Peds Flashcards
in extension SCH frx what denotes more instability
medial commiution leading to varus
WB in titanium elastic nails for femur frx
allowed
what exacerbates sx of a peds spondy
extension
are oblique xr needed to dx a spondy
NO - lateral is enough
highest risk group for spondy slip progression
just before teen growth spurt, general reduced risk with age
OCD imaging of choice
MRI; not arthrogram; never XR
tx of peds discitis with vt osteo
IV Abx - no I&D needed
highest incidence of peds spondy in what population
Native americans
UBC tx in prox hum
generally even with frx first tx is observation - if it remains painful or cortex does NOT thicken after frx healing then C&G&BG
tx of suspected Lyme Septic arthritis
aspiration, lyme serology and oral amoxicillin 30 days
UBC by skeletal maturity
they typically resolve
what percent of peds spondy develop to needing surgery
less than 5%
how to diagnose and tx a neonatal elbow injury
get arthrogram - generally Transphyseal and need to visualize the distal humerus
achondroplasia features
lumbar stenosis, lordosis; short pedicles, post radial head dislocation, frontal bossing, genu varum
achondroplasia genetics
FGFR 3, gly-arg substitute slows prolif zone, Auto dom but 90% sporadic
SED genetics
type 2 collagen COL2A1 gene - auto dom
SED features
short trunk and limbs, abnormal epiphyses INCLUDING spine; odontoid hypoplasia and resultant atlanto axial instability; coxa vara, DDH, hearing loss, retinal detachment
what is Kniest dysplasia
same gene as SED (COL2A1); auto dom. Joint contractures, dumbell femurs, respiratory problems, cleft palate, kyphoscoliosis; retinal detachment and hearing loss.
Cleidocranial dysplasia genetics
CBFA1 - transcription factor that activates osteoblast differentiation auto dominant, affects intramembranous ossification
features of cleidocranial dysplasia
clavicles absent, delayed skull closure, frontal bossing, coxa vara (osteotomy for > 100deg); delayed ossification of pubis; genu valgum; short middle phalanx of 3-5th finger
Nail patella syndrome genetics
lin homeobox gene transcription factor; autosomal DOM. - also in eyes and kidneys
features of nail patella
aplasia or hypoplasia of patella/condyles; iliac horns; post dislocation of radial head; 30% get renal fx and glaucoma as adults
diastrophic dysplasia genetics
sulfate transporter gene - affects proteoglycan sulfate groups in cartilage - auto REC.
features of diastrophic dysplasia
short, rhizomelic, cervical kyphosis and kyphoscoliosis; hitchiker thumb; cauliflower ears; rigid club feet; skew foot; severe OA joint contractures
mucopolysacchridoses genetics
all are auto recessive except Hunters (x-link recessive)
Metaphyseal Dysplasia(MD) genetics
Schmid type defect in collagen X (COL10A1); Jansen type - PTHreceptor defect which regulates chondrocyte differentiation; McKusick type worse type - affects ribosome nucelic acid component of mitochondria
MD features schmid
mild; coxa vara, genu valgum
MD features jansen
short, squat stature, hyper Ca; bulbous metaphyseal expansion of long bones; extremity malalignment
MD McKusick type
C1-2 instability; hypoplastic cartilage; immunocomp; malignancies, thin hair, intestinal malabsorption/megacolon; ankle deformities due to fibular overgrowth; ligamentous laxity; genu varum and pectus abnormalities
pseudoachondroplasia genetics
COMP gene on C19 - extracellular matrix glycoprotein in cartilage - Auto Dom
pseudoachondroplasia features
DDH, early OA, scoliosis; norma face, c1-2 instability due to odontoid dyspasia; metaphyseal flaring
multiple epiphyseal dysplasia (MED) genetics
COMP, COL 9A2, COL9A3, for collagen 9 ; links collagen 2 to cartilage- auto dom.
MED features
short; does not involv spine; genu vulgum; hip osteoNec; double layer patella
Ellis van crevel EVCgenetics
mutation in EVC gene; auto recessive
Ellis van crevel features
acromesomelic shortening (middle and distal imbs); POST axial polydactyly’ genu valgum; 60% congenital heart disease; medial iliac spikes; fusion of carpals - capitate and hamate
diaphyseal dysplasia also called
camurati-engelemen - symmetric thick cortex of tibia, femur, humerus - tx with NSAIDS - watch for LLD
Leri Weil dyschondrosteosis genetics
SHOX gene; auto dom. On sex chromosomes
Leri Weil features
mild short stature mesomelic shortening; madelung deformity
what does CFBA code for
TF for osteocalcin
MED height
patients are NORMAL height EARLY on but then develop their short stature later
SED types
AD , COL2A; milder version is rarer shows up later 8-10y and is X-recessive; BOTH have C-spine instability
marfan genetics
Fibrillin 1-FBN 1 n C15; auto dom.
