Peds Flashcards
Peds multisystem organ failure vs adult
Peds: occurs early after admission, affects ALL ORGANS simultaneously***
Adult: occurs 48 hours after injury and begins with lungs**
how many mL of intravascular blood volume per kg in a 5 year old child?
75-80 mL/kg**
Cast burn risk higher in plaster or fiberglass?
fiberglass***
What are 5 zones of physical growth plate? Diseases?
1- Reserve zone*
Cells store lipids, glycogen, PG for later
Dz: Gaucher’s*, diastrophic dysplasia, psuedoachondroplasia
2- Proliferative zone
Proliferation of chondrocytes w/ longitudinal growth and stacking of chondrocytes
Highest rate of extracellular matrix production
Increased O2 tension inhibits calcification
Dz: Achondroplasia, Gigantism, MHE*
3- Hypertrophic zone
Zone of maturation, chondrocyte hypertrophy and calcification
3 zones w/in hypertrophic
1-Maturation: prep for calcification and growth
2-Degenerative zone: further prep and growth in size (5X)
3-Zone of provisional calcification: chondrocyte death to release Ca2+ for calcification
Type X collagen produced** (important for mineralization)
dz: SCFE*
Rickets*
Fx’s most common through zone of provisional calcification**
4- Primary spongiosa
Vascular invasion, osteoblasts algin on cartilage bars, forms woven bone that later remodels
dz: metaphyseal “corner fx” in NAT**, Scruvy
5 - Secondary spongiosa
Internal remodeling, replacing woven bone w/ lamellar bone
dz: renal SCFE
What growth factor regulates chondrocyte maturation?
Indian headgehog gene***
What is Groove of Ranvier and why important?
dz?
During fist year of life, zone spreads over adjacent metaphysic to form a fibrous circumferential ring bridging from epiphysis to diaphysis
- Ring increases mechanical strength of physics and is responsible for APPOSITIONAL bone growth
dz: osteochondroma
Distal humerus physeal separation - what to be worried about? findings on XR?
Tx?
Worried about NAT**
XR: posteromedial displacement of the radial and ulnar shaft relative to distal humerus***, forearm not aligned with humeral shaft
Tx: generally CRPP, combine w/ arthrogram to determine direction of initial displacement and adequate reduction**
complications of distal humeral physeal separtaion?
Can be indicative of NAT**
Posteromedial displacement***
May lead to:
Cubitus VARUS**
AVN of medial condyle**
When to treat humeral shaft fx operatively in peds?
Open
floating elbow
POLYTRAUMA***
Age of fusion of peds elbow?
CTE-ROI for order, internal/medial epicondyle fuses at 16-18**
How to image medial epicondyle fx in peds?
Internal oblique** or DISTAL HUMERAL AXIAL VIEW*
Improves accuracy of measuring displacement
Obtain by angling beam 25 degrees anterior to long axis of humerus
What cord doe ulnar nerve originate from in plexus? where does it run?
Ulnar from MEDIAL cord
splits two heads of FCU in proximal forearm
Runs SUPERFICIAL to transverse ligament at wrist
Runs MEDIAL to associated artery at level of wrist
Through Guyon’s canal
Which direction does fx displace for medial epicondyle fx in peds and what is best imaging to see it?
fx displaces ANTEROMEDIALLY*** (from flexor pronator mass)
Best view: distal humeral axial XR** (other best view is IR)
What happens to LCL with lateral condyle fx for peds?
Remains INTACT and attached to the lateral condyle fragment proximally and the radial neck distally***
Classification of lateral condyle fx?
Best imaging modality?
Tx?
Complications?
