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Pediatrics Flashcards

1
Q

Most common nerve injury with supracondylar humerus fractures?

A
  1. AIN (10%)
  2. Radial nerve
  3. Ulnar nerve (Occurs in flexion type ~17%)
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2
Q

What is more common flexion or extension type supracondylar humerus fractures?

A 
Extension type (98%), Flexion type (2%)
Flexion type the distal fragment is anterior and flexed
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3
Q

Supracondylar postop decisions…
remove pins at _____ weeks
PT yes/no?

A

3 weeks, no PT indicated

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4
Q

Complications of CRPP and supracondylar humerus fractures.

A

Pin migration (most common), pin infection (second most common), cubitus valgus (caused by malunion and can result in tardy ulnar nerve palsy), cubitus varus (aka gunstock deformity, cosmetic issue)

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5
Q

Risk of immobilizing elbow at >90 degrees

A

Volkmann ischemic contracture - cutting off blood flow to the forearm leading to muscle death and subsequent clawing of the hand.

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6
Q

Patient with supracondylar fracture and cool pulseless hand … what do you do?

A

Emergent CRPP and see if the pulse returns. If pulse does not return or the hand does not become warm and perfused then open exploration. If pulse does not return but the hand becomes well perfused then place arm in 45 deg of flexion and admit for vascular observation (in most cases the pulse will return in 24-48 hrs).

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7
Q

The 5 risk factors of DDH?

A
  1. First born
  2. Female
  3. Family history
  4. Breech
  5. Oligohydramnios (deficient amniotic fluid)
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8
Q

Barlow maneuver is…

A

Dislocating a DDH hip

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9
Q

Ortolani maneuver is…

A

(opening maneuver) reducing a dislocated DDH hip

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10
Q

DDH alpha angle is measured by these landmarks…

A normal alpha angle is…

A

On ultrasound, angle created by the ilium and the acetabulum
>60 deg (essentially describes the depth of the acetabulum). The femoral head should be bisected by the line drawn from the ilium.

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11
Q

Age range for ultrasound for evaluation of DDH

A

0-4 months

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12
Q

Age range for xray for DDH and associated line landmarks…

A

Beginning at 4-6 months
Hilgenreiner’s line: femoral head ossification should be inferior
Perkins Line: femoral head should be medial
Acetabular index: should be less than 25 degrees in patients over 6 mo

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13
Q

Blocks to DDH reduction?

A
  1. inverted labrum
  2. inverted limbus (fibrous tissue from hyaline cartilage of the acetabulum)
  3. TAL (contracts in patients with persistent dislocation and subsequently blocks reduction)
  4. Hip capsule constricted by psoas tendon (hourglass sign on arthrogram)
  5. Ligamentum teres
  6. Prominent pulvinar tissue
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14
Q

Indications for Pavlik harness treatment in DDH

A

<6 mo of age + reducible hip with normal neuromotor tone (ie not amenable to spina bifida pts as muscle tone needed to keep hip reduced).
Hips must be flexed 90-100 deg.

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15
Q

Complications of Pavlik harness treatment for DDH

A

AVN of femoral head with hyperabduction.

Femoral nerve palsy with hyperflexion.

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16
Q

Patient with DDH treated with Pavlik Harness is considered to fail treatment if hip does not remain reduced after ___ weeks (patients get weekly US checks). If they fail what is the next step in treatment?

A

3 weeks, semi-rigid hip abduction brace

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17
Q

Patient with DDH fails Pavlik Harness and semi-rigid brace and is 8 mo old, now what?

A

Closed reduction and spica casting

  • For patients 6-18 mos, failure of spica/semi rigid
  • Arthrography to be performed at time of reduction
  • Medial dye pool >7mm a/w poor outomes/osteonecrosis
  • Hip abduction > 55 deg a/w osteonecrosis
  • Hip reduction to be assessed with CT/MRI prior to discharge.
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18
Q

Treatment of patient with DDH who is 20 months old?

A

Open reduction + spica

  • Indications: >18mos, or failure of closed reduction
  • Hip reduction to be assessed with CT/MRI prior to discharge.
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19
Q

Treatment of patient with DDH who is 2.5 yrs old?

A

Open reduction, DDH > 2yo

  • (+ femoral osteotomy if femoral sided deformity, excessive version/coxa valga)
  • (+ pelvic osteotomy if DDH > 2 yo w acetabular dysplasia (increased AI > 25) )
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20
Q

SCFE is associated with what medical conditions?

A
  1. Hypothyroidism
  2. Renal osteodystrophy
  3. Down Syndrome
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21
Q

Indications for contralateral perc pinning for SCFE

A
  • Initial slip at young age (<10)
  • Open triradiate cartilage
  • Obese males
  • Endocrine disorder (hypothyroidism)
  • Modified oxford bone age score = 18
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22
Q

What is Klein’s line?