marfan features
60 percent have scoliosis hard to brace; need MRI prior to spinal fusion due to high rate of dural ectasia
Ehlers danlos genetics
about half are classic COL5A1 or 2 mutation; auto dom. For collagen 5; type 6 is auto recessive has severe kyphoscoliosis; type 4 is COL3A1 and auto dom - has the GI and artieral ruptures
additional workup is needed for Ehlers Danlos
echo for aortic root dilation
types of JRA
systemic type is stills disease (least common, worst); olig (4 joints or less)is most common; poly (5+ joints)
features of systemic JRA (stills disease)
hepatosplenomegaly, lymphadenopathy, pericarditis, anemia; ages 5-10 equal genders; poor prognosis
features of OLIGO JRA
peak age is 2-3; 4 joints or less; most common and more in girls; generally good long term prognosis ; uveitis is possible. Limp that imrpoves; LLD is possible, check optho exam
hypophosphatemic rickets
x-linked dominant; impaired renal absoprtion of phosphate
hypophosphatemic rickets lab values
LOW Phos; NORMAL Ca, PTH, Vit D. HIGH ALK; tx with high dose phos and vit D
Nutritional rickets values
LOW vit D Ca and Phos; HIGH PTH and ALP; tx with vit D
Vit D Dependent Rickets Type 1
cant make 1,25. LOW ca, phos, Vit D, normal 25 hydroxy D; HIGH ALP and PTH ; tx with 1,25 vit d replacement
vit D dependent rickets 2
bad receptor; LOW ca, phos. VERY HIGH vit D1,25; HIGH ALP; PTH - tx with hi dose vit 1,25 vit D and Ca
hypophosphostasia
cant make ALP; high Ca and phos, low ALP, normal PTH, vit D
patholoy in Gauchers
Auto Rec. beta glucosidase doesn_t work; lipids build up; infantile type is lethal. Can be cured with BMTx early on; earlenmeyer flask deformity
what is def of spastic CP
rigid and increased tone with rapid stretching - most benefit from ortho surgeries
Hemi vs Diplegic CP
Hemi is one half; Di is Lower
normal stance swing ratio
62% stance 38% swing
gmfcs 2,3,4
2 has some trouble with uneven ground; needs railing for stairs but NO assistive device; 3 needs a device, but can get around; 4 needs wheel mobility most of the time
gmfcs1
can do everything including runnig, jumping - BUT balance speed and cooridnation are impaired
AFO types for CP
solid ankle improve walking speed and stride length in most CP patients; hinged help prevent equinus; floor reaction help prevent crouch gait due to excess dorsiflexion
what to check before releaseing eqquinus in CP
is the contracture from the HIP/KNEE? Leading to crouch gait and eqiunus might be compensatory
scoliosis rates in CP
in hemiplegic and dipegic is 20%; quad is 60-80% and bed ridden is 100%
quadriplegic CP scoliosis after skeletal maturity
continues to progress
incidence of hip subluxation in CP
in quads up to 50% - not the same as DDH
management of CP scoli curves
age over10 and > 40-50 degrees interfering with sitting; if 90 deg or more, need to do ant release; QoL, balance and cosmesis improves with sugery
can botox prevent progression of hip migration
nope
tx of hips in CP
if < 8 and < 60% subluxation- soft tissue procedures; if > 60% or > 8y and 40% the femoral and pelvic bony work
distal recturs femoris transfer used for
swvere crouch gait, but can worsen it in GMFCS 3-4
mc cause of crouch gait
spastic hamstring
severe crouch gait fixed with
either guided growth OR closing wedge anterior osteotomy of distal femur - extension
pes planovalgus in CP
best outcoms with calc slide are before age 6; after you need to do mid foot work
fractures in CP
higher in NWB patients; consider giving IV pamidronate to those with Z score < 2
myelomingocele pathogenesis
failure to close neural tube elements at 3-4 weeks
meningocele vs myelomeningocele
meningocelee has little to no impariment bc neural elements stay in side canal ; MM-cele has spinal elements sticking out
prenatal dx of Meningocele/MM-cele
AFP in serum 60-90% accurate or via US or via Amniocentesis
RF for spina bifida
low folic acide, previous birth with SB; maternal DM; in utero exposure to valproic acid and carbamazepime
mm-cele at L3 vs 4
significant difference in ambulation; need quads and hamstrings for ambulation if these are present then 80% are comm amb with K/AFO
issues with MM-cele in the spine
tethering leading to scoliosis; syrinx; shunt problems (for treating hydrocephalus)
high vs low sacral mm-cele
low has intact GSC; high does NOT have gsc and has a gluteal lurch or pelvic obliquity
mmcele with dislocated hip
general do NOT reduce
tx of mmcele foot deformities
tenotomy over tendon transfers - better to have a flail braceable foot
sx of duchenne
decreased ambulation by 8-9; wheelchair by 12; and progressive solciosis/respiratory disease and death by second decade
CPK level of duchenne
usually diagnostic and 100x normal
EMG of duchenne
myopathic, decr amplitude, short duration of polyphasic motor
biopsy of DMD
fibrofatty replacement of muscle
weakness in duchenee
proximal muscles first
Duchenne and anesthesia
risk for malignant hyperthermia -pre-tx with dantrolene
when to treat DMD spine
after 20 deg
SMA type 1 acute
severe, death at age2
SMA type 1 chronic
delayed onset at 6-18months; weaker in LOWER extremities; hip dislocations at 60% and joint contractures common
SMA 3 - kugelberg
onset after 18 months; wheelchair by late adulthood, normal lifespan; weaker proximal muscles
SMA 4-
adult onset; moderate proximal weakness
genetics of SMA
ALL SMA types are missing SMA 1 gene (on c5; severity based on how much SMA2 gene is available; progressive loss of alpha motor neurons in anterior horn of cord
when to fuse SMA spine
generally after age 10 o greater than 40 deg; can use VEPTER rods
when to fix SMA scoliosis to pelvis
if spin is > 40 deg and FVC > 40%
SMA joint contractures
common but generally not treaated even if hip and knee ones exceed 30-40
charcot marie tooth type 1
type 1 most common; peripheral mylein degen; leads to decre motor NCV in upper limb onset in first-second decade; PMP 22 gene on c17;
charcot marie tooth type 2
second decade; auto dom. Myelin is in tact but wallerian degen occurs decreased motor AND sensory; EMG has normal or long action potential
charcot marie tooth type 3
severe; peripheral nerve demyelination; Auto recessive; presents in infacncy; enlarged peripheral nerves; ataxia; MPZ gene;
cavus foot in CMT tx
typicall p longus is over powering so transfer to p brevis and move EHL over to 1st MT to help tib ant
friedrichs ataxia timeline
onset by age 25; death from cardiac complications by 40-50s; affects UE NCV
genetic repeat in friedrichs ataxia
GAA on c-9; frataxin gene; used for cell iron homeostasis
tx of Freidrich ataxia foot
pes cavovarus and is progressive and rigid - bracing does not work - arthrodesis is the main choice
tx of Freidrich ataxia spine
when > 50 deg and DO NOT need to fuse to pelvis; cant use SSEP monitoring
RETT disease
xlinked dominant condition of gray matter of brain - kids start out normal 6-18 months then regress; females die; men get klinefelters - they get scoliosis and need to fuse spine
Klippel Feli c-spine shows
congenital vertebral abnormalities; may see a sprengels asociated as well due to thoracic spinous process tether
what to screen for in Klippel Feli
c-spine films; GU and hearing loss and cardiac
Klippel Feli and sports participation
no contact if massive c-spine fusion or C2 involvement; if below C3 there is 1 or 2 levels involved and noraml neck motion then ok to play
normal age of appearance for femoral head
4-7 months
osteomyelitis after 7 days xray appearance
erosive metaphyseal lesion with loss of cortical integrity is seen generally after 7 days
motion in LCP
restricted passive motion; can present with trendelenberg gait too
renal disease and pediatric hip pain is a scenarior for
renal osteodystrophy affecting proximal femur with physeal widening due to secondary hyper PTH - can lead to SCFE
rate of AVN afer open mod Dunn for SCFE
26-30%
when should you see femoral ossificaiton center after reduction of hip
if not seen by 12 months post reduction it_s a sign of prox femoral growth disturbance and AVN
what deformity is seen with SCFE
varus, flexion; ext rot. Causes a Lost of hip flexion and internal rotation
nerve injuries with SCH frx
AIN with extension is most common; second most common is radial; Flexion type most common Is ulnar nn
order of ossification at elbow
capitellum (1), radial head(4), medial epi (6), trochlea (8), olecranon(10), lateral epi (12)
gene involed in club foot
PITX1-TBX4 it is a SNP
what amonunt of coalition is allowed before resection in foot
generally less than 50% - requires a CT
suspected peds fem neck stress frx - what is first step
MRI - not just activity modification
what is a/w fibular hemimelia
absent ACL and absent rays of the foot
what conditions have MYH3 gene mutation
codes for myosin heavy chain 3; seen in distal arthrogyropsis; sheldon hall and freeman sheldon
sx of Beckwith Weidman
C-11; neonatal hypoglycemia, macroglossia, large organs, hemi hypertrophy and embryonal tumors like Wilms Tumor
tx of mid shaft clavcile in peds with 100 % displacement
sling
dystrophic scoliosis features seen with
NF-1- look for penciled ribs, scalloped vertebrate, severe rotation and short sharp kyphoscoliosis
clubfoot associated with what vascualr anamoly
absent anterior tibial artery
first step in treating a RECURRENT clubfoot
recasting
kingella knee infection rule out
generally need a PCR for RTX protein - common scenario for day care patient
toddler or baby with band on digit
called hair tourniquet syndrome
inheritance of tarsla coalition
auto dom.
