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z mcq of orthobullets > Peds > Flashcards

Peds Flashcards

1
Q

Obstetrical Clavicle Fracture - Risk factors

A

• Large birth weight (>4kg) • Shoulder dystocia • Prolonged gestation • Forceps delivery

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2
Q

Medial Epicondyle Fracture – Surgical Indications

A

• Absolute o Entrapment of medial epicondyle • Relative o > 5mm displacement (usually goes distal and lateral) o Associated with elbow dislocation o Dominant arm in throwing athlete o Weight-bearing extremity in athlete who weight bears through arm (gymnast)

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3
Q

Infantile Scoliosis - Risk of progression

A

• RVAD > 20 degrees • Phase 2 rib • Cobb angle > 30 degrees

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4
Q

Describe the Kocher Criteria

A

Septic hip? • Temp > 38.5 • CRP • ESR • Refusal to WB • WBC count

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5
Q

Septic Arthritis Poor prognostic factors

A

• Age < 6 months • Delay to treatment > 4 days • Hip • Joint effusion with underlying osteomyelitis

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6
Q

Neonatal Infections: Risk factors in NICU

A

• Phlebotomy sites • Indwelling catheters • Invasive monitoring • Peripheral alimentation • IV drug administration

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7
Q

Lyme Disease Features

A

NIVEA • Neuropathies • Intermittent reactive arthritis • Cardiac arrhythmias (“V-Tach”) • Erythema migrans (“bulls eye” rash) • Acute arthritis

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8
Q

ACL “Rules” to avoid physeal arrest

A
  • Avoid over-tensioning
  • Tunnels filled with soft tissue graft only (less likely to form physeal bars)
  • Avoid bone blocks and hardware at level of physis
  • Tunnels small (6-7mm) - <5% of physis (8mm tunnel in 12yr old = 3-4%)
  • Tunnels perpendicular to physis (not oblique)
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9
Q

NF dystrophic scoliosis features

A
  • short (4-6 levels), sharp curves, <6 yrs
  • Xray findings
    • scalloping end plate (posterior)
    • foraminal enlargement
    • pencilling of ribs
    • vertebral wedging
    • dysplastic pedicles
    • dural ectasia (*MRI pre-op)
    • dumbbell lesion (canal neurofibroma)
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10
Q

Proteus Syndrome - 3 characteristic findings

A
  • hemihypertrophy
  • macrodactyly
  • partial gigantism of hands/feet/both
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11
Q

Hemihypertrophy - associated with (4)

A
  • Klippel-Trenaunay-Weber syndrome
  • Proteus
  • NF-1
  • Beckwith-Wiedemann syndrome
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12
Q

Syndactyly - associated with (4)

A

PACU

  • Poland syndrome
  • Apert syndrome
  • Congentical constriction band syndrome (Streeters syndrome)
  • Ulnar longitudinal deficiency
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13
Q

Order of frequency of syndactyly webbing

A
  • 3rd webspace
  • 4th webspace
  • 2nd webspace
  • 1st webspace
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14
Q

Poland Syndrome

A
  • subclavian artery hypoplasia
  • absence of sternocostal head of pec major
  • associated with
    • limb hypoplasia (synbrachydactyly - short digits)
    • carpal coalition
    • RU synostosis
    • sprengel’s deformity
    • scoliosis
    • dextrocardia
    • nail agenesis
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15
Q

Apert Syndrome

A
  • FGFR2***
  • Associated with (TAMP)
    • tarsal coalition
    • acrosyndactyly (spadelike hand)
    • mental retardation
    • premature fusion of cranial sutures
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16
Q

Trigger thumb

A
  • constriction of FPL at A1 pulley
  • 60% bilateral
  • 30% spontaneous resolution if <1 yr
  • <10% spontaneous resolution if >1 yr
  • Surgery –> at 2 years if not resolved
    • A1 pulley release
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17
Q

Clinodactyly

A
  • radioulnar deformity of 5th digit
  • autosomal dominant
  • Associated with:
    • Down syndrome (80%)
    • Russel-Silver syndrome
    • Feingold syndrome
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18
Q

Risk factors for brachial plexus birth palsy

A
  • macrosomia
  • multiparous pregnancy
  • prolonged labour
  • difficult delivery
  • shoulder dystocia
  • difficult arm/head extraction in breech
  • previous BPBP
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19
Q

Natural history of brachial plexus birth palsy

A
  • 80-90% spontaneous recovery
  • antigravity biceps by 2 mths = full recovery anticipated
  • biceps recovery at/after 5 mths= incomplete recovery anticipated
  • poor prognostic signs
    • horner syndrome
    • phrenic nerve palsy
    • total plexopathy (flail extremity)
  • most common problem = IR contracture of arm = glenoid dysplasia (posterior subluxation, humeral head flattening, increased glenoid retroversion)
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20
Q