A

Measure done in suspected SCFE patients.
On frog lateral draw a line on the superior border of femoral neck cortex, if this line dose not intersect the lateral aspect of the femoral head then there is likely slippage/SCFE present.

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23
Q

Contraindications to flex nailing in pediatric patients with femoral shaft fractures?

A
  • Length unstable fx (spiral, comminution)
  • Age >11
  • Weight >100 lbs
  • for patients age 5-11 with spiral fx or comminution, bridge plating is best option. If less than 5 yo, then spica casting. If >11 then IMN.
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24
Q

Most common age and bacteria of osteomyelitis in pediatric patients?

A

Average age 6.6 yrs (2.5x more common in males)
Staph most common overall, GBS most common in neonates, Pseudomonas most common with foot punctures, Staph most common with sickle cell but salmonella is possible

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25
Why do osteomyelitis infections occur at the metaphysis in peds patients?
Area of sluggish blood flow, low pH and low oxygen tension which all favor bacterial seeding.
26
What is a sequestrem?
Area of necrotic walled-off bone that occurs during chronic osteomyelitis. Can be a nidus for infx.
27
What is an involucrum?
An area of new bone formed over an osteomyelitic infection that has arisen from the periosteum.
28
Antibiotic choice for peds osteomyelitis?
Nafcillin or oxacillin to cover staph aureus, however if high rate of MRSA in area then do Clindamycin or Vancomycin (binds D-ala D-ala moiety in bacterial cell walls). If gram stain is negative then add 3rd generation Cephalosporin (Ceftriaxone)
29
Peds patients with osteomyelitis infx are at a higher risk of ______? Other associated risk factors are?
``` DVT Risk Factors: CRP>6 Surgical Tx Age >8 MRSA *patients can also be at risk of LLD/growth disturbance ```
30
50% of peds septic hips occur in patients less than ___ yrs of age?
2 years, if teenager be concerned for N. gonnorhea which can be treated without OR and just IV Penicillin.
31
Risk factors for pediatric septic hip?
Caesarian section Prematurity Patients treated in NICU Invasive procedures such as umbilical catheterization, venous catheterization, or heel puncture which could lead to transient bacteremia.
32
Joints with intra-articular metaphysis and are at risk for develop septic joint with osteomyelitis?
``` SHEA Shoulder Hip Elbow Ankle ```
33
Kocher criteria for pediatric septic hip
1. Inability to bear weight 2. Fever >38.5 (101.3) 3. WBC >12,000 4. ESR >40 * 2/4= 40% chance of septic joint * 3/4= 93% chance of septic joint * 4/4= 99.6% chance of septic joint Also although not part of Kocher criteria, CRP>20 + inability to bear weight = 74% chance of septic joint
34
What are the deformities associated with clubfoot and order of correction with the Ponsetti method?
The goal is to rotate the foot laterally around a fixed talus. "CAVE" 1. Cavus - tight intrinsics, FHL, FDL ->dorsiflex 1st ray 2. Adduction of forefoot - tight posterior tibialis -> ABduct to total of 45 deg relative to thigh 3. Varus - tight Achilles, posterior tibialis, anterior tibialis -> achilles tenotomy 4. Equinus - tight Achilles Then, **5. Heel cord tenotomy needed in 80-90% of children (week 8) **6. Foot ankle orthosis (full time 3 months, then @night 2-4 yrs)
35
Regardless of etiology, clubfoot is associated with this anatomic anomaly....
absent/hypoplastic anterior tibial artery
36
After treatment of clubfoot with Ponsetti method a patient has dynamic supination of the foot during swing phase. What causes this and how is it corrected?
This is caused by pull of the tibialis anterior muscle which becomes more of a supinator than a dorsiflexor with an incompletely reduced navicular on the talus from prior clubfoot deformity. When this occurs there is a risk for recurrence of hindfoot varus so a whole tendon transfer of the tibialis anterior from the medial cuneiform/base of 1st MT to the lateral cuneiform is recommended.
37
Describe the purpose of the Coleman Block test?
Test to determine if hindfoot varus deformity is due to plantar-flexed first ray vs an independent component. -If deformity corrects with Coleman block, this suggests a forefoot driven varus deformity. -If deformity does not correct with Coleman block, this suggests hindfoot driven varus defromity. Note: a rigid hindfoot will not correct into neutral
38
Orthopedic manifestations of CMT?
``` Pes cavovarus Hammer toes Scoliosis Hip dysplasia Hand muscle atrophy/weakness ```
39
CMT Type I vs. Type II
Type 1 = demyelinating disease, cavus foot (due to unopposed pull of peroneus longus which inserts on plantar medial cuneiform) Type 2 = Wallerian degeneration, flaccid foot
40
CMT genetics