which group of genetic conditions has more tarsal coalitions
FGFR related conditions Apert,
sprengels caused by
vascular interruption at subclavian artery
what perecnt of CBC is elevated in osteo and septic OA
25% for osteo; 30-60% for septic joint
CRP and ESR in peds septic joint timeline
generally rises to abnormal by 6 hours; >2 is predictive; ESR takes 3-5 days for peak.
XR Timeline of osteo
4-7 days new periosteal bone; 10-14d, osteolysis; 1-2 weeks metaphyseal rarefaction and intraosseous abscess
kocher criteria
ESR>40; temp over 38.5; inability to bear weight, CRP > 2; and WBC > 12
how to choose MRI for septic joint vs going to OR
if > 3 of these 5 criteria; ag >4; sx > 3d; CRP > 13.8; platelets < 314k, and ANC > 8600
PMN and Leukocyte difference in Transient synovitis vs Septic Hip
TS - 25% PMN; 5-10K cellcount; vs 75% PMN and 50K cell count
peds osteo can mimic
LEUKEMIA! - CBC will show leukopenia or anemia!! But all other labs may look like infection (ESR, CRp)
elevated urine or serum homovanillic acid HVA or vanillylmandelic VMA
metastatic neuroblastoma
diagnosis of CRMO
whole body bone scan or MRI - lab markers can be normal
demographics of CRMO
girls more than boys generally age of onset is around 10
tx of CRMO
scheduled NSAIDS works for upto 80%
Kingella features
Gr-; needs PCR; kids < 4y; 50% of Septic joint under age 2; might present as subacute infection; can use oropharynx swab
most common spot for TB in kids
spine; typically ant 2/3 of vt body; usually in TL jxn, joint invovlement tends to be hip or knee
diagnosis of septic TB in kids
acid fast bacilli on stain
lab values in lyme OA
typically ESR and CRP are elevated but WBC can be normal
tx of lyme
oral abx including doxy, amox, and cefuroxime
medium for growing gonorrhea culture
chocolate blood agar
how soon does septic oA damage cartilage
8 hours
cause of septic joint in peds 2w to 4wks
Group B Strep
shoe puncture infections
stilll more common to get s aureus but pseudomonas is a concern; only 1% become deep infection
tx of shoe puncture deep infection
if deep then most likely pseudomonas
Discitis diagnosis and tx
xray is normal for 2-3 weeks but MAY show loss of sagittal contour; MRI confirms; abx is mainstay - do NOT need biopsy ; typically kids under 5
vertebral osteo
older children more painful on exam than diskitis; MRI again for diagnosi; tx with anti-staph abx
in sickle cell how to rule out infection vs crisi
labs and MRI are simillar and not helpful - need aspirate or Gram stain
risk factors for DDH
12-33% have affected family member; 6% risk if sibling; 12% parents; 36% if sibling AND parent; female, breech, first born, and ANY intrauterine packing condition
packing conditions a/w DDH
metatarsus adductus, muscular torticolis
how do toddlers with dislocated hips present
LORDOSIS
DDH and dislocation rates
1% and .1% for dislocation
when can you use xray for DDH
after 6 months
normal ultrasound angles
alpha should be GREATER than 60; Beta shouild be < 55 - alpha goes DOWN
how much coverage should you see on normal hip ultrasound
at least 50% acetab coverage
normal actab index
less than 25deg by age 12; less than 20 by 2 years
normal latearl center edge angle (seen on AP) for PEDS
at least 20 deg
who gets US at birth for DDH
ONLY if risk factors; otherwise wait to 4-6 weeks
tx od DDH
< 6month - pavlik, 6-18 month open vs closed reduction and spica; >18months
pavlik for DDH
tx for 6-8 weeks with weekly US, if still dislocated by 3-4 weeks discontinue - generally 90% success
risks of pavlik
excess abduction > 60 leads to osteonecrosis or pavlik disease which is deformation of posterosup acetab rim; excess flexion beyond 100 can cause fem nn palsy
how to confirm hip reduction in 6-18 month old
arthrogram with < 5mm of medial dye pooling
max age for surgery for dislocation hip
unliteral 10years; bilatearl 6-8 years
after age 2 dislocated hip what must be done
shorteing femoral osteotomy
is IV abx with clinical infection but neg. MRI
yes, start IV abx in setting of suspected infection and cover for MRSA
peds abx for osteo
always cover for MRSA
what does Harris view show for Talocalc coalition
can show an oblique medial facet, suggestive of fibrous or cartilaginous connection
popliteal cysts are between what two structures
gastroc and semi-M bursa
early infant with hip instability what is next step
apply brace and repeat exam in 2 weeks with ultrasound
TL kyphosis in achondroplasia follows what course
resolves with independent walking
which children get overgrowth after femur frx
ages 2-10
gymnasts wrist
distal radius epiphysiolysese - look for wide distal radius physis - tx with SAC for 6 weeks
flexion SCH requires what extra step
are inhertyl unstable and may require open reduction if medial gapping -due to ulnar nerve entrapment.