Brachial plexus birth palsy - signs of preganglionic lesion (4)

A
  • horner syndrome
  • elevated hemidiaphragm
  • winged scapula
  • absence of rhomboid/rotator cuff/lat dorsi function
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21
Q

Brachial plexus birth palsy - Indications for microsurgery

A
  • no biceps function at 3-6 mths
  • flail extremity + horners at 3 mths
  • others say - flail or horners @ 1 mth
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22
Q

Erb’s Palsy treatment

A
  • “waiter’s tip” - arm adducted, IR, pronated, extended at elbow
  • can trial splinting (sup, ER)
  • sx options
    • pec major release
    • subscap release
    • anterior capsule release
    • lat dorsi & teres major transfer (in young patients to try and prevent progression of dysplasia)
    • external rotation osteotomy of humerus (in significant dysplasia)
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23
Q

What is Sprengel’s deformity

A
  • small, undescended scapula
  • associated with
    • scapular winging
    • hypoplasia
    • omovertebral connections (bony or fibrous connection from scapula to vertebral column)
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24
Q

Disorders/diseases associated with Sprengel’s

A
  • Congenital scoliosis
  • Klippel-Feil
  • Torticollis
  • Poland Syndrome
  • Facial asymmetry
  • UE abnormalities
  • Diastematomyelia
  • Pulmnary or renal dx

PPT FUCKeD

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25
Q

Components of Madelung’s Deformity

A

VARA

  • Vicker’s ligament (lunate to radius*)
  • increased radial inclination
  • volar subluxation of the carpus
  • apparent dorsal subluxation of the ulna
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26
Q

Teratologic DDH associations

A
  • arthrogryposis
  • myelomeningocele
  • SMA
  • CMT
  • CP
  • Larsen’s
  • Ehlers-Danlos
  • Down Syndrome
  • Mucopolysaccharoidosis (later in life)
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27
Q

DDH associated with packaging problems

A
  • prematurity
  • oligohydramnios
  • multiparous birth
  • congenital knee dislocation
  • congenital torticollis (20%)
  • metatarsus adductus (10%)
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28
Q

Indications for screening US in DDH

A
  • positive family hx (parent or sibling)
  • breech position in utero
  • congenital muscular torticollis
  • congenital knee dislocation
  • positive physical exam
  • equivocal exam in patient at risk
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29
Q

DDH Ultrasound Parameters

A
  • Alpha angle = bony acetabular roof + ileum
    • Normal > 60
  • Beta angle = cartilaginous acetabular roof + ileum
    • Normal < 55
    • *BIG BETA BAD
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30
Q

DDH Radiographic Parameters

A
  • Hilgenreiner’s line - horizontal across superior aspect of both triradiate cartilage
  • Perkin’s line - perpendicular to H at lateral edge of acetabulum
    • *ossific nucleus in infero-medial quadrant
    • *if no ossificationuse medial aspect of femoral neck
  • Shenton’s line
  • Acetabular Index (AI)
    • >30 abnormal in infant (1 yr)
    • >20 abnormal >2 yrs
  • Center-edge angle of Wiberg
    • <20 abnormal
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31
Q

DDH Blocks to Reduction

A

*OUTSIDE –> IN

  • iliopsoas and adductor longus contracture
  • hip capsule
  • inverted labrum
  • inverted limbus (hypertrophied labrum)
  • TAL
  • pulvinar (fatty tissue filling space)
  • ligamentum teres
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32
Q

Pavlik Harness - Position & Complications

A
  • 90 degrees flexion (anterior strap)
    • Risk: Femoral nerve palsy
  • <60 degrees abduction (posterior strap)
    • Risk: AVN (impingement of posterosuperior branch of MFCA)
  • *Length of Pavlik tx = age + 3 mths (1/2 full time, 1/2 part time)
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33
Q

DDH Closed Reduction Technique and Principles

A
  • traction, flexion, abduction
  • confirm with medial dye pool < 5-7mm
  • “safe zone” of Ramsey
    • maximum passive ABD to ADD where hip is stable
  • adductor tenotomy - as required to increase safe zone
  • spica cast - “in 90-100 degrees flexion within the safe zone avoiding > 60 degrees abduction and neutral rotation”
  • post-op CT or MRI
  • cast x 3-4 mths, change at 6 weeks
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34
Q

DDH Indications for Open Reduction

A
  • failed closed treatment
  • non-concentric reduction (likely block present)
  • reduction requiring extreme, dangerous positioning
  • gross instability
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35
Q

