Peds 1 Flashcards
Name 5 fractures that should trigger NAT workup
Spiral humerus
Transverse > spiral femur - nonamb pts
Corner frx
Distal humeral transphyseal frx
Posterior rib frx
3 step workup for NAT
Skeletal survey
Admit to peds
CPS
What is special about a peds C spine board
Occiput is cut out - kids have huge heads
Flat board hyper flexes
Physeal frx:
What part of the growth plate affected
Name the SH classification
Which SH are intra-artic frx
ZPA within zone of hypertrophy
SH: SALTR
1 Straight through
2 Above (metaphysis)
3 beLow (epiphysis) *intra-artic
4 Through (meta + epi) *intra-artic
5 cRushed
Complications increase through the classification
What are the 2 presentations of physeal arrest after SH frx
3 ways to trt
LLD vs angular deformity
Trt
1 >2cm growth remaining OR <50% physis involved = bar resection w/ interposition
2 Shut down the whole growth plate
3 Address the other limb to match
What kind of injuries are SC dislocations in kids?
Physeal frx dislocation
Not actually a dislocation
Acceptable reduction for proximal humerus frx
<5yo: 70deg, 100% disp
5-12yo: <70deg
>12yo: <40deg, 50% disp
Prox hum
How much total humerus growth from prox hum physis
Non op mgmt
Op mgmt
80%
Hanging arm cast
Op pins - watch for pin migration
Humeral shaft
- Workup
- Non op parameter and method
- Op method
Beware NAT
<30deg ang - sling and swathe
Op: flex nail
SCH
Most common nerve palsy
Less common nerve palsy
Describe typical malunion
AIN > radial - ext type
Ulnar - flex type
- Medial gapping may indicate entrapment and a reason for open reduction
Varus + extension malunion 2/2 medial comm
Name Gartland classification and treatment
1: ND, LAC 3-4wks
2: angulated, LAC vs CRPP
3: completely displaced, OR vs CRPP
4: globally unstable, OR vs CRPP
Walk through the algorithm for pink pulseless
+ perfused
+ non perfused (white)
Perfused -> go to CRPP, monitor 24hr
Non perfused
1. Reduce
If now pink, pin and observe (even w/o pulse)
2. Still white, open
NO indication for a-gram, you know where the problem is (at frx site)
RF for infx in SCH
Younger age
Lat cond frx:
Best XR
Milch classification
What is your key to det displaced?
Trt displaced vs non displaced
Int oblique
Displacement - look for a metaphyseal fleck on the lat condyle, can’t look at the distal hum since mostly cartilage
Milch:
1: frx lat to trochlea
2: frx into trochlea
ND - LAC
Disp
1. Arthrogram to figure out if articular displacement
2. ORIF - anatomic reduction since articular
Ways to ORIF lat cond frx
Screw > pins
Pro : faster ROM
Con: 2nd OR to ROH
Name 4 complications of lat cond frx
1 Nonunion - higher risk than other elbow frx
2 Cubitus valgus - tardy ulnar nerve palsy
3 AVN
- Posterior BS goes into capitellum
- Mostly impt so if you have to address a nonunion, don’t dissect posterior
4 Physeal growth arrest
Medial condyle frx:
Associated with what other injury
Best XR
Possible sequelae
Elbow dislocation - post reduction see this incarcerated in the joint
Distal humeral axial view (flexed PA elbow)
Possible valgus instability bc UCL attached
Usually do much better than lat condyle
Transphyseal distal hum frx:
What SH classification
How to differentiate from elbow dislocation
Trt
Complications (2)
SH 1 (through) or 2 (above)
Radius and capitellum are reduced (vs dislocation)
CRPP if displaced
Comp:
1. Cubitus varus 2/2 malreduction
2. Medial condyle AVN
What is the key to treating Monteggia frx
Restore ulnar length to get and keep radial head reduced
Proximal radius frx:
How much displacement requires a reduction?
Reduction options (2)
Complications (3)
Reduce if >30-45deg
Reduction:
1. Closed = varus force in sup + ext, traction, then flex pronate
2. IMN via Metaizeau technique
Comp: avoid open reduction at all costs bc
1. Stiffness
2. AVN
3. Synostosis
Both bone forearm fractures:
Acceptable reduction parameters under vs over 9yo
How tell good AP and lat XRs
Bayonet apposition OK!
<9yo - 15 angulation, 45 rotation
>9yo - 30 rotation
10 prox angulation
15 distal angulation
AP: radial styloid and biceps tub 180deg
Lat: ulnar styloid and coronoid 180deg
Distal radius fractures
Trt torus frx
Greenstick parameters that need CR
Torus frx = buckle frx = removable brace
Greenstick w/ >10-15deg needs CR
Pelvis avulsion frx
Non-op vs op trt
Name the muscle:
ASIS
AIIS
Ischial tuberosity
LT
Crest
Non op = 4-6wks PWB
Op only if sciatic n sx
ASIS - sartorius
AIIS - rectus
Ischial tuberosity - HS
LT - IP
Crest - ext obliques
Peds pelvis frx:
How many frx lines
Complication
Can be only 1 fracture line since ring more ductile
Comp = premature triradiate closure when involving the tab -> hip dysplasia
Peds hip dislocation:
Comp
Post reduction test
Comp = SH frx prox fem physis if to aggressive with reduction
+/- MRI post reduction if any concern for non-concentric
Prox fem frx:
Comp of frx through the prox fem physis
Key for good outcomes frx through fem neck
IT frx
- What path frx
- Trt stable vs unstable
Prox fem physis - AVN
Neck frx = reduction timing (more so than for adults!)