what scoliosis curve is ATYPICAL
LEFT THORACIC
Uveitis in JIA symptoms
chronic and asymptomatic can cause permanent vision loss in 20-30%
growing rod vs PSF for scoliosis
usually the cutt off for growing rods is < 10
tx for infantile idiopathic scoliosis
ages 0-3 and if RVAD (rib vertebral angle difference ) is < 20 then observe; afte 20deg then begin serial casting
What type of fusion for SMA patients scoliosis
generally PSF is enough unless curve is > 100 deg.
congen vert talus tx
reverse ponsetii casting followed by achiles tenotomy and bracing
DVT with osteo in peds population is seen with
genrally more common with MRSA and those expressing the panton-valentine leukocidin
sprengle is most common in which condition
Klippel Feli
tx of infantile blounts
tib fib osteotomy before age 4
risk of MRSA infection includes risk of
DVT or PE ; needs chemical DVT prophylaxis
torticolis after virus tx
often requires CT or radiographs to asses if rotatory subluxation of c1-2 - tx would involve traction and then halo vest; if unable to reduce then C1-2 fusion
indicator of NF scoliosis progression
rib pencilling;
dystrophic vs non dystrophic scoliosis
dystrophic is more severe, has higher rates of dural ectasia, faster curve progression; nerve injury etc and cannot be treated like idiopathic scoliosis
features of dystrophic scoliosis
faster curve progression, more kyphosis, more neuro injury, dural extasia, dumbell foramina from NF, scallping, rib pencilling, spindling of the TP, severe apical rotation, severe vertebral wedging,
what determines modulatio of non-dystrophic scolosis to dystrophic scoloisis
age, generally if presenting before age 7 up to 80% can modulate.
best xray for peds medial epicondyle displacement
AXIAL view; 45 deg abducted arm with elbow at 90. xray tube is 25 deg from axis of of hum shaft
what injury is associated with peds tib tubercle frx
ogden 3 is a/w Meniscus tear
persistent drainage after I&D of septic hip -what next
check MRI for prox femur osteo
most common complication of transphyseal distal hum frx
cubital varus due to either AVN of medial epicondyle, malunion, or growth arrest - higher than with SCH
what SH type is seen with distal humerus frx
if < 3 SH 1; if > 3 SH 2
when to switch from pavlik to rigid abduction brace
if hip is unstable at 3-4 weeks
camptodactylly
contractures of the fingers
where is GNAS mutation in fibrous dysplasia
c-20
what femur frx pattern is a/w non accidental trauma
transverse; NOT spiral
tx of osteoid osteoma in sacrum
excision
advantage of screw fixation for medial epicondyle frx
shortern immobilization and earlier motion
tx of toddlers frx
WBAT in cast or boot
whats optimal cast index
less than .8
what are recommendation to avoud Little league shouilder
avoid overhead throwing at least 2-3 months with a break from COMPETITIVE pitching for 4 months
Erb vs Klumpke palsy
erb is more common and is UPPER; Klumpke is LOWER and worse
disciod meniscus types
1 and 2 are stable but either complete or incomplete; 3 looks like a normal meniscus but posterior horn is BIG and unattached -requires stabilization (Wrisberg variant)
physiologic genu varum timeline and severity
general improves by 16-18monts but rarely EXCEEDS 20deg
capsule management in a slipped SCFE
open decompression to reduce risk of AVN
early switch to oral abx for peds osteo vs prolonged IV
early switch to orals has shown SIMILAR tx failure rates and less rehospitalizations or ED visits due to lower cathetar related concerns
predictors of MRSA in osteo
temp > 38; WBC > 12k; hematocrit < 34%; CRP >13; if all 4 then 92% chance MRSA; if 3 then 46%, then drops to 10% and 1%
bilateral congenital knee dislocation is what condition
Larsen - need to check C-spine before anything else
how to cofirm newborn CVT vs calcaneovalgus
plantarflexion lateral; talus does NOT line up with 1st MT in CVT
defects in collagen 3 cause
Ehlers Danlos
lipomeningocele associated with
TETHERING ; form of lumbosacral lipoma
risk of spina bifida
low folic acid need to get .4-.8mg per day before conception; 4mg DAILY if prior history
L3/L4 MM-cele has what function
has quads and POOR hamstrings
what does L5 mmcele NOT have
glut medius - therefore waddle gait
whats associted with mmcele
arnold chiari (descent of cerebellar tonsils); feeding/crying/breathing issues from lower CN involvment,
what is diastematomyelia
bone or fibrous, or cartilage bar diving the spinal cord longitudinally
how do you pick up tethered cord syndrome
change in neuro sx or urologic sx after a rapid growth or rapid change in scoliosis.; ususally a decreased muscle stretngh or sensation
latex allergy with mm-cele
acute IGE mediated; and delayed T-cell mediated allergy
beckers is more prone to
cardiomyopathy due to prolonged course
when do complications of Duchene scoliosis fusion increase
when FVC <35%
clubfoot associated with what condition
arthrogyropsis
Distal Arthrogryposis
type 1 TMP2 gene; fast twitch muscle fibgers
what is predictive of long term function of CP kids
GMFCS level ; also relates to rate of hip dislocation
prognosis to walk with CP assoc with
sit indepently by age 2
goal of selective dorsal rhizotomy
to reduce stretch reflex
best candidate for dorsal rhizotomy
ambulatroy GMFCS 1/2 spastic diplegic, ambulatory
best orthotic for crouch gait
ground reaction AFO
when to extend spinal fusion to pelvis
if 90 deg and non-ambulator
salvage pelvic osteotomies
Chiari and Shelf
potential causes of perthes
second hand smoke, carbon monoxide, collagen 2 problems, transient synovitis
associated factors of perthes
ADHD up to 30% and skeletally immature with delayed bone age up to 90%
histo of LCP
histo is ABNORMAL in cartilage, epiphysis and metaphysis
LLD in LCP
mild; may seem bigger due to hip contracture or fem head collapse
Risk factors for worse LCP
gage sign; lateral calcifications from epiphysis, horizontal epiphyseal scar, lateral subluxation of fem head
prognosis based on pillar classification and age for LCP
if younger than 6 good outcome generally no matter which tx; if >8 then generally surgery in Pillar B; if Pillar C - bad outcome either way
what osteotomy is used for Perthes salvage
VALGUS And FLEXION producing
mecahnical factors that increase risk of SCFE
increased physeal obliquity, obesity, retroversion of femur; decreased neck shaft angle
optimal fixation for SCFE
6.5mm screw cannulated, fully threaded, one screw is usually enough, two sometimes for unstable SCFE
what position does SCFE fall
neck moves anterior and flexed. Screw needs to start on anterolateral femoral neck
what two things can cause osteonecrosis from SCFE
unstable is biggest risk factor, BUT screw placement in post/sup neck can do it too
risk of fracture with SCFE fixation
higher if screw entry is lateral and starting beloe the lesser troch
scfe slip progression risk
1-2% with insitu single screw fixation
cox vara demographics
equal gender , no laterality, bilateral 30-50%
what else is seen with bilateral coxa vara
increased lumbar lordosis
what Is Hilgenreiner-epiphyseal angle
assess severity of coxa vara by angle of epiphysis. 25 is normal, up to 45 observe, 45-60 intermediate risk of progression, 60 deg or more high risk of progression
surgery to correct coxa vara should_.
