Pediatric Orthopedics Flashcards
Why do kids gets certain fractures?
■ thicker, more active periosteum results in pediatric-specific fractures: greenstick (one cortex), torus (i.e. ‘buckle’, impacted cortex) and plastic (bowing)
adults fracture through both cortices
Most common fractures in children
distal radius fracture most common in children (phalanges second), the majority are treated with closed reduction and casting
Epiphyseal growth plate
■ weaker part of bone, susceptible to fractures
■ plate often mistaken for fracture on x-ray and vice versa (X-ray opposite limb for comparison), especially in elbow
■ tensile strength of bone < ligaments in children, therefore clinician must be confident that fracture and/or growth plate injury have been ruled out before diagnosing a sprain
■ intra-articular fractures have worse consequences in children because they usually involve the growth plate
Role of anatomic reduction in children
■ gold standard with adults
■ may cause limb length discrepancy in children (overgrowth)
■ accept greater angular deformity in children (remodelling minimizes deformity)
Greenstick fractures are easy to reduce but can redisplace while in cast due to intact periosteum
When should you have a higher suspicion of child abuse
■ high index of suspicion with fractures in non-ambulating children (<1 yr); look for other signs, including X-ray evidence of healing fractures at different sites and different stages of healing
■ common suspicious fractures in children: metaphyseal corner fracture (hallmark of non-accidental trauma), femur fracture < 1 yo, humeral shaft < 3 yo, sternal fractures, posterior rib fractures, spinous process fractures
Stress fracture mechanism
• insufficiency fracture
■ stress applied to a weak or structurally deficien bone
• fatigue fracture
■ repetitive, excessive force applied to normal bone
• most common in adolescent athletes
Stress fracture most common site
tibia
Stress fracture diagnosis
- localized pain and tenderness over the involved bone
- plain films may not show fracture for 2 wk
- bone scan positive in 12-15 d
Stress fracture treatment
rest (can take several months)
Epiphyseal injury classification
Salter-Harris
Salter-Harris I description and treatment
Straight through; stable
Transverse through growth plate
Closed reduction and cast immobilization (except SCFE – ORIF); heals well, 95% do not affect growth
Salter-Harris II description and treatment
Above
Through metaphysis and along growth plate
Closed reduction and cast if anatomic; otherwise ORIF
Salter-Harris III description and treatment
Low
Through epiphysis to plate and along growth plate
Anatomic reduction by ORIF to prevent growth arrest, avoid fixation across growth plate
Salter-Harris IV description and treatment
Through and through
Through epiphysis and metaphysis
Closed reduction and cast if anatomic; otherwise ORIF
Salter-Harris V description and treatment
Ram
Crush injury of growth plate
High incidence of growth arrest; no specific treatment
What Salter Harris types are more likely to cause growth arrest and progressive deformity
III-V
Slipped Capital Femoral Epiphysis definition and risk factors
- type I Salter-Harris epiphyseal injury at proximal hip
- most common adolescent hip disorder, peak incidence at pubertal growth spurt risk factors: male, obese (#1 factor), hypothyroid (risk of bilateral involvement)
Slipped Capital Femoral Epiphysis etiology
• multifactorial
■ genetic: autosomal dominant, black children at highest risk
■ cartilaginous physis hypertrophies too rapidly under growth hormone effects
■ sex hormone secretion, which stabilizes physis, has not yet begun
■ overweight: mechanical stress
■ trauma: causes acute slip
Slipped Capital Femoral Epiphysis clinical features
• acute: sudden, severe pain with limp
• chronic (typically): groin and anterior thigh pain, may present with knee pain
■ positive Trendelenburg sign on affected side, due to weakened gluteal muscles
• tender over joint capsule
• restricted internal rotation, abduction, flexion
■ Whitman’s sign: obligatory external rotation during passive flexion of hip
• Loder classification: stable vs. unstable (provides prognostic information)
■ unstable means patient cannot ambulate even with crutches
Slipped Capital Femoral Epiphysis investigations
• X-ray: AP, frog-leg, lateral radiographs both hips
■ posterior and medial slip of epiphysis
■ disruption of Klein’s line
■ AP view may be normal or show widened/lucent growth plate compared with opposite side
Slipped Capital Femoral Epiphysis treatment
• operative
■ mild/moderate slip: stabilize physis with pins in current position
■ severe slip: ORIF or pin physis without reduction and osteotomy after epiphyseal fusion
Slipped Capital Femoral Epiphysis complications
• AVN (roughly half of unstable hips), chondrolysis (loss of articular cartilage, resulting in narrowing of joint space), pin penetration, premature OA, loss of ROM
What is Klein’s Line
On AP view, line drawn along supero-lateral border of femoral neck should cross at least a portion of the femoral epiphysis. If it does not, suspect SCFE
Developmental Dysplasia of the Hip definition
- abnormal development of hip, resulting in dysplasia and subluxation/dislocation of hip
- most common orthopedic disorder in newborns
Developmental Dysplasia of the Hip etiology
• due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of acetabular roof
• spectrum of conditions
■ dislocated femoral head completely out of acetabulum
■ dislocatable head in socket
■ head subluxates out of joint when provoked
■ dysplastic acetabulum, more shallow and more vertical than normal