Milch classficiation
Type I: fx line is lateral to trochlear groove
Imaging: INTERNAL OBLIQUE view most accurately shows displacement as fx is POSTEROLATERAL***
Tx:
If <2 mm displacement can tx in LAC for 4-6 wks
2-4 mm displacement = CRPP
>4 mm displacement = ORIF***
AVOID POSTERIOR dissection = –> blood supply from posterior***
Complications
Most common: stiffness
NONUNION = higher than other elbow fx*
CUBITUS VALGUS and TARDY ULNAR NERVE PALSY*
Due to physeal arrest or more commonly a nonunion**, 10% of time, tx w/ supracondylar osteotomy after maturity and ulnar n. transposition
LATERAL OVERGROWTH
Up to 50% no matter what - counsel family, disruption of periosteum, lateral periosteum realignment will prevent this**
Tx of radial neck fx?
Nonop
<30 degrees angulation, immobilize for 7 days
CRPP
>30 degrees of residual angulation after closed reduction***
ORIF
>45 degrees with closed or perc methods
Ass’d with greater decrease ROM, increased AVN** (up to 70% with ORIF***)
Who does worse after radial neck fx fixation in peds?
Patients OVER 10 YEARS OLD***
What position does child keep arm in for nursemaid elbow? Tx?
slightly flexed and pronated*
Reduce in supination and flexion***
Most common nerve injury after supracondylar humerus fx in kids? second? Flexion type?
Most common: AIN (ok sign), median nerve
2nd: radial
flexion: Ulnar***
Benefit of crossed pin in SCH fx?
Better torsional stability***
When to remove pins in SCH fx? How to deal with postop stiffness?
3 weeks*** in clinic
stiffness: rare, but will normalize by 6 months***, no PT necessary
What type of SCH fx is more likely to require open reduction?
Flexion type***
Also ulnar nerve deficits
What causes cubits varus after SCH fx?
Reason to fix?
Malreduction of fx***
NOT overgrowth of lateral physics or growth arrest of medial physis***
Reason to fix generally COSMESIS***
Most common fx ass’d with peds elbow dislocation”
Medial epicondyle fx***
When to no longer reduce peds DRF?
After one week after injury***
Risk factors for cast burn?
hot dipping water
More than 8 layers of plaster
Placing arm on pillow while casting
Fiberglass over plaster
how to immobilize Monteggia fx in kids…type I? Type II? Type III?
Type I: anterior displacement of radial head, immobilize in 110 degrees of flexion and FULL SUPINATION to tighten interosseous membrane and relax biceps***
Type II: posterior displacement of radial head, immobilize in full extension**
type III: lateral displacement of radial head, full extension with valgus mold
What does splinting in supination and 110 deg of flexion accomplish for peds type I Monteggia fx?
Tightens interosseous membrane***
Also relaxes biceps*
Highest chance of requiring re-maninpulation after BBFFx in peds?
initial TRANSLATION of fx, not angulation***
Most predictive femoral fx for child abuse?
Transverse pattern***
not spiral or oblique*
When can do operation in polytrauma peds patient w/ closed head injury?
Can do early (<24 hours)***
Decreased LoS, femoral shaft fx NOT ass’d w/ pulmonary complications*
How to tx peds femur fx?
<6 mo?
6 mo - 5 years?
when to tx operatively?
<6 months: Pavlik***
6 months - 5 years: Spica casting*** (don’t use w/ open or shortening w/ >2-3 cm or polytrauma
Operative: kids >5
Weighing <100 lbs/49kg: flexi nails*** (if fx stable)
Unstable and >5 years and >100 lbs: sub muscular plate
> 11 yo and >100 lbs: IMN
Polytrauma, open, vac injury, segmental/sig comminution: ex fix
Most common complication in younger patients (peds) after femur fx?
Leg length discrepancy***, generally overgrowth
What deformity from peds proximal tibial traction pin?
Proximal tibial recurvatum from tibial tubercle growth arrest***
Most common complication from peds spica cast tx for femoral shaft fx?
Loss of reduction* (malunion 3x more likely than LLD)
Peds distal femoral fx…what zone of physis?
Which side is Thurston-Holland fragment?
Physeal arrest?
