Pediatric Orthopedics- Nathan Apple Flashcards
is hip dysplasia more common in boys or girls?
girls- 70%
what is the main cause of hip dysplasia
breech birth, too small intrauterine space (too much baby not enough space, bc of multiples or large child)
which test is better for testing hip dysplasia
ortoloanis, bc u are reducing a hip that is already out instead of dislocating a hip thats in like u do in barlows- causes unnecessary stress on hip ligature
how do babies present with hip displasia
leg length differences, galeazzi, uneven thigh folds, waddling gait with lordosis, one limited hip abduction, trendelenburg with circumduction (may not look much diff than normal toddler gait) overpronation
diagnosing hip displasia
ultrasound (6-8 wks), radiography wont work til after 4 months bc all bone is still cartilage
when does femoral head ossification begin
4-9 months
DDH
developmental displasia of hip
shenton’s line
inferior neck and infer. border of superior pubic ramus should make a nice arch
hilgenreiner’s line
ossification center should be center of horizontal line drawn through the triradiate cartilages
Perkin’s line
perpendicular to hilgenreiner’s line
Acetabular angle
hilgenreiner’s line at triradiate to acetabular roof, want it to be less than 20 degrees at 24 mo. greater than 40 deg= significant at birth
DDH treatment
6-12 months of abduction orthotics…
when is the critical age to catch DDH by?
6 months
who is a pavlik brace for. What do u need to watch for?
immobile babies, watch for brachial plexus and femoral nerve palsys- look for favoring of one arm/leg and waiter’s tip deformity
when do u stop a pavlik brace
if no progress in 3 weeks, or if palsys
what does the success rate drop to if DDH is caught after 6 months
drops by 50%
factors for success with treating DDH
diagnosed under 6 wks
bilateral
acetabular angle under 35 degrees
who wears a rhino brace
older, mobile kids, ortalani positive
PT management of DDH
ROM, strength, gross motor skills, during immobilization, after immobilization, after surgery
what if they need surgery
12 months or older
mm release and proximal femoral osteotomy
spica cast until stable
Talipes Equinovarus
club foot
3 types of club foot
equinus, varus, adductus
tx for mild club foot
serial casting, weekly progression
tx for severe club foot
most likely underlying neuro issues, sx correction at 4-6 months, night splints
PT management of club foot
ROM, strength, gross motor
Metatarsus adductus
forefoot curves medially
calcaneovalgus
“rocker bottom”
forefoot curves laterally, mid foot and hind foot goes valgus, navicular rides the floor
when does a child’s arch devleop?
age 3-5
pes planus
dont worry too much about it, but… if it’s unilateral use it as a litmus test to look for other issues, is there a leg length discrepancy, are they hemophiliac and a growth plate shut down??
does pes planus need an orthotic
no. only if kid is older and its painful, then maybe a SMO or a SURESTEP. most these kids are so ligament laxity they will just roll over whatever u give them
tx for pes planus
strengthening, stretching…
what does a positive gowers sign tell u
duchenne’s
ask parent’s the tough questions
night pain? gnawing pain? does he not want to put wt. on it?
whats a good way to see a kid get down and back up?
dead bug!
what do u want to always look for??
laterality
gait
wt. bearing vs. non wt. bearing
torticollis: 3 types
> congenital muscular
benign paroxysmal
toticollis spasmodica
congenital mm tort. (CMT)
infancy
benign paroxysmal tort. (BPT)
childhood
torticollis spasmodica
childhood to adulthood, cervical dystonia
causes of tort.
intrauterine crowding
define torticollis
shortening of the sternocleidomastoid
function of SCM
tilts to same side, rotates to oppostite side- causes contralateral head rotation coupled with ipsilateral tilt
how is tort. named
named to the side of the tilt
what does tort. do to the shape of the skull
forms it like a parallelogram- plagiocephaly
what effect does plagiocephaly have on appearance, etc.
ears are uneven, eye on same side of frontal bulge appears larger and more forward
what if ears are plum but head looks misshapen?
check for premature closing of sutures, this will need plastic surgery and can cause brain damage if not addressed
causes of tort.
intrauterine crowding, contracture, birth trauma, positional (placed on vent, etc.) , direct mm trauma, compartment syndrome (nerve, mm damage, swelling, fibrosis)
Eval of a tort. bebe
> history: birth wt., multiples, unplanned events, NICU? vent?
observation: posture, movement?cranial asymmetry, palpate cerv. mm, milestones, development? extremities and spine?
vision- tracking, nystagmus (maybe need a referral)
ROM and strength in spine and extremities
tone?
myotomes
neglect? is it neurological or just visual neglect bc he’s always turned away from it?
what is a syndrome that presents like tort.?
Sandifers, its a reflux problem that the position of comfort looks a lot like torticollis.
when is it best to catch tort?
6-8 wks, mostly parent education and instruction, 3-4 visits
tort protocol and prognoisis
begin ASAP
- before 3 mo. =0 surgical need
- after 3 mo= 25% require sx
- with consistent, timely, therapy, 85-90% CMT should reslove within 4-5 months
what can u do to help with AROM for tort.
bring toys to other side, make them turn to look at them…
orthotics for tort.
shaping helmets
what is the window for shaping helmets?