Spica Position after Open Reduction/Pelvic Osteotomy

A
  • 30 degrees flexion
  • 30 degrees abduction
  • minor IR
  • *cast x 6 weeks, abduction brace x 6 weeks
  • *if medial approach = spica x 3 months
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36
Q

Bony Changes in DDH (femur & acetabulum)

A
  • Femur
    • small head
    • short anteverted neck
    • valgus
    • posterior GT
    • tight isthmus (esp M/L)
  • Acetabulum
    • shallow, hypoplastic
    • anteverted
    • anterolateral & superior deficiency
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37
Q

DDH Anterior Approach - Advantages & Disadvantages

A
  • Advantages
    • Capsulorrhaphy possible*
    • Lower risk of osteonecrosis (MFCA)*
    • Direct access to acetabulum/blocks to reduction
    • Able to do pelvic osteotomy through same incision
    • Shorter duration of spica (6 wks)
    • Familiar surgical approach
    • For high-riding dislocations, older patients (>1 yr)
  • Disadvantages
    • Post-op stiffness
    • Potential blood loss
    • Risk to LFCN
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38
Q

DDH Medial Approach - Advantages & Disadvantages

A
  • Advantages
    • Direct access to medial structures (lig teres)
    • Avoid damage to abductors, splitting iliac crest apophysis
    • Less stiffness
    • Less invasive, minimal dissection, quicker
    • Less blood loss*
    • Better scar
  • Disadvantages
    • Capsulorrhaphy not possible*
    • Pelvic osteotomy not possible (ie use in <18 mths)
    • Poor visualization of acetabulum
    • Labrum not accessible
    • Higher risk osteonecrosis*
    • Longer duration of cast (3 mths)*
      • dont have capsulorrhaphy to help maintain reduction as in anterior approach
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39
Q

Perthes - Poor Prognostic Factors

A
  • onset of symptoms > age 8*
  • female
  • premature physeal closure
  • lateral hip subluxation
  • reduced hip ROM (abd)
  • >50% femoral head involvement/collapse*
  • aspherical head, incongruent joint (Stulberg)
  • Herring B or C
  • Catterall III or IV
  • Salter-Thompson B
  • 2+ Catterall at risk signs
  • ***head involvement (shape, congruency) + age at onset of disease most important risk factors***
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40
Q

Perthes - Catterall Radiographic Head-At-Risk Signs

A
  • Need 2 or more
    • Gage sign (“V” in lateral epiphysis)
    • Calcification lateral to epiphysis
    • Lateral subluxation of femoral head
    • Horizontal physis
    • Metaphyseal cysts

*G-MLCH

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41
Q

Perthes - Waldenstrom’s Radiographic Stages

A
  1. Initial (xrays normal 3-6 mths)
  2. Fragmentation (lasts 1 yr) - use all classifications during this stage*
  3. Re-ossification (3-5 yrs)
  4. Remodeling
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42
Q

Perthes - Catterall Classification

A
  • Group I = anterior head involvement only
  • Group II = anterolateral/central head
  • Group III = 75% head involvement
  • Group IV = total head involvement

*fragmentation stage

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43
Q

Perthes - Stulberg Classification

A
  • *At maturity - correlates shape of head and development of radiographic OA
    • Type 1 = normal hip joint
    • Type 2 = spherical head
    • Type 3 = non-spherical head (60% develop OA within 40 yrs)
    • Type 4 = flat head
    • Type 5 = flat head with incongruent hip joint
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44
Q

Perthes - Herring Classification

A
  • Group A = no involvement of lateral pillar
  • Group B = >50% lateral pillar maintained
  • Group C = <50% latearl pillar maintained
  • Group B/C*
  • lateral pillar = lateral 15-30% of epiphysis
  • use during fragmentation stage
  • BEST PREDICTOR OF LONG TERM OUTCOME*
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45
Q

Perthes - Salter-Thompson Classification

A
  • Group A = subchondral fracture/crescent affected <50% of femoral head
  • Group B = >50%
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46
Q

Salter Pelvic Osteotomy - Amount of Coverage Achieved

A

up to 15 deg lateral coverage

and 25 deg anterior coverage

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47
Q

Risk Factors for SCFE

A
  • african descent/pacific islanders
  • male gender
  • renal failure
  • endocrine abnormalities
  • radiation/chemo
  • obesity
  • down syndrome

REAM ROD

48
Q

Indications for Endocrinology workup in SCFE

A
  • Age < 10
  • Weight < 50th percentile

Labs: TSH, GH, BUN/Cr (renal osteodystrophy)

49
Q

Conditions that weaken physis (associated with SCFE)

A
  • hypothyroidism
  • panhypopituitarism
  • GH abnormalities
  • hypogonadism
  • hyper- or hypoPTH
  • renal osteodystrophy
  • previous radiation/chemo
50
Q