overcorrect to avoid the 50% recurrence. Up to 89% can have premature closure of proximal fem physis about 1-2 years post-op
which club feet are hardest to treat
those a/w arthrogyposis; amniotic band; diastrophic dyspasia; mm-cele - more prone to relapse with these conditions
how long to wear dennis brown orthosis after club foot casting
3 months of 23 hrs/day then nights and naps for 2-3 years
CVT vs oblique talus
on plantarflex view in CVT The navicular will NOT reduce down
what are you trying to strech in reverse ponseti
dorso LATERAL soft tissue for CVT
calcaneovalgus is associated with
posteromedial bowing
cavus foot assoc with
neurologic condition; usually CMT - due to excess calcaneaus dorsiflexion
peds patient with lots of ankle sprains - look for
cavus due to CMT or other neuro condition
unilateral cavus requires what other work up
MRI spine
what is mearys angle
lateral foot view, angle made by long axis of 1st MT an talus - should be co linear or > 5. increased in cavus, decreased in pes planovalgus
normal heel -forefoot alignment
heel bisects 2nd web space
natural course of metatarsus adductus
resolves by age 4 most of the time
what is skewfoot
adducted forefoot; valgus hindfoot and plantarflexed talsu
when to investigate toe walking
after 2y
CN vs TC coalition
CN is 8-12y and more common; TC is 12-15y and second most common
which conditions have multiple tarsal coalitions
apert and fibular deficiency
if severe valgus at time of coalition resection
the need to do calc osteotomy to improve outcome and prevent recurrence of the coalition
best view to see accessory navicular
external oblique view of foot
when does Kohlers resolve
generally symptoms resolve in 6-15 months; and reconstitutes in 6months to 48 months without disability
overlapping 5th toe caused by
contracted EDL, famial and bilateral generally
curly toe caused by
contracted FDL or FDB perform tenotomy at 3-4 years
multiplier method is most accurate for
congenital discrepencies iN LLD that are constantly proportional
teloradiograph adv and d-adv
single exposure and good for angular deformity; BUT magnificaiton error
orthoradiograph adv and d-adv
three exposures hip, knee, ankle on single cassette, eliminates mag error, BUT cant assess angular deformity and movement error
scanogram adv and d-adv
same as orthogram, but smaller cassette, no mag error, but same d-adv as ortho
CT scanogram adv and d-adv
accurate even with joint contractures BUT cant assess angular deformity
when do to limb lengtehnign
If LLD is going to be greater than 5cm
what is best predcitor of self resolution or progressoin in blounts
if metaphyseal diaphaseal angle is < 10 deg then 95% resolve if > 16 deg then 95% progression
when to brace blounts
ages 2-3 with stage 1-2 disease
what is adv to doing prox tib osteotomy for blounts before age 4
less risk of recurrence
normal deg and progression of physiologic genu valgum
at 3-4y its around 20 deg and then by age 7 should be restored to 12 deg with a intramalleolar distance < 8cm
femoral anteversion from birth to adulthood
starts at 30 and reduces to 15 by skeletal maturity
amount of rotation to correct excess anteversion
(prone internal - prone external) divided by2
what is normal transmalleolar axis
20 deg ext rotated
normal tibial internal torsion
presents by age 1-2 and resolved by age 6; surgery only after age 8 and if severe
how to prevent tibial pseudoarthrosis in AL bowing
clamshell total contact cast
PFFD sugery timing
best when 2.5-3 years and projected LLD is 20cm or LESS; need a stable hip, functional foot
what bowing is associated with fibular hemimelia
anteroMEDIAL
LLD with paralysis how do you correct
undercorrect slightly to allow for foot clearance
surgery for congenital knee dislocation best done
before 6 months
address deformity in what order
angulation, translation, length, rotation
where should HTO be
if deformityis < 10 deg then above tib tubercle; if > 10 then go BELOW the tib tubercle
what is the MOST common posttraumatic deformity
Rotational
tx of persistent hip dyspasia
by age 5 ideally perform your receonstructive osteotomy - do not jus observe
timeline of sx in little league shoulder
2.6months to sx resolution, 4 months to RTP
r/f for recurrence of Little league shoulder
GIRD
when is Little league elbow get the most forces
during late cocking , early acceleration
what radiopgraphic signs are seen with LL elbow
apophysitis, hypertrophy or radial head or Med. Epicondyle
when to fix medial epicondyle
when greater than 5mm dispacement
consequence of aggressive debridement of osteophye in valgus extension overload
elbow instability
conseqeunce of untreated gymnasts wrist
positive ulnar variance and resultant TFCC pathology
tx of gymansts wrist
at least some form of immobilization, splint to cast depending on severity.
