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Orthopaedic Surgery > Peds > Flashcards

Peds Flashcards

Lateral Condyle DDH Rotational Deforities Blount's

1
Q

Pediatric Lateral condyle fractures classification?

Two (Milch vs. Displacement).

A

Milch:
Type 1. Fracture lateral to trochlear groove, SHIV
Type 2. Fracture line into trochlear groove, SHII

Displacement:
1. 4mm, displaced and rotated

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2
Q

Best view in addition to AP and lateral for lateral condyle fractures?

A

Internal oblique view most accurately shows maximum displacement and fracture pattern

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3
Q

Treatment options and indications for lateral condyle fractures?

A

Non operative - if displaced less than 2mm. Follow weekly.

Operative -

  1. CRPP if undisplaced but worried about follow up, arthrogram is best to define reduction
  2. Open reduction percutaneous pinning. Fragment is typically displaced posterior and lateral.
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4
Q

Approach to lateral condyle fracture?

A

Direct lateral
Kocher interval

Anterior half of capitellum is safe. Blood supply is posterior.

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5
Q

Lateral condyle fracture two complications?

A

Mal-union, Non-union and avn.

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6
Q

Follow up for lateral condyle fractures? What palsy? What deformity?

A 
Pins out 3-6 wks.
Watch for union
Lateral condyle overgrowth
Cubitus valgus in non-union 
Cubitus varus in lateral overgrowth
Tardy ulnar palsy
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7
Q

What is panner’s disease?

A

Injury to the radiocapitellar joint. Age <10.

Abnormal valgus force.

Osteochondrosis of the capitellum, focal avascular lesion.

Self limiting - good prognosis, treat w short course of immobilisation

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8
Q

What is the blood supply to the capitellum?

A

Radial recurrent artery

Os

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9
Q

Features of OCD?

A

Age > 10

Focal osteonecrosis w subchondral separation

Usually have loss of terminal extension

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10
Q

Surgical reduction of dysplastic hip. What blocks reduction?

A

lliopsoas, pulvinar (debatable), ligamentum teres, transverse acetabular ligament, capsule, inverted labrum, inverted limbus

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11
Q

Arthroscopic staging of OCD?

A

Grade 1: a focal area of cartilaginous softening
Grade 2: a breach in the cartilage with a non-displaceable fragment.
Grade 3: displaceable fragment attached by a flap of cartilage.
Grade 4: completely detached fragment or loose body within the joint.

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12
Q

Normal rotational development of lower limb?

A

Femoral anteversion 30-40 degrees then 10-15 as adult

Tibia rotates out as well from 5 degrees to 10-15

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13
Q

What to ask patient about when there is a rotational deformity?

A

Metatarsus adductus - should be able to abduct them opposite direction away from midline - if not cast em

Maternal history - pregnancy

Vitamin d resistant rickets,

W sitting w increased femoral anteversion

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14
Q

What is the staheli rotational profile?

A

Foot progression angle usually 5-10 degrees of out toeing

Hip IR 40 - 50 degrees * these two should be equal
Hip ER 40 - 50 degrees

Thigh foot angle - prone, knee flexed, tmt line foot bisector
Usually 15 degrees

Do these all prone

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15
Q

What defines Forefoot adductus?

A

Lateral border of foot is straight

Bisector goes through second toe.

Mild moderate severe as bisector moves out towards third, fourth, fifth toe

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16
Q

Operative indications for rotational correction?

A

Pain or unacceptable cosmesis, age greater than 5

Technique supramalleolar osteotomy of tibia alone but debatable

Femoral anteversion can be corrected with plate or nail (preferable)

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17
Q

Miserable malalignment syndrome?

A

Excess fem anteversion

Excessive outward rotation of tibia

Patellofemoral pain

Treat w both femoral and tibial deformities

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18
Q

Infantile blounts disease?

A

Pathological bowing - progressive onset at walking

Medial physis of tibia bone growth arrest

Metaphysical diaphyseal angle greater than 16 degrees

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19
Q

What is tarsal coalition? What two types are symptomatic?

A

Partial or complete fusion of two or more bones in the foot

Most Congenital

Fibrous, cartilaginous or bony union

Some acquired if untreated clubfoot

2 symptomatic;

Talocalcaneal
Calcaneonavicular

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20
Q

Ten yr old referral from er for mcl injury. What are you worried about?

A

Distal sh type 1 fracture!

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21
Q

What’s the Thurston holland sign?

A

SH type II frxs, there is a division between epiphysis & metaphysis except for a flake of metaphyseal bone is carried w/ epiphysis

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22
Q

How do you treat a sh4 distal femur #?