Physeal zone affected in SCFE

A

HYPERTROPHIC

(think fat kid)

51
Q

Deformity of distal fragment in SCFE

A
  • Varus in coronal plane
  • Extension in sagital plane
  • External rotation in axial plane
  • (VAR-EX-EX)
52
Q

SCFE - Imaging Findings

A
  • Retroversion deformity
  • Metaphyseal blanch sign of Steel (double density)
  • Klein’s line (AP)
  • Trethowan’s sign (asymmetry in Klein’s line)
  • Scham’s sign
  • Southwick angle (AP&frog) - normal 12
53
Q

SCFE Classification Systems

A
  • Temporal (acute <3 weeks, chronic >3 weeks, acute on chronic)
  • Percent slippage (mild 0-33%, mod 33-66%, severe >66%)
  • Loder Classification (stable vs unstable)
  • Southwick angle difference (mild <30 deg, mod 30-60, severe >60)
54
Q

Indications for prophylactic fixation of opposite hip in SCFE

A
  • Age <10
  • Associated condition (endocrinopathy)
  • Mental delay
  • Poor compliance/follow-up
  • Symptoms on other side***
  • Posterior sloping angle >12

PAM SPA

55
Q

SCFE In Situ Fixation - Key Points

A
  • Fracture table, gentle* traction
  • Guide pin starts anterolateral (screw heads posterior)
  • Avoid start point at/distal to LT
  • Keep start point lateral to intertrochanteric line (impingement)
  • 7.3 mm cannulated screw, 4-5 threads minimum crossing
  • Approach-withdraw method to confirm no screw penetration
  • Single vs multiple screws (unstable SCFE)
  • Stable = PWB, unstable = NWB
56
Q

SCFE - Late Treatment Osteotomy

A
  • Left with retroversion deformity + anterior FAI
  • Flexion intertrochanteric osteotomy = Imhauser osteotomy
    • lateral approach to femur
    • osteotomy just proximal to LT
    • FLEXION primary goal (anterior wedge of bone removed from osteotomy)
    • IR distal shaft (anteverts head)
    • mild valgus
    • ttwb x 3 mths
57
Q

Coxa Vara - Types

A
  • Developmental (genetics - AD)
  • Congenital (eg with PFFD)
  • Dysplastic (skeletal dysplasias, OI, rickets)
  • Acquired/traumatic

C-DAD

58
Q

Coxa Vara - Op vs Non-Op

A
  • Non-Op
    • Asymptomatic, HE angle < 45
    • Asymptomatic, HE angle 45-60 (follow with serial radiographs)
  • Operative
    • Symptomatic, HE angle 45-60
    • HE angle >60 likely to progress
    • Progressive decrease NSA <100
    • GOAL = HE < 38
59
Q

Hemihypertrophy - important association***

A

Get renal/abdominal US to rule out visceral malignancy

Beckwith-Wiedemann = Wilm’s tumor

60
Q

LLD - Prediction Methods

A
  • Arithmetic method
  • Anderson & Green tables
  • Moseley straight line graph
  • Paley multiplier method* (most accurate)

An AMP

61
Q

Limb growth / year

A

Leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)

  • 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)
62
Q

Physeal Bar Excision - Indications

A

<50% of the physis

At least 2 yrs growth remaining

63
Q

LLD General Treatment Principles (based on length)

A
  • 0-2 cm = shoe lift
  • 2-5cm = contralateral epiphysiodesis, shortening (if after skeletal maturity)
  • 5-20cm = lengthening
  • 15-20cm = lengthening + epiphysiodesis/shortening, amputation
64
Q

Max Shortening Parameters

A
  • 10-20% of length
    • Femur 5cm
    • Tibia 3cm
    • Humerus 4cm
65
Q

Hueter Volkmann Law

A
  • theory suggest that mechanical forces influence longitudinal growth
  • growth accelerated by tension
  • compressive forces inhibit growth
  • implicated in scoliosis*
  • also idea behind 8-plates
66
Q

Limb Lengthening Important Points

A
  • lengthen at metaphyseal level
  • delay lengthening after corticotomy by 5-7 days
  • lengthen at rate of 1 mm/day (0.25mm 4x/day)
  • limit lengthening to <20% bone length
    • femur 8cm
    • tibia 5cm
67
Q

Lower Limb Alignment Milestones Through Growth

A
  • Birth: 10-15 varus
  • 6 mths: 20 varus (max)
  • 18 mths: neutral
  • 3 yrs: 12 valgus (up to 20)
  • 6 yrs: standard 7 valgus

