoral epiphysis, suggests
    osteonecrosis
  2. Mild soft tissue swelling around
    right hip with mild lateral
    displacement of femoral head
  3. No abnormal finding in left hip
  4. Legg-Calve-Perthes disease could
    be considered if no other detectable
    cause from history
52
Q

Legg-Calves-Perthes Disease management

A
  • Conservative management 3-12
    years old
  • Pain medication
  • Physical therapy
  • Acetabular rotational osteotomy
    (Salter osteotomy)
53
Q

Nursemaid’s Elbow presentation

A
  • 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
54
Q

Most common elbow injury in children

A

Nursemaid’s Elbow

55
Q

Nursemaid’s Elbow diagnosis

A
  • 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
56
Q

Nursemaid’s Elbow Management

A
  • Treatment involves closed reduction of the subluxation
  • Splinting & immobilization are unnecessary after reduction
  • Pain medications prn
57
Q

Nursemaid’s Elbow Reduction: Hyperpronation method

A
  • 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
58
Q

Nursemaid’s Elbow Reduction: Supination method

A
  • 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
59
Q

Adolescent Idiopathic Scoliosis Presentation

A
  • 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
60
Q

Adolescent Idiopathic Scoliosis Diagnosis

A
  • Adam’s forward bend test, inclinometer, & visual inspection to assess for
    asymmetrical chest, back, pelvis, waist, &/or shoulders
61
Q

What is Adam’s forward bend test used to check for?

A

Scoliosis

62
Q

Adolescent Idiopathic Scoliosis imaging studies

A
  • Scoliosis confirmed on
    posteroanterior (PA) view with
    Cobb angle ≥ 10°
63
Q

Calculating the Cobb angle (PA view x-ray)

A
  • 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
64
Q

Adolescent Idiopathic Scoliosis Management goal

A
  • Prevent curve progression,
  • Keep curve < 50o at maturity
65
Q

Adolescent Idiopathic Scoliosis Management

A
  • 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°
66
Q

Salter-Harris Fractures

A
  • 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
67
Q

Salter-Harris classifications

A

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)

68
Q

Most common type, making up approximately 75% of Salter-Harris fractures.

A

Type II

69
Q

Type II salter-harris fracture

A
  • 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
70
Q

Salter-Harris I

A
  • 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
71
Q

Salter-Harris III

A
  • 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
72
Q

Salter-Harris IV

A
  • 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
73
Q

Salter-Harris V

A
  • 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

Pediatrics Exam 3 (7 decks)

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