Pediatrics Flashcards
Intrauterine crowding and positioning may contribute to:
Torticollis, Club Feet, Intoeing and Developmental Dysplasia of Hip (DDH)
Developmental Dysplasia of Hip (DDH)
A spectrum of disorders describing abnormal development resulting in dysplasia and possible subluxation of dislocation of the hip. The femoral head is pulled up and makes it’s own pseudo-joint.
Barlow Maneuver:
apply posterior pressure onto hip while holding at knee (so you are pushing from the front), bring leg into adduction, hip subluxes out of acetabulum with posterior pressure and adduction (clunk): “out to the bar- barlow pushes it out”
Ortolani Maneuver:
apply pressure to the posterior acetabulum (you are pushing from the back), hip is reduced back into acetabulum over neolimbus during abduction (clunk): “order in- ortalani pushes it in”
Galeazzi Test:
supine, hips flexed, knees bent, affected leg’s knee appears lower
Treatment for Developmental Dysplasia of Hip (DDH)
1st line tx: Pavlik harness: pushes hip back in socket. Operative if too severe of harness fails to help.
Risk Factors for Developmental Dysplasia of Hip (DDH)
First-born Females (4-5X MC), breech delivery (Funky), Firstborn infants, oligohydraminos, FHx DDH, limited Fetal mobility (limited hip abduction). THE FIVE F’s!!!
Special Tests for Developmental Dysplasia of Hip (DDH)
Barlow Maneuver, Ortolani Maneuver, and the Galeazzi Test.
Imaging for Extra for Developmental Dysplasia of Hip (DDH)
Radiographs are not generally useful prior to the ossification of the femoral head (between 4-6 mo). US can be helpful!
Congenital Torticollis
unilateral SCM contraction that causes ipsilateral head tilt
Risk Factors for Congenital Torticollis
Primiparous mother, heavy male baby in breech position, multiple birth, maternal uterine abnormalities, male gender
Treatment for Congenital Torticollis
PT (stretch the muscle- can take as long as 6-8mo), surgery or botox inj into SCM to relax it.
Congenital Torticollis associated disorders
DDH, Metarsus Adductus, Traumatic Delivery, Plagiocephally
Acquired Scoliosis
spinal curvature, cobb angle > 10 degrees, not only C shaped curve, also has twisting.
Risk Factors for `Scoliosis
Adolescents, F>M, rapidly progresses during rapid growth, ask girls if they have gotten their period- chance of progression during growth period before period (can help before).
Treatment of Scoliosis
Observation, Bracing (16-23hrs) for those with growth potential and curve magnitude 20-45 degrees. Spinal fusion if curve >45 degrees. Curvature remains fairly stable after skeletal maturity.
Diagnosing Scoliosis
Testing: diff height shoulders, protruding shoulder blade, diff length arm, protruding side of back when bending over. Measure COBB angle.
COBB angle:
Identify upper and lower end vertebrae, draw lines extending along vertebral borders, measure cobb Angle directly or geometrically.
Which type of curve is most common for Scoliosis?
Rightward thoracic curves
Genu Varum
Physiologic Bowing, bowing for first two years it is normal
Risks for Genu Varum
Early walkers, overweight children
Diagnosing Genu Varum
Differentiate btwn Blount’s dz (proximal tibia physis abnormality, stops growing on medial side), ricketts, skeletal dysplasias.
Genu Varum in adolescents over 10
Less severe, unilateral, usually due to obesity
Genu Valgum
(knock-knees); 5-7 degrees of valgus is normal in adults & children older than 6-7yrs age.
Complication of Genu Valgum
May result in “miserable malalignment syndrome”: contributing to patellofemoral dysfunction.
Treatment of Genu Valgum
Typically improves with growth, lateral aspect has most pressure
Goal for Genu Valgum
Goal is to differentiate between what it “normal” and what is pathological (Ricketts, tumors, skeletal dysplasia)
Intoeing
The feet turn inward instead of pointing straight ahead. It is commonly referred to as being “pigeon-toed.”
Causes of Intoe:
- Feet are turning in: metatarsus adductus (flat feet),
- Lower legs are turning in: tibial torsion,
- Hips/Thighs are turning in: femoral anteversion.
Physical Exam for Intoeing
Examine by putting in prone position and bending at knee, the foot will twist in medially.
Femoral anteversion
(hips/thighs turn in)- increased twist of prox femur (Results in “turning in” of femur, knee, and feet). Sit in a “w” position
Treatment of Femoral anteversion
Typically improves with growth, best to examine extremities when young. No indication for special shoes, bracing, or PT
Tibial Torsion
(lower legs turn in)- twisting in of tibia. Examine by putting in prone position and bending at knee, the foot will twist in medially.
Treatment of Tibial Torsion
Typically improves with growth. No need for special shoes, bracing, or PT
Foot Disorders
Metatarsus Adductus (flatfeet)- “C- Shaped foot” and Talipes equinovarus (Clubfoot)
Metatarsus Adductus
(flatfeet)- “C- Shaped foot”. Medial deviation (adduction contractures of TMT joints, metatarsals are oriented medially).
Treatment of Metatarsus Adductus
Flexible, mild metatarsus adductus, typically improves with growth. Rigid, severe metatarsus adductus may require casting.
