Pediatric Orthopedics Flashcards
A true groin pull is actually what type of strain?
adductor strain
common injuries along with groin pain
- Avulsion fractures of the pelvis are common in young adults
- Stress fractures of the femoral neck is a common injury
Refusal to bear weight at all
Refusal to move hip
Pain more than 24-48 hours
dx?
tx?
groin pain
PT, NSAIDs, rest
3 types of knee pain
- acute
- chronic
- popping
acute knee pain causes
- ligaments - torn ACL, MCL
- fx - tibial spine or osteochondral fx (MC), patellar sleeve
- PE:
- Ballotment Test - effusion
- Patellar Apprehension test - patellar dislocation
- Lachman - ligamentous injury
- Anterior Drawer - ligamentous injury
- McMurray’s Test - meniscus tears
- Varus and Valgus injuries - may be associated with popliteal artery injury
an important bony prominence that anchors the attachment of the ACL
Tibial spine
an avulsion fracture of the ? is the equivalent of an ACL rupture in adults
tibial spine
tibial spine fx s/s
Hemarthrosis, joint pain, markedly decreased ROM, sudden pain
tx for tibial spine fx
- Nondisplaced - immobilization in extension, ortho f/u; dx by radiographs, repeat in 2 weeks to check healing
- Displaced - reduction and immediate ortho consult
Osteochondral fractures to the intra-articular portions of the femoral condyles or tibial plateau MC associated with what other injuries?
- frequently accompany patellar dislocation
- ligament tears
- meniscal injuries
what findng may arise from Osteochondral Fractures?
Results in mechanical sx (catching, locking)
If untreated, will develop in osteoarthritis
Will complain of continued pain, swelling, and mechanical
Osteochondral fragments
screening of choice for Osteochondral Fracture
MRI
refer to peds ortho
- Caused by an indirect force applied to the patella through sudden, forceful contraction of quadriceps to a flexed knee
- someone lands on feet after jumping from moderate height or comes to sudden stop from full sprint
- knee joint effusion or hemarthrosis and focal tenderness of patella
- May not be able to extend knee against gravity
dx?
w/u?
tx?
- Patellar Sleeve Avulsion Fracture
- XR, MRI
- immobilize knee with ortho referral for surgery
Should the force generated by the quadriceps exceed the strength of the patella, what often results?
avulsion fracture - Separation between cartilage “sleeve” and main part of patella
T/F: patellar sleeve fx - hemarthrosis and PE findings are more predictive than XR findings
T
what is osteochhondritis dissecans
- Osteonecrosis of subchondral bone due to overuse
- Similar to AVN
- Localized lesion in which segment of subchondral bone and articular cartilage separates from underlying bone
- necrotic bone is replaced by subchondral trabeculae or cartilage - focal areas of demineralization and repeated shear forces = detachment of bone and overlying cartilage
w/u and tx for osteochondritis dissecans
- XR initially, MRI is dx of choice
- PT/knee immobilization 4-6 weeks
- Surgery for those who do not respond
- Pain journal
osteochondritis dissecans Can result in ? if not adequately treated .
premature arthritis
possible causes of popping knee pain?
tx?
- Pain, Edema? after an injury ?
- More and more loose / unstable?
- Cartilage damage?
- Abnormal meniscus?
- Tx: bracing and PT; May need an MRI/ Ortho
MC ankle sprain
Calcaneofibular ligament and anterior talofibular ligament
s/s of sprain ankle?
tx?