*Salenius and Vankka graph

68
Q

Angular Measurements for Tibia Vara

A
  • Metaphyseal-diaphyseal angle
    • MD < 10 physiologic
    • MD > 16 Blounts
  • Tibiofemoral angle: >15 abnormal
  • Epiphyseal-metaphyseal angle: >20-30 abnormal
  • Ratio of femoral MDA and tibial MDA
    • >1 = physiologic
    • <1 = more likely Blounts (more angle from tibia than femur)
69
Q

Blounts Classification

A

Langenskiold Classification (Infantile Blounts)

  • I = beak
  • II = saucer
  • III = step
  • IV = bent
  • V = double epiphysis
  • VI = bony bar

= increasing medial metaphyseal sloping with bony bridge @ V/VI

BullShit SlotBack Defensive Back

70
Q

Infantile Blounts - Indications for Surgery

A
  • Age 3-4
  • Langenskiold stage III or above
  • MD angle > 16
  • Progressive deformity

*risk of recurrence slighly less if performed before age 4

71
Q

Infantile Blounts - Surgical Principles

A

Proximal tibial valgus & rotational osteotomy

  • Multiplanar*
    • valgus, lateral translation, ER
    • correct increased posterior slope
  • Lateral & anterior compartment fasciotomy
  • Fibular osteotomy (resect 1 cm)
  • Osteotomy below tibial tubercle, at CORA
  • Dome osteotomy, convex proximal
  • Over-correct into 10-15 valgus
  • May need bony bar resection, medial tibial plateau elevation if any joint depression (V, VI)
72
Q

Skeletal Dysplasias causing Genu Valgum

A

PEMMS

  • Pseudoachondroplasia
  • Ellis-Van Creveld (EVC)
  • MED
  • Morquio
  • SED

ME PMS

73
Q

Genu Valgum - Indications for Surgery

A
  • TF angle > 15
  • Intermalleolar distance > 10cm
  • Mechanical axis at lateral plateau in children age > 10
74
Q

Causes of Intoeing by Age

A
  • Infant = metatarsus adductus
  • Toddler = internal tibial torsion
  • >3 yrs = femoral anteversion
75
Q

Lower Extremity Rotational Profile - Normals

A
  • Femoral anteversion: 15 degrees
  • Hip IR: 30-60
  • Hip ER: 30-60
  • Thigh-foot angle: 10 ER (-5 to +20)
  • Transmalleolar axis: 20 ER
  • Heel-bissector line: 2nd webspace

*GT prominence test - IR until GT most prominent = femoral anteversion

76
Q

Indications for Derotation Osteotomy in Femoral Anteversion

A
  • age > 8 with pain, <10 ER
  • anteversion > 50 and IR > 80

*amount of rotation needed to correct excessive anteversion = prone IR-ER/2

*WAIT UNTIL AGE 8 to do any surgery

77
Q

Tibial Bowing

A
  • Anterolateral = NF
    • pseudarthrosis
    • bracing to prevent #
    • if get # - IM nail & bone graft
    • amp option = symes
  • Posteromedial = physiologic, calcaneovalgus
    • spontaneous improvement
    • LLD - avg 4cm, deal with later (epiphysiodesis)
  • Anteromedial = fibular hemimelia
    • osteotomy with lengthening vs. amp
78
Q

Optimal age for amputation in limb deficiency

A

10 mths - 2 yrs

  • Syme - simple, tapered prosthesis
  • Boyd - prevents heel pad migration, better end bearing - but longer length
79
Q

PFFD - Classification

A
  • spectrum of problems @ acetabulum, prox femur, knee, lower leg (mild/mod/severe)
  • Aitken classification - Class A-D based on acetabulum and femoral head severity
  • Gillespie/Torode Classification - best
    • Group A = congenital short femur - long enough to allow WB
    • Group B = PFFD, need prosthesis to WB, however have anterior displacement of tibia
    • Group C = little to no femur, but without anterior displacement of tibia = easier prosthesis fit
80
Q

Fibular Hemimelia - Associated Abnormalities

A
  • shortening of femur (PFFD) and tibia
    • hip dysplasia, coxa vara
  • LLD
  • genu valgum - lateral femoral condyle hypoplasia
  • cruciate ligament deficiency, absent menisci
  • anteriomedial tibial bowing
  • patella alta
  • equinovalgus
  • tarsal coalition (talocalcaneal - complete)
    • = ball and socket joint
  • absent lateral ray(s)
81
Q

Fibular Hemimelia - Classification

A
  • Birch Classification
    • depends on foot function - if preservable or requires amp
    • Type 1 = foot preservable
      • % inequality/LLD determines tx
    • Type 2 = foot nonpreservable
      • function of upper extremity determines early amp vs salvage
82
Q