panners vs OCD of capitellum
panners is 1st decade, benign course and self resolves. OCD is after age 10 and can cause permanent disability
drilling vs fixation of OCD
drilling has good success for type 1 and stable 2, fixation has variable success especially if size is big
best elbow portal to visualize the capitellum for OCD
posterior portals and anconeus portal
most common site of OCD in kids
knee; specifically lateral aspect of medial femoral condyle
non op tx of OCD in knee
first rest and activty mod - but then immobilization for 6 weeks before considering surgery
Rehab after knee OCD
after fixation, immediate active assis tmotion and pass motion; and quad work right away with TTWB
risk of growth disturbance after peds acl recon
determined by age of patient; younger has higher risk
rehab of peds ACL
no start-stop or cutting until 8 to 12 months
alignment risk factors for patellar instability
femoral anteversion; tibial EXTERNAl torsion; high q angle; dysplasia or patella alta
for patellar instability need to assess
all alignment variables - may require hemiepiphysiodesis or osteotomies in addition to MPFL
surgical pearls for patella instability
tension at 30 deg; should be isometric 0-60; do not overtension; in teens above physis in younger kids below physis for femoral fixation
most important predictor of recurrent patellar dislocation
severe trochlear dysplasia
mri of meniscus in pt < 10 shows what
high false positive rate of meniscus tear due to vascularity
what is gold standard for meniscus repair
inside out vertical mattress
m/c cause of death in kids over 1
trauma
most predictive of in house mortality after trauma
initial hypotension and Low GCS; GCS < 8 carries high risk of mortality
GCS motor at 72 hours is related to what
permanent disability severity
what to look for with abdominal bruising after MVC
visceral injuries and spine frx
trauma response in kids vs adult
damp systemic response; better local response; organs fail simultaneously instead of sequential; lower risk of acute lung injury
GCS scoring
6motor;5movement;4vision;
when does head trauma spasticity begin
within days to weeks of injury
what is effect of TBI on fractures
heal faster
what lab value can portend HO after TBI
increase in ALP
what reduces risk of multi organ failure after polytrauma
fixation within 48 hours
predictor of long term morbidity
GCS at 6 weeks
timing of I&D for peds open frx
within 24 hours; no differnece between < 24 vs < 6 hrs
failure to report child abuse has what risk
30-50% of repeat offense and 5-10% of death
which prox humerus fractures need reduction
grade 3 and 5; basically anythin with >33% displacement of humerus width
what can block reduction of prox hum frx
LH biceps or periosteum
which prox humerus need Surgery
TEENS with grade 3 or 4
last physis in body to closer
medial clavicle
which SCH type 2 can be treated in cast
no medial comminution, and ant humeral cortex bisects the capitellum
risk of iatrogenic ulnar nn injury in SCH frx
3-8%
best view for lateral condyle fractures
internal oblique
when to begin motion after medial epicondyle frx
after 3-5 days
how to fix med epicondyle
ideally screw fixation to allow early motion- very young kids can use K-wires
most common ages for distal humerus physeal frx
usually < 3years but up to 6 can have it
sch frx displacement direction and nn injury
extension - AIN; PosteroLATERAL -median; PosteroMEDIAL -radial; flexion - ulnar
when should closed reduction of transphyseal humerus frx NOT be done
after 5-7days to avoid physeal injury - switch to OPEN
indications for surgery of radial head frx
30 deg residual angulation or 3-4mm of translation after closed reduction; OR less than 45 deg of pronation supination
position of casting for greenstick
if apex volar- then pronate; if apex dorsal then supinate
rate of PIN injury with monteggia
10% but generally self resolves
peds metacarpal frx toleraances
10-20 deg SAGITTAL angulation for index; 20-30 for long; 30-40 for ring; 40-50 for pinky
can buckle frx be tx with removeable wrist splint
YES
subacute physeal distal radius frx - how to tx
immobilize and treat without surgery or reduction
asymptomatic scoliosis in Duchene - tx?
FUSE
rectus inserts on what part of pelvis
AIIS
sartorius inserts on what part of pelvis
ASIS
pectus is assoc with
syndactyly
blounts <10 vs > 10
after 10 and up do epiphysiodesis NOT osteotomy; osteotomy reserved for skeletally mature
adolescent blounts
more likely UNILATERAL less common, more severe; obesity is r/f; NO CLASSIFICATION; often includes femoral deformity; never treated with bracing
lateral elbow spurring
a complication seen with fixation of lateral condyle frx due to periosteum - reduce periosteum to avoid this complication - happens about 50% - related to initial displacement
tx of radial head dislocation
radial head resection at skeletal maturity if significant disability
base of dens fuses at
3-6 years
what coverage does salter provide
anterior coverage at the expense of posterior coverage
pediatric burst fracture what else to look for
another vertebral level inovled, 30-50% have another invovled level
coverage loss in CP hips
posterior and superior
indications for fixation of peds pelvic frx
unstable vertical or rotational; more than 2cm displacement in ring for teens to prevent LLD; or poly trauma
vertically unstable pelvic frx can lead to
LLD
surgery for peds hip frx
generally closed reduction is preferred
fixation of peds hip frx
Delbet 1 - K wire or cannulated screws; 2 and 3 - cannulated screws; 4 gets DHS or locking plate
delbet classification
peds hip frx 1 - physeal (SCFE); 2 middle neck;3 - base of neck; 4 - Intertroch
risk of osteonecrosis based on delbet
1 -90-100%; 2 - 50%; 3 - 25%; 4; 10%
common complication of non-op peds hip frx
coxa vara and nonunion - esp Delbet 3-4
which femur frx need work up for NAT
femoral shaft under 3 years; and any femur frx under 1
contraindication to spica in peds fem frx
shortening greater than 2.5-3 cm
common complication after submuscular plating for femur frx
distal femoral valgus; plate should end 2cm proximal to physis
how effective is RF ablation for osteoid osteoma
95% after one treatment
what is delayed in duchenne
duchenne kids hit NORMAL milestones by 2 - except language can be delayed. Also a/w delayed learning disability in 30-50%; risk of autism, ADHD and OCD in boys
pediatric rigid femoral nail starting point
ideally LATERAL entry; trochanteric entry has a lower risk of osteoNec but still 1.4%
what additional workup does beckwith wiedemann need
must get abd/pelvic US and AFP levels 3-4 x a year until age 8 to rule out Wilms tumor
what to do with hypoplastic thumb stage 3
check CMC joint stability - if UNSTABLE -then amputation with index pollicization or toe transfer; if CMC stable then ok to reconstruct
peds both bone frx with minimal to no trauma
consider Neurofibromatosis - look for absent intramedullary canals in distal third forearm; pseudoarthrosis of forearm is in up to 50% of NF cases
peds jones frx get
Perc screw fixation; not ORIF
radial dysplasia is caused by
defect in Apical ectodermal ridge
PHEX codes for
x-linked hypophosphatemia
proximal humerus frx in kids vs teens - which get surgery
< 13 does NOT generally get surgery; over 13 follow parameters of displacement and angulation > 30 deg
tx of peds hip dislocation
ALWAYS general, closed ideally; never in ED with conscious sedation
first line tx for spondylolysis
bracing and PT for 3 months
order of closure of neurochondral synostosis
cervical, lumbar, thoracic
both bone angulation parameters by age
under age 8 can allow up to 20 deg angulation and 100% displacement and 45 deg rotation, after age 10, 10 deg, 100% tanslation and 30 deg rotation.