A

All metaphyseal screw, all epiphyseal screw

Arthrotomy, ct, open or closed w fluro

Don’t forget what you see on a lateral - deepest part of notch and blumensaat’s line

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23
Q

Sequelae of physeal injury ?

A 
Complete vs partial growth arrest 
(note can get angular deformity w complete ie. if fibula keeps growing) (Leg length deformity)
Healing and remodelling 
Stimulation of growth
malunion 
Non union
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24
Q

Harris growth arrest lines?

A

6-12 weeks after injury, radiographic sign of recovery from physeal insult
Calcified cartilage line

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25
Q

Pamidronate given every three months to a kid. What does this look at in kids X-ray, what is it treating?

A

Harris arrest lines, osteogenesis imperfecta

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26
Q

How do you treat physeal arrest?

A

C/l epiphysisodesis
C/l shortening
….look up the other options

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27
Q

Lateral condyle fracture- what view do you need?

A

30 degree internal rotation view

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28
Q

What three conditions demonstrate bilateral toe walking?

A

Diplegic cerebral palsy, muscular dystrophy and idiopathic toe walking

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29
Q

What is infantile Blount’s disease?

A

Pathologic genu varum, 0-3 yo, bilateral, often associated with internal tibial torsion

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30
Q

What is adolescent Blount’s disease?

A

Pathologic genu varum in >10 yo, typically unilateral and severe, often femoral deformity

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31
Q

What is the pathology of Infantile Blount’s? Adolescent?

A

Osteochondrosis of medial proximal tibial physics and epiphysis that can progress to a physeal bar. In adolescent its a dyschondrosis of medial physis

32
Q

Explain Genu Varum in children. Age range?

A

Physiologic - less than two years (bowed legs), Neutral by 2 years, 3 years Knock knees, physiologic valgus by 4 years

33
Q

Do you know a classification for Infantile Blount’s?

A

Langenskiold - type 1-4 medial metaphyseal beaking and sloping
Type 5-6 have a epiphyseal-metapyseal bong bridge (congenital bar across physis)

34
Q

What is the metaphyseal-diaphyseal angle (Drennan)? (related to Blount’s)

A

Angle between line connecting metaphyseal beaks and a line perpendicular to long axis of tibia
>16 degrees is abnormal and will progress
<10 degrees will have a natural resolution

35
Q

What is treatment for Infantile Blount’s?

A

Non op - Stage 1 and 2 - total contact bracing (1 yr max)
Op - Proximal tibia/fibula valgus osteotomy
Stage greater than 2 - do early less than 4 yo
(May need a ephiphysiolysis)

36
Q

What is the goal of correction of Infantile Blount’s?

A

Overcorrect 10 - 15 degrees.

37
Q

How do 8 plates work? Heuter Volkman principle

A

Increases compression forces across the physis, slows longitudinal growth

38
Q

What is the mainstay of treatment for adolescent?

A

Operative treatment. Lateral tibial and fibular epiphysiodesis. Can do transient or permanent hemiephysiodesis.
Consider Proximal tibia/fibula osteotomy. Do not overcorrect. HTO vs. Ilizarov vs. Taylor Spatial Frame.

39
Q

For adolescent Blount’s when would you do a Osteotomy and Ex fix?

A

When you have a concomitant LLD. Typically greater than 2.5cm

40
Q

What is CRITOE?

A 
Capetellum - 1
Radial Head - 3 
Internal Medial Epicondyle - 5
Trochlea - 7
Olecranon - 9
External Lateral Epicondyle - 11
41
Q

DDH encorporates a spectrum disease. Name 5.

A
  1. Dysplasia - shallow socket
  2. Subluxation
  3. Dislocation
  4. Teratologic Hip (dislocated in utero)
  5. Late Adolescent Dysplasia
42
Q

Risk factors for DDH?

A
  1. Female (left)
  2. First born
  3. Frank Breech
  4. Family History
  5. Oligohydramnios
43
Q

What is DDH associated with?

A

Torticolis, metatarsus adductus, congenital knee dislocation (? increased type 3 collagen)

44
Q

Where is the acetabular deficiency? What about in spastic CP?

A

Anterior or anterolateral. In CP its posterior-superior.

45
Q

How do the Ortolani and Barlow tests work?

A

Dislocated - Ortolani positive early, may be negative late
Dislocatable - Barlow positive
Subluxatable - Barlow suggestive

46
Q

How does your DDH exam differ after 3 months?

A

Ortolani Barlow ill be rarely positive.