- Edema around the site, not ON the bone
- Improves over a few days time
- Tx: Brace, support, NSAIDS; Still need controlled ROM
ligament sprain grading
- grade I - stretching, small tears
- Grade II - larger, but incomplete tear
- Grade III - complete tear
possible causes of a limp in child
- INJURY / INFLAMMATION OR INFECTION
- TUMOR OR CANCERS
- CONGENITAL ANOMALIES
- LCP DISEASE
- SCFE
- DISKITIS
- CNS DISORDER
- MCC for inflammatory childhood limp
- an inflammation of the joint- hips and knee affected MC
- occurs after a recent URI
Toxic synovitis
a bacterial infection of the hip and far more dangerous
Septic arthritis
criteria for septic arthritis
Kosher Criteria: >101.3, ESR > 40 , WBC >12K, NO wt-bearing
- Level 1 - 3% chance of SA
- Level 2 - 40%
- Levels 3 & 4 - almost definite
w/u and tx for Transient Synovitis vs Septic Hip
- AP pelvis w/ frog leg views
- Hip effusions, bony changes, soft tissue shadows - in both
- U/S for effusions - both
- MRI of pelvis (septic) - bone marrow destruction / bone erosion / cartilage destruction - Labs - CBC, ESR, CRP, BMP
- I&D if needed - aspiration of joint fluid; abx - cover staph aureus
MCC of Intoeing in infants birth to < 1y/o
Metatarsus Adductus
- Inward deviation of the forefoot in relation to the hind foot
- Does not involve the ankle
- Ventral crease in medial aspect of the arch
- “C”-shaped foot or “kidney bean” shape
Metatarsus Adductus
Metatarsus Adductus is linked to ___ ___ and postion in the womb
intrauterine molding
RF for metatarsus adductus
breech presentation, family history of MA, hip dysplasia, decreased amniotic fluid, first born, twins
which foot is MC seen with metatarsus adductus?
Left - if unilateral
when does Metatarsus Adductus usually resolve?
MC 1st birthday
rest by 5-6 y/o w/o intervention
category severity of metatarsus adductus
- Mild – examiner can passively over-correct the deformity into abduction with little effort
- Moderate – examiner can passively correct the deformity only into middle position
- Severe – examiner is unable to correct the deformity to midline
tx for metatarsus adducutus
- mild-mod: Treatment - stretching, observation
- severe: corrective casting before 8 months of age or surgery in severe cases
- Congenital deformity present at birth or on prenatal US
- Foot points downward and inward and soles of feet face each other - foot appears internally rotated at ankle
- Shortening of Achilles tendon, tendons of medial lower leg, unusual shape to talus bone
- Idiopathic or isolated 80%
- Males > females
Clubfoot (Talipes Equinovarus)
- Calf muscles appear underdeveloped
- Plantar flexion of the foot and ankle
- Inversion of the heel
- Medial deviation of the forefoot
Clubfoot
Clubfoot associated conditions?
- dec amniotic fluid, genetic factors, familial history, twins, spina bifida
- smoking during pregnancy (20x avg risk), infection during pregnancy or illicit drug use while pregnant
types of clubfoot
- Congenital: Unknown etiology (MC)
- Syndromic: Spina Bifida
- Positional: Intrauterine crowding, Breech, Low amniotic fluid
tx for clubfoot
- Ponseti Method - foot manipulation, casting
- Surgery - achilles tendon release
- French Functional Method - stretches and exercise, massage, immobilize and taping foot position, PT until 2 y/o
Most common cause of intoeing and out-toeing in older children
Tibial Torsion - “Knock-knees” or “Pigeon-toes”
MCC of intoeing in children aged 1 - 3
Internal Tibial Torsion
- Inward twisting of tibia (tibia rotated inward)
- Usually noticed when toddlers start to walk
- Medially deviated foot with patella facing forward
Internal Tibial Torsion
Fastest runners are typically ? (sprinters and athletes)
in-toed
Tibial Torsion usually resolves by what age when tibia rotates laterally
5 yrs
mgmt for tibial torsion?
- XR to R/O hip dysplasia
- CT scan of hips and femur
- No tx unless feet still turn inward by >15 degrees at age 5 – spontaneous correction unlikely at that point
- Refer to orthopedics if > 8 y/o and activity is limited or cosmetic reasons
- orthotics is ineffective
- MCC of out-toeing in toddlers and young children
- identified when child begins to walk
- Medial malleolus is anterior to lateral malleolus
- Can be discovered later at 4-7 years old or early adolescence
- Can worsen over time but doesn’t cause sx
- Normal rotational variant due to intrauterine positioning
External Tibial Torsion
- Increased angle of rotation of femoral neck in relation to transcondylar axis of femur
- Prefer sitting in “W” position
- “Egg-beater” or “Windmill” pattern of walking and swimming
- Familial
- Refer if persists past 11 years of age
- Femoral derotational osteotomy (child with severe dysfunction or deformity)
Femoral Anteversion
MCC of intoeing after 3 y/o
Inward facing feet and patella
Femoral Anteversion
definition of unstable hip?