Tibial Deficiency - Classification

A
  • Jones Classification
    • Type 1 = tibia not seen at birth
      • 1A = no tibia (no functional knee)
      • 1B = upper tibia late to ossify (functional knee*)
    • Type 2 = prox tibia w absent distal tibia
      • functional knee*
    • Type 3 = absent prox tibia w distal tibia
      • more rare, no knee
    • Type 4 = diastases of tib/fib
      • most common
      • no ankle mortise, foot in rigid equinus
83
Q

Congenital Knee Dislocation - Associated Orthoapedic Issues

A
  • metatarsus adductus
  • equinovarus foot
  • CVT
  • clubfoot
  • ipsilateral hip dislocation (70-100%)
84
Q

Congenital Knee Dislocation - Classification

A
  • Type 1
    • recurvatum, can passively flex to 90
  • Type 2
    • subluxation, can passively flex to 45
  • Type 3
    • dislocation
85
Q

Congenital Patellar Dislocation - Associations

A

DAN LED

  • Down’s
  • Arthrogryposis
  • Nail-Patella syndrome
  • Larsens
  • Ellis-Van Creveld syndrome
  • Diastrophic dysplasia

DAN LED

86
Q

Clubfoot Perani Grading System

A
  • Posterior crease
  • Empty heel
  • Rigid equinus
  • Medial crease
  • Curved lateral border
  • Lateral head of talus

​REP MCL

  • Each graded 0, 0.5, or 1
  • 3 or greater = likely to need at least 4 casts with tenotomy
87
Q

Clubfoot - Associated Conditions

A
  • tibial hemimelia
  • hand abnormalities
  • arthrogryposis
  • diastrophic dysplasia
  • myelomeningocele
  • amniotic band syndrome
  • larsen’s

HAD MALT

88
Q

Clubfoot - Posteromedial Release General Concepts

A
  • prone, cincinnati incision
  • if <18mths - TA tenotomy/lengthening
  • release ankle capsule
  • release subtalar joint
  • FHL lengthening
  • Tib post lengthening
  • FDL, abductor hallucis lengthening
  • *do not release plantar fascia (planovalgus)
  • release TN joint
  • release spring ligament
  • release CC joint
  • Realign foot & pin
    • straight lateral border of foot
    • 1st MT lateral to talar axis (abducted)
    • hindfoot valgus
  • Cast x 3 mths, pins out at 4-6 wks
89
Q

Congenital Vertical Talus - Associated Systemic Conditions

A
  • SNAIL
    • syndromic (trisomy 13/15/18)
    • neural tube defects (myelomeningocele*, sacral agenesis, diastematomelia)
    • arthrogryposis
    • idiopathic
    • larsens

(think of snail shaped like a vertical talus - AK)

90
Q

CVT - Deformity

A
  • severe flatfoot
  • fixed hindfoot equinus & valgus
    • tight achilles/peroneals
  • midfoot dorsiflexion
    • dorsolateral dislocation of navicular on talus
  • forefoot abduction and dorsiflexion
    • tight dorsolateral muscles (TA/EHL/EDL/PB/PL)
  • hypoplastic talar neck
  • hypoplastic, wedge-shaped navicular
  • talar plantar flexion
  • calcaneus plantar flexion - can see cuboid d/l
  • attenuation of spring ligament
91
Q

CVT - Classification

A
  • Coleman classification
    • Type 1 = no cuboid subluxation/dislocation
    • Type 2 = cuboid subluxation/dislocation
      • harder to treat
92
Q

CVT - Radiographic Findings

A
  • Lateral radiograph
    • Talar axis metatarsal base angle (TAMBA)
      • >35 = pathognomonic for CVT
      • navicular ossifies at age 3 - 1st MT used as proxy
  • Forced PF lateral - Eyre Brook view
    • persistent dorsal dislocation of TN joint
    • *oblique talus reduces on this view
  • Forced DF lateral
    • persistent plantarflexion of talus and calc
  • AP
    • talocalcaneal angle >40 (N 20-40)
    • valgus midfoot
93
Q

CVT - Treatment

A
  • serial casting to stretch dorsolateral soft tissues
    • 5-6 weekly casts
    • opposite correction to clubfoot - equinus last
    • bring into equinus, hindfoot varus and forefoot adduction
    • last cast = maximal PF and inversion
  • K-wire pinning of TN joint
    • retrograde from navicular into talus - want TAMBA <30 - bury pins
    • small 1 cm open incision over TN joint - do not cut capsule
      • unless not reduced and need to open subtalar joint with a 2 cm medial incision and transfer for tib ant to dorsal aspect of talar neck to help correct deformity*
  • fractional lengthening of dorsolat tendons
    • if PF limited to <25 - lengthen EDC/tib ant
    • if forefoot adduction <10 - lengthen PB
  • perc tenotomy of achilles (*med to lat)
  • long leg cast, 5-10 DF, pins out at 6 weeks
  • boots & bars full-time 2 mths, nighttime 2 yrs
94
Q