Look for abduction, thats the key. When is it decreased symmetrically? B/L dislocations.

47
Q

What might you see on a >1 yo with DDH?

A

Pelvic obliquity, Lumbar lordosis, Trendelenburg gait, Toe walking

48
Q

Radiographs for DDH? What ages are useful?

A

Yes AP pelvis, frog leg laterals. 4-6 months.

Center Edge angle - vertical line from centre of femoral head to lateral edge of acetabulum. Less than 20 degrees is abnormal. This is useful when they are greater than 5 years old.

49
Q

Hilgenreiners line?

A

Through both Triradiate -femoral head below

50
Q

Perkins line?

A

perpendicular to hilgenreiners at lateral margin of acetabulum, femoral head ossification medial to this line

51
Q

Shentons line?

A

Arc from femoral neck to superior margin of obturator foramen.

52
Q

Acetabular index ?

A

Less than 25 degrees by 6/12

53
Q

Center Edge angle ?

A

Vertical line from centre of femoral head to lateral edge of acetabulum. Less than 20 degrees is abnormal. This is useful when they are greater than 5 years old.

54
Q

Explain the timing of Ultrasound in DDH?

A

Useful before 4-6 months but after 4-6 weeks.

55
Q

Explain Alpha and Beta angles in DDH.

A

Alpha - angle created by lines along bony acetabulum and ilium. Normal >60 degrees
Beta - Angle from lines on labrum and ilium. Normal < 55 degrees.

56
Q

When is a arthrogram useful in DDH?

A

Confirm reduction post closed reduction. Identify potential blocks. Inverted labrum, inverted limbus, TAL, Capsule, Pulvinar, Ligamentum teres

57
Q

What is the study of choice to assess closed reduction and spica?

A

CT

58
Q

How to treat DDH if <6 months and has reducible hip?

A

Pavlik harness. (C/I in tertologic, spina bifida, spasticity). Success of 90%. Abandon after 3-4 months if not working.

59
Q

What about DDH in a kid 6-18 months old who has failed pavlik?

A

Closed reduction and spica

60
Q

What about open reduction in DDH?

A

DDH in patient greater than 18 months, failure of closed reduction, open reduce and spica

61
Q

What about open reduction and femoral osteotomy?

A

DDH greater than 2 with residual dysplasia, anatomic changes on femoral side ( look for femoral anteversion, coxa valga), best in children less than 4

62
Q

Re DDH - indications for Open reduction and pelvic osteotomy?

A

DDH >2 yr with residual dysplasia, patients with increased acetabular index, more common in older >4 year olds

63
Q

Pavlik harness. What is the goal of positioning?

A

90-100 degrees flexion, abduction 50 degrees.

64
Q

Complications of Pavlik?

A

AVN, transient femoral nerve palsy.

65
Q

What is Pavlik disease?

A

Erosion of the pelvis superior to the acetabulum and prevention of the development of the posterior wall of the acetabulum

66
Q

How long do you keep in Pavlik?

A

23 hrs a day x 6 weeks. Or until hip is stable. Monitor every 4-6 weeks. Wean afterwards.

67
Q

What position to you mold a spica in? (If associated with a closed reduction what operative treatment might you add?

A

Human position - 100 degrees hip flexion, 45 degrees abduction, neutral rotation.
Adductor tenotomy.

68
Q

What approach do you use for an open reduction to DDH? What artery to avoid?

A

Smith peterson- decrease risk of MCFA

69
Q

DDH - When do you consider a Femoral Osteotomy?

A

If excessive femoral ante version or valgus, shortening may prevent AVN

70
Q

DDH - when do you consider pelvic Osteotomies?What do you confirm first and on what X-ray?

A

Increase anterior or anterior lateral coverage

Used after reduction is confirm on abduction internal rotation views

71
Q

DDH - Explain Salter Redirectional Osteotomy

A

Indicated - young open triradiate. Cut above acetabulum to sciatic notch. Acetabulum hinges on symphysis. Redirectional - lateral 20-25 degrees and 10 - 15 degrees anterior coverage.

72
Q

what are the three types of physeal bars?

A

Peripheral, elongated/linear, central

73
Q

When is bar resection indicated?

A

Less than 50% of physis involved
2 years of growth remaining
Angular deformity less than 20 degrees

74
Q

What is the bado classification of Monteggia fractures?

A
  1. Anterior radial dislocation
  2. Posterior radial dislocation
  3. Lateral radial dislocation
  4. Radius fracture and dislocation
75
Q

Indication for hemiepiphysiodesis in congential scoliosis

A

Age

Orthopaedic Surgery (17 decks)

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