hip loose in socket with abnormal movement
definition of subluxation hip
partial dislocation (hip partly out of socket)
definition of dislocated hip
hip completely out of socket
definition of hip Dysplasia
wide spectrum term ranging from unstable to dysplastic to malformed
definition of Newborn hip instability preferred term by AAP
hip noted to enter and exit socket
- Normally formed hip that becomes displaced in utero or at ≤ 1 yr of age in otherwise healthy child
Instability or looseness of hip joint. Head of femur loose and may dislocate
DDH – Developmental Dysplasia of Hip
RF for DDH
- Familial link – 30x more likely
- Girls
- Breech, Twins, First born
- Swaddling link
which hip is MC affected with DDH?
left hip
- Asymmetrical buttock or thigh hip creases / skin folds
- Hip clicks - may be normal
- Difficulty diapering
- Painless, but exaggerated waddling limp after learning to walk
- Swayback
- Limited abduction of the hip
- Trendelenburg sign
DDH
painless limp and lurch to one side with a dip in pelvis on opposite side when child stands on affected leg (secondary to weakness of gluteal muscle)
Trendelenburg
barlow maneuver?
- Thigh grasped loosely with examiner’s index and middle finger along the greater trochanter and thumb along inner thigh
- Hip adducted and posteriorly directed pressure applied
- “jerk” or “clunk”
Ortolani Maneuver?
- Thigh grasped loosely in same manner as the Barlow Maneuver
- From an adducted position – the hip is abducted while lifting the trochanter anteriorly
- “jerk” or “clunk”, even a sliding type sensation like a “ball moving in a bowl”
types of DDH
- Subluxated: Head of femur loose in socket; Bone moved during physical exam but won’t dislocate
- Dislocatable: Head of femur is in acetabulum but easily pushed out during physical examination
- Dislocated: Most severe; Head of femur completely out of socket
w/u for DDH
- US – standard for diagnosis
- XR – AP pelvis, bilateral hips and frog leg views
when to US suspected DDH?
- Any child w/ instability
- born breech > 34 weeks gestation should be screened
- FHx DDH
when to XR for suspected DDH
- Any child 4 - 6 months of age and older with instability
- Any child with a limp or unstable gait when able to walk
tx for DDH
- MC resolve by 2 – 6 wks of age
- Positive Ortolani at any age - refer
- Positive Barlow - observe and follow
- 0 – 6 mo – Pavlik Harness
- 6 – 18 mo – closed reduction, Spica casting x 2-3 mo
- 18 mo – 6 yrs – closed reduction vs. open reduction
- > 6 yrs – no tx
- Inflammation of the patellar tendon
- Growth spurts during puberty
- Pain and tenderness to tibial tubercle +/- edema
- Worsens with activity / Improves with rest
- Tightness in surrounding muscles
- Usually unilateral, BL 25 – 50%
- Overuse injury caused by repetitive strain and chronic avulsion of ossification center of tibial tubercle
Osgood Schlatter Disease
tx for OSD
- RICE, stretching quads, PT if needed
- Complete avoidance of PE not recommended – playing IS permitted. No crutches or knee immobilizers
Most common chronic anterior knee pain in athletes
Degeneration of cartilage due to poor alignment of kneecap
Abnormal tracking allows patella to grate over the femur causing chronic inflammation
Patellofemoral Syndrome
Patellofemoral Syndrome - who is at highest risk?
teenage females
- Aggravated by activity or prolonged sitting with bent knees – “theatre sign”
- Vague discomfort inner front knee with running, climbing, jumping and stairs
- Patient points to anterior knee or around entire patella as area of pain
- Knock-knee, flat footed
dx?
w/u?
tx?
- Patellofemoral Syndrome
- Clinical, may see on x-ray or MRI
- Ice, NSAIDS, DC activity causing the pain
Ball of upper end of femur slips off in a backward direction secondary to weakness in the growth plate
One of the most common hip disorders in adolescents
Slipped Capital Femoral Epiphysis
biggest RF for Slipped Capital Femoral Epiphysis
obesity
Slipped Capital Femoral Epiphysis MC seen at which hip?
left hip
- Several weeks or months of hip or knee pain, intermittent limp. Pain during exam with limited internal hip rotation.