Cavovarus - muscle imbalance

A
  • peroneus longus > tib ant (PF)
  • tib post > peroneus brevis (inv)
  • weak instrinsics (DF MTP, flex IP)
95
Q

Cavovarus - treatment options

A
  • Depends on deformity, flexible vs fixed
  • Toe deformities
    • Girdlestone-Taylor (flex to ext)
    • Jones (IP fusion + EHL to 1st MT neck)
  • Soft tissue procedures
    • plantar fascia release* (ALL)
    • TAL (equinus)
  • Osteotomies
    • Forefoot = cotton (1st MT DF osteotomy)
    • Midfoot = midfoot closing wedge osteotomy
    • Calcaneus = lateral closing wedge/slide
  • Tendon transfer
    • tib post - to lateral cuneiform (for DF)
    • PL to PB
  • Arthrodesis - triple = salvage
96
Q

Tarsal Coalition - Important Points

A
  • calcaneonavicular > talocalcaneal (middle facet*)
  • 50% bilateral
  • associations
    • fibular hemimelia
    • Apert syndrome
    • clubfoot
  • onset of symptoms
    • age 8-12 = CN
    • age 12-15 = TC
97
Q

Accessory Navicular - Types

A
  • Type 1 = sesamoid in tib post tendon
  • Type 2 = separate ossicle attached via synchondrosis
  • Type 3 = bony enlargement
98
Q

Hallux Varus - classification (congenital)

A
  • Congenital - classification
    • Type 1 = normal toe, tight AbdH
    • Type 2 = polydactyly or longitudinal epiphyseal bracket*
      • Delta phalanx*
        • associated with tarsal coalitions, apert syndrome
    • Type 3 = dysplasia (diastrophic)
99
Q

Physis & Associated Conditions

A
  • Reserve zone
    • Gaucher disease
    • Diastrophic dysplasia
    • Pseudoachondroplasia
  • Proliferative zone (*ECM)
    • Achondroplasia
    • Gigantism
    • MHE
    • SED
  • Hypertrophic zone (Maturation zone, Degeneration zone, Zone of provisional calcification )
    • SCFE
    • Rickets
    • Mucopolysacharide dx
    • Fractures (zone of prov calc)
  • Primary Spongiosa
    • Scurvy
100
Q

Achondroplasia

A
  • most common skeletal dysplasia
  • autosomal dominant - but 90% new mutations
  • FGFR-3
    • gain in function - inhibits chondrocytes = reduced endochondral ossification, reduced growth
  • Growth arrest at PROLIFERATIVE zone
  • Features
    • Rhizomelic shortening (prox > distal limb)
    • Foramen magnum stenosis*
    • TL kyphosis, TL stenosis, hyperlordosis
      • *narrow interpedicular distance (L1-L5)
    • NOT cervical instability
    • Champagne glass pelvis
    • Genu varum
101
Q

Pseudoachondroplasia

A
  • autosomal dominant
  • COMP mutation - chromosome 19
  • epiphysis are delayed/abdnormal
  • rhizomelic shortening
  • normal facies
  • cervical instability*
  • lower extremity bowing
  • joint hyperlaxity, DDH, early OA
102
Q

Diatrophic Dysplasia

A
  • autosomal recessive
  • mutation in sulphate transport protein
  • rhizomelic shortening
  • A-A instability, cervical kyphosis
  • cleft palae, cauliflower ears

Think of a messed up wrestler… like Neufeld

RACCC

103
Q

Cleidocranial Dysostosis

A
  • autosomal dominant
  • proportionate dwarfism
  • defect in CBFA-1 - transcription factor for osteocalcin
    • affects IM ossification - skull, clavicle, pelvis
  • mild short stature
  • frontal bossing
  • delayed teeth
  • absent clavicles
  • coxa vara

CAPS C FAD

104
Q

Common features of mucopolysaccharidoses

A
  • Lysosomal storage diseases
  • Autosomal recessive
    • Hunter’s = X-linked recessive
  • Urine test - mucopolysaccharide breakdown products
  • Features
    • short stature
    • corneal clouding
    • bullet-shaped phalanges*
    • mental retardation (except Morquio’s*)
    • cervical instability*
    • DDH
    • carpal tunnel syndrome