does clubfoot delay ambulation
generally NO - neither does hip dysplasia; if delayed walking by 18months - needs work up for neurologic disorder
peds jones RE fracture
IM screw; no more casting
air bag reccs
turn off if < 80lb
m/c complication of distal femur frx
malunion is MOST common complication of NON-PHYSEAL frx; in PHYSEAL - gorwth arrest is m/c complication
complicatio of anterior displaced epiphysis in distal femur frx
popliteal artery and compartment syndrome
distal fem frx with vascular compormise - what is first step
REDUCE the fracture - can be tenting the vessel
age for patella sleeve frx
8-12 years-look for a normal xray with patella alta!
can you non-op patella frx
yes if non displaced with INTACT extensor mechanism
non op tx of tibial spine frx
must be type 1 or reduced within mm - cast at 0-20 of flexion; may need to arthrocentesis for hematoma before casting
what is often trapped in peds tibial spine fr
anterior horn of medial meniscus
what must be evaluated with tubercle type 3 frx
evaluate articular surface for congruity and meniscus tears
tx of prox tib physeal frx
typically k wires for I and II; but III and IV might need cannulated screws
avg age for tib shaft frx
typically 8 years; healing for toddlers frx takes 3-4 WEEKS
surgical parameters for tib shaft frx
if 10 deg angulated or 1cm short
what deformity is seen with tibia frx if closed reduc fails
if ISOLATED tib - VARUS; if COMBO Tib Fib - then valgus
order closure of distal tibia physis
central, posterior, medial, lateral
can you closed reduce and non -op (Tillaux) salter 3 distal tibia
YES but need post-reduction CT to show < 2-3mm articular displacement; non displaced triplane can also be non-op IF CT is good
which distal tib frx have highest risk of growth arrest
medial sided salter 4
peds lis franc tx
k-wires for young kids; cannulated screws for teens
normal t-spine kyphosis and l-spine lordosis
20-45 for t-spine; 30-60 lumbar
most commmon curve pattern in INFANTILE idiopathic scoli
LEFT THORACIC
risk of curve progression in infantile scoli
overall 10% but higher risk of Neuro abnormality if RVAD is > 20 or phase 2 - overlap of rib head at apical vertebrate - up to 80% need neurosx
juvenile idiopathic scoli demographics
female > male; RIGHT THORACIC is more common;
juveniile scoli curve over 20 deg must get
MRI - 25 % chance of abnormality
fastest area of spine growth
T1-L5 before age 5 is fastest RATE
AIS demographics
if curve is small then 1-1 ratio; 10-1 ratio for females if curve > 30
which AIS curves likely to get surgery
cuves greater than 30 deg at peak heigh velocity in females - typicall JUST before menses
RVAD angle
is CONCAVE angle - convex angle at apical vertebrate
what is curve progression AFTER skeletal maturity
T-spine > 50 or L spine > 40 continues about 1 deg per year
curve progression in AIS and lung fxn
after 60 deg lung function is affected BUT not clinically relevant until 90 deg
which AIS needs MRI
left thoracic, curves growing > 1deg/month; 20 deg curves or higher in AGE < 10
which conditions see dural ectasisa
NF, Marfan, and Ehlers Danlos
ages for idiopathic scoli classificaiton
infantile <3y; juveile 3-10; AIS starts at 10y
which scoli is cured by casting sometimes
18-24 month kids with curves < 40-50
what t-spine curve is a relative contraindication to bracing
t-spine HYPOkyphosis
when is TLSO most effective for scoli
when apex of curve is BELOW T7
surgery for infantile or juvenile scoli
at least 50-70 deg
short term complications of AIS PSF
ileus; atelectasis, SMA syndrome; ADH secretion; stomach pain
early PSF infection
before 6 months; do NOT remove implants
when to do wake up test for spinal fusion
if after removal/revers of steps and IV steroids signals do not return to baseline
3 types of hemi vertebrate
segmented, semi segment, and un segment -has to do with if disc space is present
worst prognosis of congenital scoli
unilateral bar with contralateral hemi vert - 5-10 deg/year
jarco-levin syndrome
fusion of t-spine either to each vertebrate or to ribs - leading to pulm dysfunction
how to manage hemivertebrate WITHOUT trunk inbalance
if segmented, <5years, and a flexible curve < 40 then can do hemiepiphysiodesis on contralateral side with fusion if progression occurs.
