Peds Flashcards
Staheli’s Test
- Child placed prone, legs hanging over the table. Examiner extends one limb at a time trying to get limb to neutral.
- If child can’t get to neutral, may be fixed flexion contracture.
Thomas’s Test
- Tests for flexion contracture (illiopspoas)
- Child supine, with knees to chest. Allow one leg to extend.
Ober’s Test
Tests for hip abduction contracture
Ely’s Test
Tests for Rectus Femoris contracture
Ryder’s Test
- Measures femoral antetorsion
- Normal is 10˚ internally rotated
- If femur is ext rotated, there is retrotorsion
- If femur is int rotated, there is antetorsion
APGAR score
Skin Color:
0 - blue
1 - body pink, extrem blue
2 - completely pink
HR:
0 - asystole
1 - 100 bpm
RR:
0 - absent
1 - slow/irregular
2 - good (>60 bpm)
Stimulation Response
0 - no response
1 - facial grimace
2 - sneeze/cough
Muscle Tone
0 - limp/no tone
1 - some flexion of extrems
2 - active motion
What APGAR score indicates extreme distress
1-2 (highest score = 10)
Barlow’s Test
To identify a hip that is fully located (or subluxed), but which can be additionally subluxed or fully dislocated
When to take APGAR score
@ 1 min, 5 min, then q 5 min until normalize
Ortoloni’s Test
To identify a hip that is doslocated but reducible
Palmen’s Sign
A finding of subluxation
Telescoping Sign
To identify a dislocated mobile proximal femur
Galeazzi’s Sign
To identify an apparently short femur in hip dislocation
Allis’ Sign
Tests for shortening in the limb
Trendelenberg’s Test
Tests for weakness of the hip abductors (especially gluteus medius)
Gower’s Sign
Identifies weak hip extensors
Confusion Sign
- Have pt do maneuver unrelated to ankle dorsiflexion, but it will produce reflex ankle
- Seen in children that are neurologically abnormal, with spasticity
Calcaneovarus deformities
ankle = calcaneus FF = supinated (adducted/varus)
Causes of Calcaneovarus
- NM in nature
- tibialis anterior = only muscle really working well (adducted/varus)
- weakness in posterior, lateral, and other anterior muscle groups
Difference b/w calcaneovarus and calcaneus deformity
calcaneus deformity = no forefoot malposition (all anterior muscle groups functioning)
Similarities:
- also NM in nature
- neither are talipes (congenital) deformities
Triad of Talipes Calcaneovalgus
- Ankle Calcaneus
- STJ pronation
- TN subluxation (NOT dislocated – i.e., how to differentiate from vertical talus, in which TNJ is dislocated!)
- note: ankle in calcaneus with PF to neutral only until ~6 mo… after 6mo, ankle in equinus and PF 20 deg (OBLIQUE TALUS AND TALIPES CALCANEOVALGUS = ONE IN THE SAME AFTE 6 MONTHS)
- i.e., ankle equinus, STJ pronated/subluxed, FF abducted
Etiology of Talipes Calcaneovalgus
- congenital (in utero positioning - packaging defect) **most common
- neurological (paralysis below L5)
Tx of Talipes Calcaneovalgus
- serial casting followed by orthotics (UCBL or Type C Heel Stabilizers)
Causes of rigid pediatric flatfoot
- Congenital Convex Pes Valgus (Vertical Talus)
- Tarsal Coalition
- Severe Talipes Calcaneovalgus (more common than CCPV*)
Oblique Talus - flexible or rigid?