6-10 mo, after that skull not plastic enough
back up tx options for tort.?
sx or botox
diff. dx of types of tort.
BPT: childhood
CMT: infancy
torticollis spasmodica: childhood to adulthood, verv. dystonia
refractory tort.
torticollis that does not respond to traditional protocol after 4-5 months of PT and the child becomes 7-8 mo. old. Physician needs to be notified and radiographs taken.
Legg-Calve-Perthes
avascular necrosis of femoral head
LCP population
boys 3-13, 3x more likely than girls
causes of LCP
trauma, vascular anomalies, infection, thrombic incidents
presentation with LCP
pain in groin, knee, thigh, loss of IR, abduction, extension of hip, antalgic gait and trendelenberg gait
SCFE
femoral head slips off rest of bone
causes of SCFE
trauma, obesity, development, african americans, inner city kids
presentation of SCFE
antalgic gait, pain in groin, medial thigh, lack of adduction and flexion tho, this is how u diff. from LCP
SCFE pose
captain morgan
4 stages of LCP
1) condensation- femoral head turns necrotic
2) fragmentation- necrotic bone splinters and is reabsorbed, revascularization occurs, deformation of fem. head and flattening of acetabulum
3) reossification with return of vascular supply
4) remodeling at acetabulum
diff. diag. btween SCFE and LCP??
areas of restriction!
SCFE= captain morgans, loss of adduction and flexion
LCP= loss of abduction, ext, and IR
grades of SCFE
I- up to 1/3 width of neck
II- 1/3 to 1/2 width of neck
III- greater than 1/2 width of neck
PT management of SCFE?
core work, make sure they get sx first…
healing rates of ped. fractures
infants: 2-3 wks
preschool: 4 wks
7-10 years: 6 wks
adolescent: 8-10 wks
Salter Harris classifications of Physeal injuries
I-through growth plate only
II- through growth plate and metaphysis
III- through growth plate and epiphysis
IV- through growth plate, metaphysis and epiphysis
V- compression crushes growth plate and damages eiphysis and metaphysis
which growth plates get most growth?
distal femur, prox tibia close last and get most growth
why would u want to hinder growth plates
to correct imbalance deformities, stop growth for prosthetics, etc.
Tibial Eminence (spine) fracture
result of hyperextension injury with fracture through subchondral bone beneath ACL insertion. The ACL should’ve torn but it was stronger than the bone so the tibial eminence avulsed instead…
tibial eminence fractures only occur if…
growth plate is still open! otherwise the ACL just tears.
presentation of tibial eminence fx
presents just like ACL tear, pain swelling, hemarthrosis, instability, lack of ROM
types of TEFx
I- physis only
II- physis and bone flap up
III- physis and bone completely disassociated
if a kid has sx to fix a TEfx where they use the IT band to bandaid it, what does this mean for PT
CONSERVATIVE! be careful, most likely TTWB for awhile
tx of TEfx
I- cast in flight flexion
II- evaluate in operating room, confirm reduction with CT scan
III- operative tx using IT band
tibial tuberacle fx
still have lots of pain, just like in TEfx, but pt can’t extend knee, too much pain, maybe slight wiggle in ant. tibia, in adult it would be a patellar tendon rupture
when does the tib. tub. physis close in kids?
males-15-19
females- 13-15
causes of tib tub. fx
trauma, sports injuries, violent stop to progression of leg while violent quadriceps contraction is occurring “think blocked punt”
which types of tib. tub. fxs require ORIF?
types II, III= ORIF
complications of tib. tub. fx
compartment syndrome, recurvatum deformity,
extension lag,
patella baja
fixation complications
epiphysitis vs. Apophysitis
epiphysitis involves growth plates, apophysis involves a projection of a bone, an outcropping or swelling of a bony prominence
osgood schlatter
tibial tub. epiphysis
sinding-larsen-johansson
inferior patella epiphysis
sever’s disease
calcaneal epiphysis
little leaguer’s shoulder
prox. humeral epiphysis
what do u HAVE to HAVE to diagnose little leaguer’s shoulder?
bilateral A/P radiographs!
Little league elbow
medial humeral epicondyle apophysitis
treatment of apophysitis or epiphysitis
> modalities and rest for acute symptoms
address underlying causes, strengthen whats weak and stretch whats tight
education on activity modification
don’t forget about the breaks- eccentric control! kids always have the gas pedal (concentric)
in the state of KS, can a PT legally clear a kid for back to sport?
no, need physician clearance
treatment for refractory torticollis if radiographs are normal
continue PROM, AROM PT program, botox,
tx of refractory torticollis if radiographs are abnormal
STOP PROM! continue AROM and positioning, refer to orthopedic surgery, consider botox
pediatric fractures
>Avulsion- ligament stronger than bone, ORIF >Bend- deformation without fx >buckle- compression, equal bulge in cortex >greenstick- fx on tension side only >transverse- horizontal fx >oblique- angled fx >spiral- pre-made biscuit tube >communited- mult. fragments
