Pediatric orthopedics

Question 1

Slipped capital femoral epiphysis (SCFE)

Answer 1

• Femoral neck slips out from femoral head
• Etiology is unknown, obesity (mechanical) very likely
• Most common in 10-16 yo boys
• Related factors: obesity, african american
• Presentation (delayed Dx common): hip, thigh, KNEE pain
• Limp/can’t bear weight
• PE: obligate external rotation of the femur upon hip flexion
• To confirm Dx get X-rays: AP and later, and of both hips
• Rx is surgery: pins in situ

Question 2

Leg-calve-perthes (LCP) disease

Answer 2

• Idiopathic avascular necrosis of femoral head in children
• Usually 4-8 yo, often boys
• Related factors: hematologic (coagulopathies)
• Presentation: limp, w/ groin, hip, thigh or knee pain (usually activity related)
• Dx: X-rays (later/AP of both hips), sometimes MRI
• Younger age of onset is better prognosis
• Majority of hips will not require Rx other than symptomatic and supportive care, other Rx controversial

Question 3

Scoliosis 1

Answer 3

• Abnormal lateral curvature of spine (>10 deg)
• Most common type: adolescent idiopathic scoliosis
• Mostly in children 10-16, no underlying cause/complants
• Normal neuro exam
• Dx of exclusion, more often affects girls
• Congential scoliosis: failure of spine to form completely or separate properly (hemivertebrae)

Question 4

Scoliosis 2

Answer 4

• Also neuromuscular scoliosis (cerebral palsy, muscular dystrophy, spina bifida)
• Early signs of scoliosis: uneven shoulders, prominent shoulder blades, uneven waist line, lumbar prominence, leaning to one side, adam’s forward bending test
• Complications: pulmonary compromise (>100 deg), decreases thoracic volume
• Rx: observation, bracing (25-45 deg, less than 12-13), surgery (>45 deg)

Question 5

Fractures in children

Answer 5

• Causes: blunt trauma (abuse, falls, MVA)
• Common sites: fingers, distal radius, UE much more common than LE
• Epiphysis: head of long bone, metaphysis is below the epiphysis
• Btwn these two is the physis, or the growth plate
• Physis fractures classified by the salter-harris scale

Question 6

Salter-harris classification of fractures

Answer 6

• 1: S=Same. Fracture of the cartilage of the physis
• 2: A=Above. Fracture above the physis (metaphysis side)
• 3: L=Lower. Fracture is below the physis, in the epiphysis
• 4: T=Through. Fracture is thru the metaphysis, physis, and epiphysis
• 5: ER: Erased (crushed): physis has been crushed

Question 7

Growth disturbances from fractures

Answer 7

• Physeal injury
• Premature shortening of bone
• Malangulation of bone
• But fractures can remodel in children: there is asymmetric growth of physis, and concavity filled (resorption of one side and growth of the other)

Question 8

Supracondylar humerus fracture

Answer 8

• Most common operative fracture (6-7 yr)
• 10% risk of neuromuscular injury
• Most common is anterior interosseous nerve, can check by having them give the ok sign
• Flexion type of complication: damage to ulnar nerve
• Rx: nails to re-align the humerus

Question 9

Infections of synovium and bone in children

Answer 9

• Osteo/septic arthritis: usually staph aureus
• In neonates: group B strep
• In sexually active teens: Nisseria gonorrhea
• Kocher criteria: to help differentiate septic arthritis and transient synovitis
• 5 predictors: fever, non-weight bearing (NWB), WBC>12, ESR>40, and CRP>2
• More than 3 and it is most likely septic arthritis

Question 10

Natural hx of knee alignment in children

Answer 10

-Varus then valgus then normal