fully flexible triplane pronation foot
Congenital Convex Pes Valgus - other names
- rock-bottom flatfoot
- persian slipper
- vertical talus
Difference b/w CCPV and Talipes Calcaneovalgus
- CCPV - DISLOCATED STJ
Most common cause of CCPV
- Myelomeningocele
Bone/Joint Abnormalities of CCPV
- TNJ dislocation (navicular wedged b/w dorsal talar neck and anterior tibia)
- ankle in equinus, but foot in calcaneus (b/c talus extremely PF, but foot looks DF on AJ)
- talar neck hypoplastic (“Washington monument”), small talus
- calcaneus in equinus
- elongated spring ligament
- tight anterior compartment tendons, triceps surae, and peroneals
Treatment of CCPV
- Dobb’s Technique = serial casting based on reversal of Ponsetti technique
- do serial casting and then limited midfoot release if necessary
- late initiation of tx worsens prognosis
Talipes Equinovarus (TEV) - 3 components
- ankle and foot equinus
- STJ varus (STJ supinated)
- FF adductus (and in some degree of cavus, 1st met PF)
Etiology of TEV
- idiopathic ** most common form
- unknown, probably genetic
- males > females (females get it wore when present)
Arterial abnormality seen in TEV
80-85% - anterior tibial artery abnormality - usually does not develop distal to lower 1/3 of leg
Pathological anatomy TEV
- ankle/foot equinus
- STJ varus
- talar neck short & deviated medially/plantarly
- navicular is down, medial, and proximal on the talar head (SUBLUXED) and 2/3 the size of normal - follows abnormal position of talus and may be so medial that forms false articulation with anterior aspect of medial mall
- can’t palpate the talar head medially b/c of navicular covg
- calcanus in varus and rotated so that distal portion almost directly inferior to talar head (medially and downward)
- severe capsular/ligamentous contractures
- invoved foot is smaller involved leg is smaller (look at calf musculature)
- no sinus tarsi (talar head fills it)
- redundant skin over talar head, thin and hyperpigmented – caused by the uncovering of the dorsolateral aspect of talar head (long standing pressure of head against skin)
Gold standard of TEV correction
PONSETTI TECHIQUE = manipulation and serial casting (MUST BE ABOVE THE KNEE)
- supinate the FF to remove the 1st ray cavus and get FF parallel to RF
- correct FF and STJ as unit
- correct AJ equinus only after (PQ AT tenotomy! not lengthening)
** long term shoe/bar splinting - Dobb’s brace = what is used today (or can use Filauer bar if non-ambulatory or when sleeping/resting)
When to do surgery on TEV
- salvage px
- wait until at least 9 mo of age (so they can tolerate)
- if pt not corrected by serial casting/manipulation before 1 year - want to consider sx before start standing on the deformity
- usually need to d posterio-medio-latero-plantar release
Cincinnati incision
big incision - from 1st met base up to Tendo Achilles to cuboid/5th met base
Clinical Picture of Met Adductus
- mets 2-5 adducted due to bowing of prox shaft; vs. distal medial cuneiform is malaligned so that it directs medially (not 1st met)
- concave medially w/ apex at 1st TMTJ and deep vertical skin crease
- convex laterally w/ apex at 5th met base (prominent)
- regular hindfoot
- hallux varus may be present
- wide 1st interdigital space
- contracted abductor hallucis
4 Findings that constitute the screening for met adductus
- simple inspection
- passive overcorrection
- active overcorrection (note: response involutes after 1 yr)
- evaluation standing (deformity usually worse)
Most common cause of met adductus
most likely intra-uterine packing
* also genetic component
Which is easier to fix met adductus type: flexible or rigid?
rigid
When should you definitively decide to treat met adductus
if it has not spontaneously corrected by 6-8 months
Gold standard treatment of met adductus
- manipulation and serial casting, change weekly (as long as
Indications for met adductus surgical intervention
- persistant hallux varus
- age > 3
- recurrence
- failure of non-op tx
Heyman, Herndon, and Strong Px
- TMTJ lig (only medial, dorsal, and plantar) release with 2nd met osteotomy
- for younger children
Fowler Px
- used mostly for skewfoot when need deformity correction in all three planes
- includes: 1. opening wedge osteotomy of medial cuneiform, 2. abducting osteotomies of lesser mets, 3. possible lateral column lengthening, 4. possible varus osteotomy of calcaneus
Berman-Gartland Px
- crescentic osteotomies to abduct metatarsals (base osteotomies)
- older children (b/c ca no longer remodel cartilage as you can w/ HHS) with persisting deformity
- be careful w/ 1st met – need to make 1.5 distal to base due to open physis
Stereotypical Blount’s Dz Pt
- short, fat, early walker
- African American
- Female
is Blount’s real AVN
no
Current theory on Pathophysiology of Blounts Dz
- progressive upper medial tibial physeal dysfunction (may be due to early loading / walking of someone already in varoid position)
- decrease growth medial side, cntnd growth laterally
Xray findings Blounts
- beak on medial side w/ flattening
- tibiometaphyseal (Levine-Dennen’s Angle) >16 = suggestive for Blounts (