Diagnosed via PCR or chromosomal analysis: Autosomal dominant duplication of chromosome 17 (most common) -codes for peripheral myelin protein 22 (PMP 22) expressed in Schwann cells (most common)
41
Males grow until age _____, females grow until age ____
males 16, females 14
42
Growth rate per year of the lower extremity...
proximal femur - 3 mm / yr (1/8 in) distal femur - 9 mm / yr (3/8 in) proximal tibia - 6 mm / yr (1/4 in) distal tibia - 5 mm / yr (3/16 in)
43
For final limb length inequality of <2 cm the treatment is?
shoe lift
44
For final limb projected length inequality of 2-5cm the treatment is?
Shorten the non-effected/longer side via shutting down the growth plates/epiphysiodesis.
45
For final limb projected length inequality of >5cm the treatment is?
Lengthen the shortened side
46
When is it appropriate to do a physeal bar excision?
When the physeal bar involves <50% of the physis and there are atleast 2 yrs of growth left. This prevents deformity.
47
Achondroplasia is associated with this mutation
Fibroblast growth factor recptor 3 (FGFR3) | [affects proliferative zone of the physis]
48
Relative frequency of nerve injuries in supracondylar humerus fractures in order (extension type)?
ARM-UP 1. AIN 5.3% 2. Radial 4.5% 3. Median 3.3% 4. Ulnar 2.3% 5. PIN 1.1%
49
Most common nerve injury in flexion type supracondylar humerus fx?
Ulnar nerve ~17%
50
Steps in cool pulseless extremity after supracondylar fx?
1. Emergent reduction and stabilization (do not delay fo r angiography!) 2. Reassess vascular status 3. If remains dysvascular, then open exploration of antecubital fossa. If arm warm but pulseless, watch carefully.
51
For DDH Ultrasound what is normal femoral head coverage and normal alpha angle (ilium and bony acetabulum?
Coverage >50% | Alpha angle should be >60 deg, and sharp
52
Absence of spontaneous kicking or quad fxn in baby in pavlik harness is concerning for...
Femoral nerve palsy due to too much hip flexion and compression of the femoral nerve under the inguinal ligament -Significant risk for pavlik failure
53
Acute SCFE
Symptoms that persist for less than 3 weeks
54
Chronic SCFE
Symptoms that persist for more than 3 weeks
55
Stable SCFE
Able to bear weight with or without crutches | Minimal risk of osteonecrosis (<10%)
56
Unstable SCFE
Unable to ambulate (not even with crutches) | High risk of osteonecrosis (originally ~47%, recent data ~24%)
57
A patient with SCFE merrits and endocrine work-up when...
Age <10 | Weight < 50th %
58
SCFE and Salter harris fx proceed through this cartilage zone?
Hypertrophic
59
Southwick slip angle denotes what? And is measured how?
Severity of SCFE slip (mild <30 deg, mod 30-50, severe >50) | Angle perpendicular to femoral head physis and then down the shaft of femur
60
Treatment of femoral shaft fractures?
``` Rule of 6's 0-6 mo = Pavlik Harness 6 mo - 6 yrs = Spica Casting 6 - 12 yrs = Flex nailing, submuscular plating 12+ yrs = Rigid IMN ```
61
Flex nailing for femur fx requires the fracture pattern to be _________
Length stable. Do not use in patients >12 yo or >50kg
62
Submuscular plating for femoral shaft fx are indicated in....
Patients with far proximal or distal fractures, length unstable fractures, and heavier children.
63
Rigid IMN for femur fractures should never have this start point...
Piriformis start is contraindicated due to a high risk of AVN in pediatric patients (due to disruption of the deep branch of the medial femoral circumflex artery). Lateral entry or trochanteric starts are preferred.
64
Risk Factors for pediatric non-accidental trauma?
``` Parental -age <20 -lower education -psychiatric disease -stress Child -age <3 -premature -step children -handicapped ```
65
Physical injuries or signs concerning for NAT
Long bone fractures in a child that is not yet walking. Transphyseal separation of the distal humerus. Metaphyseal corner fractures. Multiple fx in various stages of healing. Posterior rib fx
66
Characteristics of anterolateral bowing of the tibia
Thinning of the medullary canal and cortical thickening at the apex. Pseudoarthroses frequently occur and when present are associated with Neurofibromatosis Type 1 in 50-80% of cases. Initial treatment is aimed to prevent fracture and pseudoarthrosis with clamshell casting
67
Characteristics of posteromedial bowing of the tibia
``` Congenital deformity (possibly due to intrauterine packaging disorder). Requires years of growth to improve, patients often left with 2-5 cm leg length discrepancy. Can be associated with calcaneovalgus foot deformity. ```
68
Skeletal maturity is achieved when?
Risser stage 4 or 5 (more than 75% ossification of the iliac apophysis). Two years post-menarche. No growth over 2 consecutive office visits. Sanders stage 5 to 7 (hand radiographs)
69
Syndacytly is autosomal ______ and most common in the _______ finger and then the ________ finger
Dominant, long, ring. | More common in males, also.

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