IT
- ABC/UBC path frx
- Stable + young = spica
- Unstable or older = ORIF
Femoral shaft trt for kids <6mo
Pavlik
Femoral shaft trt for kids 6mo-5yo
Spica (1 or 2 legs)
Up to 2cm shortening ok because can expect some overgrowth
Describe how to apply spica cast
How much time in the cast
Complications
Apply long leg first (pulling traction through short leg can cause pop fossa compression)
+valgus mold
Time in cast = age (yrs) + 3 wks
Comp: compartment syndrome
Femoral shaft trt kids >5yo (3 options)
ORIF
Flex nail
- <11yo
- <50kg (100lbs)
- Goal = 80% canal fill
Rigid nail - older or heavier kids 2/2 nonunion risk
Submuscular plates for length unstable patterns, but ROH to prevent genu valgum at knee
Distal femur frx:
How much growth from this physis
What injury can be confused for this
Trt
9mm/yr - high rate physeal closure
Don’t confuse MCL/LCL sprains - physis is weaker
CR vs OR - watch for vascular injuries
Tib tubercle frx:
What is BS
Best tests
Associated knee injury
Order of physis closure
Ant recurrent br = why compartment syndrome
CT or MR to eval intra articular extension
Meniscus entrapment, lat>med
Growth plate closure:
P -> A
Med -> lat
Anterolateral is last to close
Classification tibial spine frx + trt
1 - ND, LLC
2 - ant 1/3 is elevated, try to reduce w/ extension, LLC
3 - complete avulsion
4 - flipped up into joint
3/4 - scope vs open reduction, ORIF somehow (anchors vs screws vs pins)
Complications peds tibial spine frx
Stiffness
Late ACL instability 2/2 plastic deformation
Sequelae of a Cozen frx
Cozen = proximal tibia frx
Late valgus deformity abt 6mo after injury for no good reason
Auto corrects over 1-2yrs - monitor clinically
Trt tibial shaft frx vs toddler frx
Tibial shaft
Acceptable alignment 5-10deg V/V
LLC vs flex nails w/ cast if physes open
Toddler - SLC vs CAM
Describe treatment and complications of distal tibia frx by SH classification
SH 1/2
- CR + LLC
- RF for arrest = post reduction frx gap >3mm (ORIF doesn’t change this risk….)
SH 3/4
- Intra articular -> anatomic reduction -> ORIF physeal sparing fixation
What is a Tillaux frx
Additional imaging
Trt
ER force on ankle - avulse the ant lat distal tibia (last part of the physis open)
CT to check displacement (2mm) if unsure
Anatomic reduction, internal fixation, no need for physeal sparing fixation since other than the frx it is closed
What is a triplane frx
How does the distal tibial physis close
AP XR = SH 3
Lat XR = SH 2
Really SH 4
Distal tibial physis closes central -> medial -> lateral
Peds spine:
Number and weight for halo pins
Trt an AO dissociation
Why are odontoid frx common? Trt
Trt TL flexion/distraction injury
6-8 pins, 2-4lbs torque (more pins, less torque)
Fuse AO dissociation
Odontoid frx common bc fuses at 6 - CR + halo
TL flex/dist injury see w/ seatbelt injuries
- Extension brace if stable
- OR if not
Name the 4 physes for hematogenous spread
Intra-articular metaphyses:
Shoulder
Elbow
Hip
Ankle
Osteo:
Most common bug
Bug for neonates
Bug for late presenting with odd sx
Common: S.aureus
Neonates: GBS
Late: Kingella - on blood culture medium or PCR
Define involucrum vs sequestrum
Involucrum = new bone
Sequestrum = necrotic bone that can be nidus for continued infection
Osteo:
Describe CRP trend for kids
Describe MR findings
What is a complication unique to MRSA, why
CRP peaks and normalizes faster
T1 dark / T2 bright
Bright T2 = pathology, don’t confuse tumor
Complication MRSA = DVT 2/2 PVL gene variant
Name the 4 Kocher criteria
What is the likelihood of septic joint w/ 3/4 vs 4/4
NWB
ESR > 40
Fever (most predictive, even over CRP)
WBC > 12
3/4 = 83%
4/4 = 93%, 99% for septic hip although paper hasnt been repeated
Trt Lyme
Young = amox
Older = doxy
Bug for foot punctures, treat
Pseudomonas
Surg debride + IV abx
Why do kids get diskitis
XR findings
BV extend from the cartilaginous region of the end plate into the disc
XR: loss lordosis
Name the disease:
LLD
Culture negative
Treated w/ NSAIDS
Chronic recurrent multifocal osteo (CRMO)
Considered a rheum condition
CP:
Cause
Pathology
MR findings
Medical mgmt goals
Botox mechanism
Anoxic brain injury (<2yo)
- 1 insult so not progressive