Talipes equinovarus
(Clubfoot), Occurs in 1:1000 births with a slight male predilection. Has some genetic component. Malalignment of: Talocalcaneal joint, Talonavicular joint, Calcaneocuboid joint
Four components of Talipes aquinovarus:
CAVE
- Flexion of hind foot and ankle (Equinus deformity)- contracture of the Achilles.
- Inward turning of the heel (Varus deformity).
- Bean shape deformity of foot with curled outer border (Adductus deformity).
- High medial arch of forefoot (Cavus deformity)
Treatment of Talipes equinovarus
Trt: manipulation: ponseti technique and serial casting, usually requires minor procedure (Achilles lengthening) at end of casting. Denis-browne splinting (at 9-10mo only wear it at night time)
Septic Arthritis
Orthopaedic Emergency!! Bacterial/fungal infection w/in joint capsule.
Most common causes of Septic Arthritis
MC bacteria: S. Aureus
Neonates- Group B Strep
1mo-3mo- S. aureus
3-13yrs- All above + H. influenza
Adolescent- S. aureus and N. gonorr.
Patient presentation with Septic Arthritis
Red swollen joint which can’t bear weight, usually presenting sign (decreased ROM). Elevated WBC, ESR, CRP. Patient often has a Hx of a fever. Kocher Criteria!!!
Most common joints affected with Septic Arthritis
Knee>Hip>Ankle>small joints
Treatment of Septic Arthritis
Surgical drainage/irrigation, debridement, metaphyseal decompression + IV Abx until clinical response is observed.
T/F: Septic Arthritis of the hip is the most common site of joint infection.
False, Second most common after the knee
Nursemaid’s Elbow
Subluxation of radial head from annular ligament
Cause of Nursemaid’s Elbow
Common when child’s arm is swung or pulled
Patient presentation of Nursemaid’s Elbow
Decreased ROM of elbow and use of arm
Imaging for Nursemaid’s Elbow
Radiographs are negative
Treatment of Nursemaid’s Elbow
Reduction: Once tension is released, joint pops back into place- apply pressure on radial head and supinate wrist and you bring patient’s elbow into 90 degrees- pt will tell you it’s not as painful anymore
Osgood Schlatter Disease
Type of juvenile traction osteochondritis: refers to partial avulsion of the tibial tuberosity (anterior surface of apophysis)
Prevelence of Osgood Schlatter Disease
Usually occurs in late childhood or early adolescence, more common in boys, may represent an over use disease, condition occurs at a time when increasing demands are made on a still immature skeleton
Cause of Osgood Schlatter Disease
Traction apophysitis at distal attachment of patella on tibial tuberosity
Patient Presentation with Osgood Schlatter Disease
Anterior knee pain at tibial tuberosity that is worse with activity, typically during rapid growth. Usually tender and swollen.
Imaging for Osgood Schlatter Disease
X-rays: may see fragmentation on lateral view of tubercle where patellar tendon inserts or irregular ossification of tibial tuberosity.
Diagnosis of Osgood Schlatter Disease
Clinical
Treatment for Osgood Schlatter Disease
Rest, Ice, NSAIDS, quadriceps stretching. Usually self-limited, symptoms may improve with conservative measures, or until growth spurt is complete.
Legg-Calve-Perthes
Idiopathic avascular necrosis of hip, a/w ADHD
Common incidences of Legg-Calve-Perthes
5-7 yo, M:F 4:1
Patient Presentation of Legg-Calve-Perthes
Limp of insidious onset, Hip pain referred to anteromedial thigh or knee. Limited internal rotation and abduction of hip. Trendlenberg Gait. Limb length inequality.
Imaging for Legg-Calve-Perthes
Fragmentation and necrosis of femoral head seen on X-rays
Prognosis for Legg-Calve-Perthes
Prognosis related to age of onset (younger = better)
Treatment for Legg-Calve-Perthes
Treatment centers around PT, Surgery sometimes necessary in older kids
Indications for a worse prognosis for Legg-Calve-Perthes
Prognosis is worse with bone age over 8, loss of ROM, Female sex, Loss of femoral head spericity.
SCFE- Slipped Capital Femoral Epiphysis
Disorder of the proximal femoral physis that allows for translation of the metaphysis. One of the most common hip disorders of adolescents.
Patient Presentation with SCFE- Slipped Capital Femoral Epiphysis
Nonradiating, dull, aching pain in hip, groin, thigh, or knee, increased with activity (chronic or intermittent). No hx trauma.
ROM decreased with internal rotation, abduction, flexion. Thigh held in flexion, abduction, external rotation (FABER position). Limp, impaired internal rotation of hip.
Risk Factors for SCFE- Slipped Capital Femoral Epiphysis
Obesity, renal failure, hypothyroidism, GH deficiency, Down syndrome, male
Special Tests for SCFE- Slipped Capital Femoral Epiphysis
Klein’s line- draw a line parallel to the femoral neck and tangential to sup cortex of femoral neck, should pass through part of the femoral head.
Treatment of SCFE- Slipped Capital Femoral Epiphysis
URGENT: refer to ortho, NON-WEIGHT BEARING IMMEDIATELY, Surgical Tx
Cause of SCFE- Slipped Capital Femoral Epiphysis
Capital femoral epiphysis displaced from femoral neck through physeal plate. Femoral epiphysis slips posteriorly “ice cream falls off ice cream cone”