- acute or chronic
- Stable – can ambulate with assistance such as crutches; foot is gradually externally rotating
- Unstable – cannot ambulate even with crutches. Non-weight bearing
dx?
w/u?
SCFE
X-ray, U/S, MRI
tx for SCFE
- Surgery – internal fixation with single cannulated screw placed in center of epiphysis
- Post-op - Limited weight bearing and crutches
how to categorize SCFE
Categorized by % displacement
- Type 1 (mild) - < 33% displaced (epiphysis < 1/3 diameter of femoral head)
- Type 2 (moderate) – 33 – 50% displaced
- Type 3 (severe) - >50% displaced
complications of SCFE
- AVN of femoral head
- Chondrolysis at hip joint (loss of cartilage); osteoarthritis
- Blood supply temporarily interrupted to femoral head
- Bone dies and easily breaks
- Idiopathic avascular necrosis of the hip
Legg-Calve Perthes Disease
Legg-Calve Perthes Disease MC affects who?
- boys
- caucasians (AA very rare)
- 3 – 12 years old, peak 5 – 7
s/s LCPD
- Limp
- Pain or stiffness in hip, groin, thigh or knee
- Limited ROM to hip joint
w/u for LCPD
- XR - May take 1-2 mo to show; Joint effusion with widening of joint space and periarticular swelling
- MRI
- Bone Scan
tx LCPD
- Protection of the joint by minimizing impact
- PT
- Avoid weight bearing
- Traction
- Casting
- Home Therapy - Activity modification, Pain meds, Ice / Heat
- Surgery controversial – tendon release, joint realignment, joint replacement
Increased risk of arthritis in adulthood
Any degree of curvature of the spine as described by the ?
Cobb’s angle
scoliosis is Screened age 8 – 9 and older by ?
Adam’s forward bend test (AFB)
how to dx scoliosis?
XR
Cobb’s angle
tx for scoliosis
- < 20 degrees – follow for progression
- > 20 degrees or progression of ≥5 degrees – refer for bracing or surgery
what is a Toddler’s Fracture?
- 9 – 36 months MC age
- Distal ½ of tibia
- Trivial injury common - Fall from low height, Tripping, Twisting ankle
- “CAST” – Childhood Accidental Spiral Tibial fracture
- Refuse to bear weight on extremity
- Screen for child abuse
- Genetic connective tissue disease
- Multiple and recurrent fractures
- Blue sclera
- Thin skin
- Hyperextensibility of ligaments
- Otosclerosis w/ hearing loss
- Deformed teeth
- Osteoporosis / Osteopenia
Osteogenesis Imperfecta
Genetic mutation causing short-limbed dwarfism - autosomal dominant w/ 80% cases from random mutation
Achondroplasia
- Short stature – usually around 4 feet tall max
- Average-sized trunk
- Short arms and legs w/ bowing
- Waddling gait
- Macrocephaly with prominent forehead
- Normal Intelligence and sexual function
dx?
tx?
- Achondroplasia
- Endocrine - growth hormone in some cases; Genetics
- Birth defect causing the early growing together of two or more bones of the skull
- Sutures close too early
- Sporadic – occurs by chance
- Asymmetrical head shape or appearance, hydrocephalus
Craniosynostosis
what is Plagiocephaly?
abnml head from how a baby is laid
- Specifically referred to as X-linked hypophosphatemia (XLH)
- 80% of all hypophosphatemia
- Mutation of the phosphate-regulating gene
Familial Hypophosphatemic Rickets
s/s of familial hypophosphatemic rickets
- Impaired growth and rickets of the femur/tibia - short stature of the lower limbs
- Dental abnormalities - delayed dentition and abscesses
- Deafness
- Chiari malformation of the brain
- Calcification of tendons, ligaments and joints
- Craniosynostosis
w/u and tx for Familial Hypophosphatemic Rickets
- XR - short, coarse long bones
- Labs - severe hypophosphatemia (< 2.5), elevated serum alk phos, Ca normal to low
- Tx: Calcitriol with Amiloride and HCTZ; GH possible option
what is Nursemaid Elbow?
tx?
- Subluxation of radial head
- 1-4 years of age MC
- Tug or pull injury
- Holds arm by side - fully pronated, refuses to use
- XR normal
- Tx: closed reduction – supinate hand and flex elbow – “pop” over radial head
