Peds Flashcards
Lateral Condyle DDH Rotational Deforities Blount's
Pediatric Lateral condyle fractures classification?
Two (Milch vs. Displacement).
Milch:
Type 1. Fracture lateral to trochlear groove, SHIV
Type 2. Fracture line into trochlear groove, SHII
Displacement:
1. 4mm, displaced and rotated
Best view in addition to AP and lateral for lateral condyle fractures?
Internal oblique view most accurately shows maximum displacement and fracture pattern
Treatment options and indications for lateral condyle fractures?
Non operative - if displaced less than 2mm. Follow weekly.
Operative -
- CRPP if undisplaced but worried about follow up, arthrogram is best to define reduction
- Open reduction percutaneous pinning. Fragment is typically displaced posterior and lateral.
Approach to lateral condyle fracture?
Direct lateral
Kocher interval
Anterior half of capitellum is safe. Blood supply is posterior.
Lateral condyle fracture two complications?
Mal-union, Non-union and avn.
Follow up for lateral condyle fractures? What palsy? What deformity?
Pins out 3-6 wks. Watch for union Lateral condyle overgrowth Cubitus valgus in non-union Cubitus varus in lateral overgrowth Tardy ulnar palsy
What is panner’s disease?
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
What is the blood supply to the capitellum?
Radial recurrent artery
Os
Features of OCD?
Age > 10
Focal osteonecrosis w subchondral separation
Usually have loss of terminal extension
Surgical reduction of dysplastic hip. What blocks reduction?
lliopsoas, pulvinar (debatable), ligamentum teres, transverse acetabular ligament, capsule, inverted labrum, inverted limbus
Arthroscopic staging of OCD?
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.
Normal rotational development of lower limb?
Femoral anteversion 30-40 degrees then 10-15 as adult
Tibia rotates out as well from 5 degrees to 10-15
What to ask patient about when there is a rotational deformity?
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
What is the staheli rotational profile?
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
What defines Forefoot adductus?
Lateral border of foot is straight
Bisector goes through second toe.
Mild moderate severe as bisector moves out towards third, fourth, fifth toe
Operative indications for rotational correction?
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)
Miserable malalignment syndrome?
Excess fem anteversion
Excessive outward rotation of tibia
Patellofemoral pain
Treat w both femoral and tibial deformities
Infantile blounts disease?
Pathological bowing - progressive onset at walking
Medial physis of tibia bone growth arrest
Metaphysical diaphyseal angle greater than 16 degrees
What is tarsal coalition? What two types are symptomatic?
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
Ten yr old referral from er for mcl injury. What are you worried about?
Distal sh type 1 fracture!
What’s the Thurston holland sign?
SH type II frxs, there is a division between epiphysis & metaphysis except for a flake of metaphyseal bone is carried w/ epiphysis
How do you treat a sh4 distal femur #?
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
Sequelae of physeal injury ?
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
Harris growth arrest lines?
6-12 weeks after injury, radiographic sign of recovery from physeal insult
Calcified cartilage line
Pamidronate given every three months to a kid. What does this look at in kids X-ray, what is it treating?
Harris arrest lines, osteogenesis imperfecta
How do you treat physeal arrest?
C/l epiphysisodesis
C/l shortening
….look up the other options
Lateral condyle fracture- what view do you need?
30 degree internal rotation view
What three conditions demonstrate bilateral toe walking?
Diplegic cerebral palsy, muscular dystrophy and idiopathic toe walking
What is infantile Blount’s disease?
Pathologic genu varum, 0-3 yo, bilateral, often associated with internal tibial torsion
What is adolescent Blount’s disease?
Pathologic genu varum in >10 yo, typically unilateral and severe, often femoral deformity
What is the pathology of Infantile Blount’s? Adolescent?
Osteochondrosis of medial proximal tibial physics and epiphysis that can progress to a physeal bar. In adolescent its a dyschondrosis of medial physis
Explain Genu Varum in children. Age range?
Physiologic - less than two years (bowed legs), Neutral by 2 years, 3 years Knock knees, physiologic valgus by 4 years
Do you know a classification for Infantile Blount’s?
Langenskiold - type 1-4 medial metaphyseal beaking and sloping
Type 5-6 have a epiphyseal-metapyseal bong bridge (congenital bar across physis)
What is the metaphyseal-diaphyseal angle (Drennan)? (related to Blount’s)
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
What is treatment for Infantile Blount’s?
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)
What is the goal of correction of Infantile Blount’s?
Overcorrect 10 - 15 degrees.
How do 8 plates work? Heuter Volkman principle
Increases compression forces across the physis, slows longitudinal growth
What is the mainstay of treatment for adolescent?