• if painful, suspect septic dislocation (normally painless)
Developmental Dysplasia of the Hip physical exam
• diagnosis is clinical
■ limited abduction of the flexed hip (<60°)
■ affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum
■ Barlow’s test (checks if hips are dislocatable ◆ flex hips and knees to 90° and grasp thigh ◆ fully adduct hips, push posteriorly to try to dislocate hips
■ Ortolani’s test (checks if hips are dislocated ◆ initial position as above but try to reduce hip with fingertips during abduction
◆ positive test: palpable clunk is felt (not heard) if hip is reduced
■ Galeazzi’s sign
◆ knees at unequal heights when hips and knees flexed
◆ dislocated hip on side of lower knee
◆ difficult test if child <1 yr
◆ Trendelenburg test and gait useful if older (>2 yr)
Developmental Dysplasia of the Hip investigations
- U/S in first few months to view cartilage (bone is not calcified in newborns until 4-6 mo)
- follow-up radiograph after 3 mo
- X-ray signs (at 4-6 mo): false acetabulum, acetabular index >25°, broken Shenton’s line, femoral neck above Hilgenreiner’s line, ossification centre outside of inner lower quadrant (quadrants formed by intersection of Hilgenreiner’s and Perkin’s lines)
Developmental Dysplasia of the Hip treatment
- 0-6 mo: reduce hip using Pavlik harness to maintain abduction and flexion
- 6-18 mo: reduction under GA, hip spica cast x 2-3 mo (if Pavlik harness fails)
- > 18 mo: open reduction; pelvic and/or femoral osteotomy
Developmental Dysplasia of the Hip complications
- redislocation, inadequate reduction, stiffness
* AVN of femoral head
Developmental Dysplasia of the Hip risk factors
5 Fs that Predispose to Developmental Dysplasia of the Hip
Family history Female Frank breech First born LeFt hip
Legg-Calve-Perthes Disease (Coxa Plana) definition
- idiopathic AVN of femoral head, presents at 4-8 yr of age
- 12% bilateral, M>F = 5:1, 1/1,200
• associations
■ family history
■ low birth weight ■ abnormal pregnancy/delivery
■ ADHD in 33% of cases, delayed bone age in 89%
■ second-hand smoke exposure
■ Asian, Inuit, Central European
• key features
■ AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual remodelling of regenerated bone
Legg-Calve-Perthes Disease (Coxa Plana) clinical features
- child with antalgic or Trendelenburg gait ± pain
- intermittent knee, hip, groin, or thigh pain
- flexion contracture (stiff hip): decreased internal rotation and abduction of hip
- limb length discrepancy (late)
Legg-Calve-Perthes Disease (Coxa Plana) investigations
- X-ray: AP pelvis, frog leg laterals
- may be negative early (if high index of suspicion, move to bone scan or MRI)
- eventually, characteristic collapse of femoral head (diagnostic)
Legg-Calve-Perthes Disease (Coxa Plana) treatment
• goal is to preserve ROM and keep femoral head contained in acetabulum
• non-operative
■ physiotherapy: ROM exercises
■ brace in flexion and abduction x 2-3 yr (controversial)
• operative
■ femoral or pelvic osteotomy (>8 yr of age or severe)
◆ prognosis better in males, <6 yr, <50% of femoral head involved, abduction >30°
- 60% of involved hips do not require operative intervention
- natural history is early onset OA and decreased ROM
Osgood-Schlatter Disease definition
inflammation of patellar ligament at insertion point on tibial tuberosity
- M>F
- age of onset: boys 12-15 yr; girls 8-12 yr
Osgood-Schlatter Disease mechanism
repetitive tensile stress on insertion of patellar tendon over the tibial tuberosity causes minor avulsion at the site and subsequent inflammatory reaction (tibial tubercle apophysitis)
Osgood-Schlatter Disease clinical features
- tender lump over tibial tuberosity
- pain on resisted leg extension
- anterior knee pain exacerbated by jumping or kneeling, relieved by rest
Osgood-Schlatter Disease investigations
• X-ray lateral knee: fragmentation of the tibial tubercle, ± ossicles in patellar tendon
Osgood-Schlatter Disease treatment
• benign, self limited condition, does not resolve until growth halts
• non-operative (majority)
■ may restrict activities such as basketball or cycling
■ NSAIDs, rest, flexibility, isometric strengthening exercises
■ casting if symptoms do not resolve with conservative management
• operative: ossicle excision in refractory cases (patient is skeletally mature with persistent symptoms)
Congenital Talipes Equinovarus (club foot) definition
- congenital foot deformity
- muscle contractures resulting in CAVE deformity
- bony deformity: talar neck medial and plantar deviated; varus calcaneus and rotated medially around talus; navicular and cuboid medially displaced
- 1-2/1,000 newborns, 50% bilateral, occurrence M>F, severity F>M
Congenital Talipes Equinovarus (club foot) etiology
- intrinsic causes (neurologic, muscular, or connective tissue diseases) vs. extrinsic (intrauterine growth restriction); may be idiopathic, neurogenic, or syndrome-associated
- fixed deformity
Congenital Talipes Equinovarus (club foot) physical exam
- examine hips for associated DDH
- examine knees for deformity
- examine back for dysraphism (unfused vertebral bodies)
Congenital Talipes Equinovarus (club foot) treatment
• largely non-operative via Ponseti Technique (serial manipulation and casting)
■ correct deformities in CAVE order
◆ change strapping/cast q1-2wk
◆ surgical release in refractory case (rare) – delayed until 3-4 mo of age
- 3 yr recurrence rate = 5-10%
- mild recurrence common; affected foot is permanently smaller/stiffer than normal foot with calf muscle atrophy
CAVE deformity
Midfoot cavus
Forefoot adductus
Hindfoot varus
Hindfoot equinus