MBCS, CDC

Mental Bowl College Champions, Centers for Disease Control

105
Q

Mucopolysaccharidoses Subtypes

A
  • I - Hurler Syndrome (most severe)
    • alpha-L-iduronidase deficiency
    • accumulation of dermatan sulfate
    • treat with bone marrow transplant
    • death in first year of life
  • II - Hunter Syndrome
    • X-linked recessive*
    • accumulation of dermatan/heparan sulfate
  • III - Sanfilippo Syndrome (most common)
    • accumulation of heparan sulfate
  • IV - Morquio Syndrome (most common)
    • Type A (galactosamine-6-sulphatase)
    • Type B (beta-galactosidase deficiency)
    • accumulation of keratan sulfate
    • *normal intelligence
106
Q

Multiple Epiphyseal Dysplasia

A
  • autosomal dominant
  • multiple genes (COMP1, COL9A2, COL9A3)
  • proportionate dwarfism
  • multiple abnormal epiphyses
  • shortened metacarpals/metatarsals
  • valgus knees*
  • double layer patella*
  • DDH
  • OA/joint contractures
  • NO spinal involvement*

AMP MS VODD

107
Q

Spondyloepiphyseal Dysplasia

A
  • proportionate dwarfism
  • cervical instability***
  • platyspondyly
  • SED congenita
    • COL2A1 gene
    • proliferative zone affected
    • coxa vara, genu valgum
    • retinal detachment, myopia
  • SED tarda
    • X-linked recessive, SEDL gene
    • milder, later onset

SED - S = Second (two types)

Spondylo = spine (cervical spine/platyspondyly)/skeleton (coxa vara/genu valgum)

Epiphyseal = eye (retinal detachment/myopia)

108
Q

Radial Head Dislocation - Associations

A

SMASHED LUCK NK

  • Silver’s syndrome
  • Marfan’s
  • Achondroplasia
  • Steel syndrome
  • Hereditary multiple exostosis
  • Ehler’s Danlos
  • Down syndrome
  • Larsen’s syndrome
  • Ulnar longitudinal deficiency
  • Cornelia de Lange
  • Klippel-Feil syndrome
  • Nail-Patella syndrome
  • Klinefelter’s
109
Q

Marfan’s Syndrome

A
  • Autosomal dominant
  • Fibrillin-1 gene (FBN1) - chromosome 15q21
  • MSK - tall, thin etc
  • 60-70% have scoliosis
    • narrow pedicles, wide TPs, vertebral scalloping
    • dural ectasia*
  • acetabular protrusio
  • pes planovalgus
  • superior lens dislocation
  • aortic root dilatation
  • Ghent classification
    • 1 major criterion from 2 different organ systems + 3rd system
110
Q

Dural ectasia associations

A
  • Marfan’s
  • Ehler’s Danlos
  • Achondroplasia
  • NF

MEAN

111
Q

Ehlers-Danlos Syndrome

A
  • Classification
    • Classic (Type 1, gravis)
      • Autosomal dominant
      • COL5A1, COL5A2 = type V collagen
    • Type III - hypermobility
      • Autosomal dominant
    • Type VI - kyphoscoliosis
      • Autosomal recessive
      • Mutation in lysyl hydroxylase
      • Severe kyphoscoliosis
    • Type VII - arthrochalasis
      • autosomal dominant
      • COL1A1, COL1A2
      • congenital bilateral hip dislocation, hypermobility
112
Q

Ca/Phos/Vit D homeostasis

A
113
Q

OI - Classification

A
  • Type 1 (dominant, blue sclera)
    • AD
  • Type II (lethal perinatal)
    • AD
  • Type III (progressive deforming)
    • AR
  • Type IV (dominant, white sclera)
    • AD
114
Q

VACTERL

A

Vertebral anomalies

Anal anomalies

Cardiac anomalies

Tracheo-esophageal fistula

Renal anomalies

Limb anomalies (radial deficiency)

115
Q

Syndromes associated with cervical instability

A

Skeletal dysplasias:

  • Pseudoachondroplasia
  • MPS - Morquio’s (type IV)
  • SED
  • Diatrophic dysplasia

Connective tissue:

  • Down’s
  • Marfans
  • Larsens
  • Ehlers-Danlos

NOT achondroplasia*

116
Q

Risk factors for DVT in paeds MRSA osteomyelitis

A

CRP > 6

Age > 8

MRSA

PVL (Panton-Valentine leukocidin)

Surgical treatment

CAMPS*

117
Q

Panton-Valentine leukocidin (PVL) associated with

A

Some strains of CA-MRSA harbor genes encoding for Panton-Valentine leukocidin (PVL)

  • Complex infections
  • Multifocal infections
  • Prolonged fever
  • Myositis
  • Pyomyositis
  • Intra-osseus or subperiosteal abscess
  • Chronic osteomyelitis
  • DVT

DIS C2M2P2

z mcq of orthobullets (27 decks)

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