how to manage hemivertebrate WITH trunk inbalance
excision of hemi vertebrate if under 6, flexible curve < 40, progressive curve
Neuromuscular scoli curves tend to be
long sweeping C-shaped curves with apex at TL junction
what FVC is risk of prolonged vent for scoliosis
FVC < 35%
sheurman kyphosos and gender
males more common 2:1 to 7:1
definition of scheurmans kyphosis
3 consecutive thoracic vertebrate with more than 5 deg of ant wedging; severe defined as thoracic kyphosis > 75 deg; pulm compromise at 100 deg
what is seen with scheurmans
lumbar sponlylolisthesis
when can you brace scheurmans
1 year of growth remaining with 50-70eg curve
how much to correct t-spine kyphosis
no more than 50% to avoid neuro injury;if < 55deg then just fuse posterior spine for some correction; if > 55 deg then vertebral resection might be needed to avoid neuro injury
artery of adamkiewicz arises and supplies what
arises from t8 to l2 but supplies T4-T9
where is spondylolysis
typically L5; but L4 < 10%;
progression of spondylolisthesis a/w
teen growth spurt; higher grade; Lumbosacral kyphosis > 40 deg; dome shaped sacrum
pain in spondy listhesis is worse with
back extension
tx of slipped spondy
if grade 1-2 then lumbosacral brace for 4-6 months + core strengthening
what slip angle is increased risk of spondy slip
50deg
downs syndrome cspine issues
61% have occiput c1 instability; 22% have C1-2 instability
when does dens fuse to its part
dens to tip by 12years; dense to base by 7 years
mcrae and mcgregor lines in cspine
mcrae is line connecting A/P of foramen magnum; mc gregor is posterior tip of hard palate to posterior foramen magnum
atlanto axial instabilty defined by
ADI > 5 (normal is 2-3 in adults; up to 5 in kids under 8 years)
what conditions show basilar invagination
Klippel feli; hypoplasia of atlas arch; occitocervical synostosis; morquio; SED; achondroplasia and osteogenesis imperfecta
tx of congen musc torticolis
passive stretching is intial tx; if > 30 deg or lasts > 1 year then surgery
atlantoaxial rotatory instability tx
NSAIDS, soft collar
when to operate on atlanto axial instability in downs
if ADI > 5 with neuro sx or > 10 without neuro sx
tx of AARD
if 1 week and reducible then head halter traction; if > 1 month halo or rigit brace; if still present then surgery with fusion of c1-2
downs mortality after c1-2 fusion
high up to 25%
c-spine trauma in kids
age < 8 has higher risk of neuro injury due to head size; horizontal facets; usually above c3
instability of SUBAXIAL C-SPINE defined as
intervertebral angulation of 11deg OR 3.5mm translation
retropharyngeal space limits
less than 6mm at C2; < 22 mm at C6
BAI should be
< 12mm in kids’
what is hangmans frx
frx of pars of c2 due to hyperextension
what injuries in TL spine are a/w neuro injury
distraction/shear - unstable pattern
Spinal cord injury wo radiographic abnormality
get MRI - this is cause of paralysis in 20-30% of kids with SC injury ; 20-50% have delayed onset
which chance frx get non-op
< 20 deg segmental kyphosis
halo parameters
if < 8 years, 8-12 pins at 2-4lb
chance frx in peds - trx
if only ligamentous; PSF; if bony - then posterior compression and distraction before fusion - these traumatic kyphosis do NOT remodel
how does diskitis develop
seed the vertebral end plate first then spread to disc space
tx of diskitis
IV abx 7-10 days then orals
lab markers of hypophosphatasia
LOW ALP ; HIGH Phos and Calcium
lab markers for renal osteodystrophy
low Ca - HIGH Phos, ALP, PTH
lab markers for type 1 Vit D rickets
low phos, Ca; HIGH ALP; high PTH; low vit 1,25 D
c-spine clearance protocols have led to
DECREASED use of CT withOUT increase in MRI to clearn c-spine - NO increase in missed injuries has been observed
what percent of gartland 3 jave vascular compromise
20% of these
tx order for AL bowing IN NF patients
full contact AFO; long leg cast - if pseudoarthrosis develops then surgery
typical features of achondronplasia spine
foramen magnum stenosis;; tl-spine gibbus formation and focal kyphosis; premature vertebral ossification leading to short pedicles; smaller foramina, short vertebrate, and narrow interpedicle distance
which factors are a/w femoral overgrowth after frx
length unstable; canal fit < .8
what deformity is most likely to occur with transphyseal ACL
bc femur outgrows tibia the femoral phsysis will have more effect - so valgus
sports reccomendation for downs with ADI 4.5-10mm
can participate but avoid some high risk like diving and football
peds MRSA assoc with
DVT more surgery, tougher course
which joints have capsules extending to metaphysis
shoulder, hip, elbow, ankle
tx of redman syndrome in kids
stop infusion; if mild reaction give diphenhydramine and ranitidine and then restart at 1/2 rate
main features of marfan
tall long bones and arachnodactyly - but also protrusio acetabuli; flatfeet; dural ectasia
Marfans scoliosis have
higher complication due to Csf leak, fixation failure; distal degen and proximal add on; can have dysplastic pedicels and lamina
when to fuse DMD scoli to pelvis
if NON ambulatory or if pelvic obliquity is > 15 deg
what is the deformity in CVT
hindfoot valgus and equinus with dorsally displaced navicular - rocker bottom
Vanc vs Clinda for MRSA
if STABLE can use clinda for first line; but if unstable or septic then go for vanc
which hip spica for fem shaft frx
single leg hip spica is enough and better for parents, car seat etc
MRI for infantile scoli
if RVAD > 20 or if progressing; should NOT do one before 12 months because hard to detect tethered cord; wait 3 months to see if curve < 20 is progressing before getting MRI
what percentage of TL kyphosis persists or progress in achondroplasia
after walking age 30% of TL kyphosis persists - OF THIS another 30% progress to severe deformity
risk factors for persistance of TL kyphosis in achondroplasia
not walking by 30months or not sitting by 14 months
long term outcome of cubital varus after SCH frx
PL rotatory instability; ulnar neuropathy, snapping triceps, lateral condyle frx;
gene in Larsens syndrome
auto dom FLNB
Ehlers Danlos genetics
COL3
natural hx of osteoid osteoma
self resolves in 2-3 years
what muscle is active during stance phase
eccentric contracture of GSC to allow tibia to fall over talus
what is basis of fibrous dysplasia
poor mineralization AND immature bone that does not respond to mechanical stress appropriately to turn into mature lamellar bone
types of fibrous dysplasi
monosototic is more common but does not progress after skeletal maturiy (but does grow proportional to skeletal growth); polyostotic DOES progress, less common more severe
risk factors for medial tibia stress syndrome
female, bmi; increased navicular drop; prior orthotics; previous running injury or reduced runnig experience, and greater hip EXTERNAL rotation; in ADULTS - reduced plantar flexor muscle endurance is a risk factor
AIS typical curve
Right Thoracic with HYPOkyphosis - any curve with HYPER kyphosis gets an MRI
tx of chronic monteggia
ulnar osteotomy
what does PHEX mutation cause
in osteocytes- leads to increased FGF23 and reduction in renal phosphate resorption or 1,25 OH vit D production - leads to decreased mineralization
Kingella gram stain
gram negative
congenital scoliosis inheritance
NONE - usually sporadic insult during gestation 4-8 weeks
peds ACL have a significant risk of
rerupture in same and other knee
how long can popliteal cysts persist
2 years
which peds pelvic frx needs surg
2cm wide symphisis
B. plexus injury leads to what shoulder deformity
internal rotation; glenoid retroversion; flat head; GH incongruity; posterior sublux of head
cleft hand/foot seen with
genetically isolated commuities; Auto Dom inheritance
medial condyle vs EPIcondyle frx
condyle needs arthrogram; epiC is a/w dislocation and CAN be non-oped
medial approach for surgical hip dislocation
normally b/w pectineus and adductors; but can be modified to pectinues and NV bundle; higher risk of dislocation and cannot address capsule
