Pediatric Top 10 Flashcards
Hip Dysplasia - When to Refer (peds ortho)
Abnormal exam
Abnormal Ultrasound
Abnormal xray
Breech position- ultrasound?
Perthes Disease age
4-8 (3-12)
Boys>>Girls
Family hx
Perthes pathogenesis
Vascular insult to femoral epiphysis
Repetitive trauma ?
Hormonal ?
Thrombophilia?
Radiographic stages Perthes
Initial, fragmentation, reossification, remodeling
Poor prognostic factors Perthes
–Age greater than 7-8
–Decreased ROM
–Deformity of head
–% of head involvement ( no lateral pillar)
–Protracted disease course
Clinical presentation Perthes
Insidious limp
Mild to moderate pain
Hip, thigh, or knee pain
Physical Exam Perthes
Limited abduction
Synovitis
Muscle spasm
Thigh atrophy
Leg length discrepancy
Imaging Perthes
Radiographs- AP and Frog lateral- pelvis xray better than hip
Tc bone scan- pinhole
MRI- can help with early diagnosis but not with staging
Treatment Perthes
Rest (reduce load)
NSAIDs
PT
Bracing?
Casts
Surgical muscle releases
When to Refer Perthes
School children with
–Hip, thigh, knee pain
–Decreased ROM
–Atrophy
–Abnormal imaging
–Labs important if xray normal to rule out other causes
Slipped Capital Femoral Epiphysis
Males>Females
B 12-15
G 10-13
Obesity
Etiology Slipped epiphysis
Mechanical Factors
Renal Osteodystrophy
Radiation therapy
Endocrine
–Hypothyroidism
–GH deficiency
Clinical features Slipped Epiphysis
Pain in thigh or knee
Limp- external rotated gait
Limited internal rotation and flexion
Types Slipped Epiphysis
Acute- less than 3 weeks symptoms
Chronic- greater than 3 weeks
Stable- can walk
Unstable- can’t walk
Treatment slipped epiphysis
In situ fixation
Osteotomy for deformity
Epiphysiodesis
Prophylactic pinning slipped epiphysis (one side slipped, pin otherside?)
Hypothyroidism
Renal Osteodystrophy
Endocrinopathies
Younger Children less than 10 years
Complications slipped epiphysis
Osteoarthritis
Chondrolysis
Osteonecrosis- MRI helpful to screen out, should be done at 1 month out
When to refer slipped epiphysis
Any SCFE needs to referred immediately
Strict nonweight bearing (send them in a wheelchair)
Intoeing Outtoeing assessment
Rotational Variation Assessment
Static (prone, look at flexion)
Dynamic- with walking
Causes of intoeing, outtoeing
Increased femoral anteversion, internal tibial torsion
When to refer intoe/outtoe
Recent specific change in gait
Functional problem
Persistent problem in older children
Family wants referral
Genu varum
bowed legs
Physiologic bowing (characteristics)
Early walkers
Family history common
Usually agile walkers
Usually bilateral
Treatment Physiological bowing
Spontaneous correction is the rule
Bracing not effective
Serial photos helpful
Diff Dx Bowing
Blounts disease
Skeletal dysplasia
Neoplastic disease
Metabolic bone disease
Hypophoshatemic rickets
Nutritional rickets
**If short stature, worry about these
Blounts Ds
Osteochondrosis
Deformity proximal medial tibia epiphysis
Fragmentation medial tibial plateau
Ultimate physeal bar formation
Progressive condition
If see _______ bowing, not physiological
unilateral
Physiological bowing usually distributed between ________
Femur and tibia
Blounts ds tx
Brace treatment- less than 2 and ½ years old
Valgus Proximal tibial osteotomy in children over 2
Bowing when to refer
Height less than 5%
Positive family history
Asymmetry
Progressive condition
Localized varus deformity
Genu valgum
Physiologic
Usually apparent after 2 years
Typically symmetric
Knockkneed
Diff Dx knockkneed
Rickets
Post-traumatic
Skeletal dysplasia
Tx valgum
Predictably remodels to normal by age 7
No effective bracing
If after 8 –
Hemiepiphysiodesis (minimal surgery)
Stapling
8 plates
Ostetomy
Genu valgum when to refer
Less than 10% for height
Asymmetry
Deformity increasing after age 7-8
History of metabolic disease
History skeletal dysplasia
Metatarsus adducts
MEdial deviation of forefoot on hind foot
Tx metatarsus adductus
Spontaneous resolution
Prognosis excellent
Stretching- be sure is not over zealous
Casting in children 6-12 months- especially rigid cases
Flexible sometimes can be treated with bebax bootie brace
Clubfoot tx
After birth- serial casts
Should be seen each week
75% plus successful
Bracing needed to prevent recurrence
Often require percutaneous achilles tenotomy
Rigid flatfoot cause
Tarsal Coalition
Congenital synostosis or failure of segmentation between 2 or more tarsal bones
Types
–Calcaneonavicular
–Talocalcaneal
–Talonavicular
–Calcaneocuboid
–Cubonavicular
Dx hip dysplasia
Ortolani (reduction) Barlows (Dislocation) - early *clunk*
Galeazzi - leg length discrepancy (later)
Imaging (Ultrasound, xrays)
Tx Hip dysplasia
Some untreated positive ortolani - heal on own
Pavlik harness (Full time 6-12 wks), otherwise closed reduction/spica casting
Clinical features metatarsus adductus
Forefoot adductus
Hindfoot neutral
Medial crease
Forefoot slightly supinated
Full dorsiflexion
Supple vs. rigid
MEtatarsus adductus when to refer
Stiff foot
No correction at 6 months
Shoe problems
Hindfoot in valgus( skewfoot) or equinus(clubfoot)
Clubfoot when to refer
All patients
Hopefully within first week or two of life
Symptoms rigid flatfood
Lack of subtalar motion
Frequent ankle sprains
Tendon spasms (tight achilles tendon)
WHen to refer Flatfeet
All rigid flatfeet
Flexible flatfeet with tight achilles
Swelling or synovitis
Painful feet
Family wants referral