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.
For adolescent Blount’s when would you do a Osteotomy and Ex fix?
When you have a concomitant LLD. Typically greater than 2.5cm
What is CRITOE?
Capetellum - 1 Radial Head - 3 Internal Medial Epicondyle - 5 Trochlea - 7 Olecranon - 9 External Lateral Epicondyle - 11
DDH encorporates a spectrum disease. Name 5.
- Dysplasia - shallow socket
- Subluxation
- Dislocation
- Teratologic Hip (dislocated in utero)
- Late Adolescent Dysplasia
Risk factors for DDH?
- Female (left)
- First born
- Frank Breech
- Family History
- Oligohydramnios
What is DDH associated with?
Torticolis, metatarsus adductus, congenital knee dislocation (? increased type 3 collagen)
Where is the acetabular deficiency? What about in spastic CP?
Anterior or anterolateral. In CP its posterior-superior.
How do the Ortolani and Barlow tests work?
Dislocated - Ortolani positive early, may be negative late
Dislocatable - Barlow positive
Subluxatable - Barlow suggestive
How does your DDH exam differ after 3 months?
Ortolani Barlow ill be rarely positive.
Look for abduction, thats the key. When is it decreased symmetrically? B/L dislocations.
What might you see on a >1 yo with DDH?
Pelvic obliquity, Lumbar lordosis, Trendelenburg gait, Toe walking
Radiographs for DDH? What ages are useful?
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.
Hilgenreiners line?
Through both Triradiate -femoral head below
Perkins line?
perpendicular to hilgenreiners at lateral margin of acetabulum, femoral head ossification medial to this line
Shentons line?
Arc from femoral neck to superior margin of obturator foramen.
Acetabular index ?
Less than 25 degrees by 6/12
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.
Explain the timing of Ultrasound in DDH?
Useful before 4-6 months but after 4-6 weeks.
Explain Alpha and Beta angles in DDH.
Alpha - angle created by lines along bony acetabulum and ilium. Normal >60 degrees
Beta - Angle from lines on labrum and ilium. Normal < 55 degrees.
When is a arthrogram useful in DDH?
Confirm reduction post closed reduction. Identify potential blocks. Inverted labrum, inverted limbus, TAL, Capsule, Pulvinar, Ligamentum teres
What is the study of choice to assess closed reduction and spica?
CT
How to treat DDH if <6 months and has reducible hip?
Pavlik harness. (C/I in tertologic, spina bifida, spasticity). Success of 90%. Abandon after 3-4 months if not working.
What about DDH in a kid 6-18 months old who has failed pavlik?
Closed reduction and spica
What about open reduction in DDH?
DDH in patient greater than 18 months, failure of closed reduction, open reduce and spica
What about open reduction and femoral osteotomy?
DDH greater than 2 with residual dysplasia, anatomic changes on femoral side ( look for femoral anteversion, coxa valga), best in children less than 4
Re DDH - indications for Open reduction and pelvic osteotomy?
DDH >2 yr with residual dysplasia, patients with increased acetabular index, more common in older >4 year olds
Pavlik harness. What is the goal of positioning?
90-100 degrees flexion, abduction 50 degrees.
Complications of Pavlik?
AVN, transient femoral nerve palsy.
What is Pavlik disease?
Erosion of the pelvis superior to the acetabulum and prevention of the development of the posterior wall of the acetabulum
How long do you keep in Pavlik?
23 hrs a day x 6 weeks. Or until hip is stable. Monitor every 4-6 weeks. Wean afterwards.
What position to you mold a spica in? (If associated with a closed reduction what operative treatment might you add?
Human position - 100 degrees hip flexion, 45 degrees abduction, neutral rotation.
Adductor tenotomy.
What approach do you use for an open reduction to DDH? What artery to avoid?
Smith peterson- decrease risk of MCFA
DDH - When do you consider a Femoral Osteotomy?
If excessive femoral ante version or valgus, shortening may prevent AVN
DDH - when do you consider pelvic Osteotomies?What do you confirm first and on what X-ray?
Increase anterior or anterior lateral coverage
Used after reduction is confirm on abduction internal rotation views
DDH - Explain Salter Redirectional Osteotomy
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.
what are the three types of physeal bars?
Peripheral, elongated/linear, central
When is bar resection indicated?
Less than 50% of physis involved
2 years of growth remaining
Angular deformity less than 20 degrees
What is the bado classification of Monteggia fractures?
- Anterior radial dislocation
- Posterior radial dislocation
- Lateral radial dislocation
- Radius fracture and dislocation
Indication for hemiepiphysiodesis in congential scoliosis
Age