- Brian injury = UMN
MR: periventricular leukomalacia
Goal = control spasticity
Botox Xs presynaptic ACH release
Describe the gross motor functional classification system for CP
1 - almost normal
2 - trouble with uneven surfaces
3 - rolling walker, self propelled WC
4 - powered WC
5 - 100% dependent
Describe 3 gait issues + treatment for CP kids
Toe walkers - AFO, casting, TAL
Crouched gait - multi level tendon release
Stiff knee gait - HS lengthening, rectus transfer
How is CP scoli different from AIS
Bracing less effective
Really treating for the caregivers
If operate, higher complication rate
Describe CP hip problems + treatment options
Dislocation
RF = contractures that limit abduction
Therefore, treat with ST releases to maximize abduction for more concentric hip
Goal to prevent irreducible/chronic dislocation
CP kids can get both equinovalgus and varus - which is more common and why do each happen
Varus > valgus - both from spastic overpull
Varus - PT
Valgus - peroneals
Pathology of arthrogryposis
Treatment considerations
Congenital decrease in anterior horn cells
Normal IQ
Not progressive
Correct knees 1st - then hips (often dislocated and don’t respond to Pavlik)
Goal feet = stiff platigrade foot
- Clubfeet or vertical tali that don’t respond to casting
Cause, pathology, and maternal RF for spina bifida
Low maternal folic acid
Incomplete neural tube closure -> high alpha fetoprotein in mothers blood (how you can test in addition to US)
Level of defect dets fxn
RF:
Mat DM
Valproic acid
Mat hyperthermia
Spina bifida
- Associated condition (allergy)
IgE mediated latex allergy
Sacral agenesis
- Associated maternal condition
Maternal DM
Genetics for DMD
Protein mutated
How is Becker different from DMD
DMD
- XLR
- Dystrophin protein
- Elevated CK
Becker overall less severe, still XLR
What medication can slow signs of DMD
Which muscle groups affected first
Corticosteroids
Prox motor 1st (Gower sign)
Freidrich ataxia
- Inheritence
- Gene
- Presentation
AR
Frataxin gene (GAA)
Spinocerebellar and post col degeneration
Wide based gait
Cardiomyopathy
Cavus foot
Scoli
Early mortality (50yo)
CMT
- Inheritance
- Pathology
Hereditary motor sensory neuropathy 2/2 myelin degeneration
AD
PMP 22 on chr 17
Describe why CMT pts get cavus feet, treat
Lose tib ant + per brevis
Over active PL = PF 1st ray
Overactive PT = varus
Trt:
1. PF release + 1st MT osteotomy
2. Hindfoot
Flexible = PT transer
Rigid = calc osteotomy
Myasthenia gravis
- Pathology
- Trt
Auto-immune
Thymus makes Ab - competitively binds Ach-R
Presents as prox muscle weakness worse with activity
Trt
Crisis: IVIG
Other: steroids, pyridostigmine (Ach-esterase inhibitor, don’t break down Ach so can compete with the Ab)
Thymectomy if applicable
Pathology behind polio
Viral destruction of anterior horn cells - muscle weakness, normal sensation
Inheritance, gene and protein for spinal muscular atrophy
AR
SMN gene -> lack SMN-1 protein
Anterior horn cell disease
Infantile blount
- Age
- Associated with
- XR findings
Infantile blount
<4yo
Int tib torsion
XR: metaphyseal diaphyseal angle >16
Metaph beaking
Adolescent Blount
- RF
- XR finding
- Trt
Obesity
Prox medial tibial metaphysis widening
Surg - bracing not effective
Name amt of growth per year
Prox fem
Dist fem
Prox tib
Dist tib
Age for end of growth girls vs boys
Prox fem 3 mm/yr
Dist fem 9
Prox tib 6
Dist tib 5
14 F / 16 M
Trt LLD
<2cm
2-5cm
>5cm
<2cm - obs/shoe lift
2-5cm
- Epiphysiodesis of long side
- Short vs lengthening
>5cm
- Shortening vs lengthening
Post-med bowing
- Associated
- Trt
- Comp
Associated calcaneovalgus foot - treat w/ stretching only!
CORRECTS on own!
Watch for LLD
Ant-med tibial bowing
- Associated with 3 things
Fib hemi
PFFD
Cox vara
AL tibial bowing
- Associated with 2 things
- Trt
Pseudoarthrosis of tibia
NF
Brace to prevent frx bc hard to get to heal once broken
Genetics for fib hemi
What determines treatment
SHH gene
Trt based on foot deformity
Less than 3 toes amputate
4-5 toes limb salvage
Inheritance for tib hemi
What determines treatment
AD
Trt based on quad function: knee disartic vs BKA
Inheritance for toe polydactyly
AD