Zone: zone of hypertrophy***
Thurston-Holland in metaphysic fails on the compression side and physics fails on tension side*
Physeal arrest 30-50%***
Increased with SH type, fx displacement, surgical hardware invading physis
What is indication to fix AIIS avulsion?
Direct head of rectus femoris bony avulsion with >2 cm of displacement**
Peds hip dislocation…if non concentric what is next step?
If requires open reduction, what approach?
If non concentric: get MRI***
If requires open reduction (non concentric), approach in direction hip was dislocated (posterior approach for posterior dislocation)**
highest risk of AVN after hip fx in peds patient?
Dislocation of epiphysis > transphyseal fx w/o dislocation > transcervical fx > basicervical > IT fx ***
Classification of tibial tubercle fx in peds?
Type I: fx of secondary ossification center near insertion of patellar tendon
Type II: fx propagates proximal between primary and secondary ossification centers
Type III: fx extending into both ossification centers (most common)
Type IV: through entire proximal tibial physis
Type V: periosteal sleeve of extensor mech
Reason for possible compartment syndrome w/ tibial tubercle fx in peds?
Most common complication?
Injury to anterior tibial recurrent artery***
Most common: recurvatum deformity (growth arrest anteriorly and posterior growth continues to decrease tibial slope)***
What is deformity that happens after proximal tibia fx in peds?
late VALGUS deformity (Cozen’s phenomenon)***
Can occur regardless of Tx*
Observe for 12-24 months***, will likely remain, but mild
Tibial eminence fx in peds - where does ACL attach vs intermeniscal ligament?
Ass’d injuries?
ACL attaches 9 mm posterior to the intermeniscal ligament**
PCL does NOT attach to spines*
Ass’d injuries: occur in 40%
Meniscal injury
Collateral ligament injury
Osteochondral fx
What can block reduction in tibial spine fx in peds?
Medial meniscus*** (anterior horn)
Common complication of surgically treated tibial spine fx in peds?
Arthrofibrosis***
Is ACL laxity common after tibial spine fx in peds? Symptomatic?
Common, but rarely symptomatic***
How does peds ankle close physis (order)?
Centeral > anteromedial > poseteromedial > lateral ***
Fibular physis closes 12-24 moths after tibia
What is Chaput fragment? Wagstaffe? Volkmanns?
Chaput tubercle: from AITFL insertion onto anterior lateral distal tibial epiphysis
Wagstaffe: from AITFL onto distal fibula
Volkmann: from posterior aspect of lateral distal tibial epiphysis to posterior aspect of distal fibula (PITFL)
What are risk factors for growth arrest in peds ankle fx?
Medial malleolus SH IV fx = highest risk**
Degree of displacement: 15% increased risk of physeal injury for every 1 mm of displacement
Residual physeal displacement* (more important than initial displacement)*
Which side in peds ankle fx will periosteum block reduction?
Periosteum interposed on tension side of injury***
What is a Tillaux fx?
SH III fx of anterolateral distal tibia epiphysis***
Avulsion of the AITFL***
Tx closed if < 2mm displacement, ORIF if > 2mm
Seen w/in one year of skeletal maturity, OLDER than triplane fx
Reduce with INTERNAL rotation***
Triplane fx in peds?
SH IV fx in multiple planes
Eiphysis fx on lateral aspect in SAGITTAL plane (same ass tillaux fx), seen on AP film*** (SH III)
Physis separated in AXIAL plane***
Metaphysic fx’d on posterior aspect in CORONAL plane, seen on lateral*** (SH II)
Reduce lateral triplane w/ internal rot, and medial triplane in eversion**
Most concerning long term consequence of triplane fx/reason to proceed to OR if not reduced acceptably?
Post traumatic arthritis*
Due to patient being close to skeletal maturity and fx occurs due to closure of physis/near closure, so growth disturbance is less of an issue
Which joints in peds develop septic arthritis after metaphyseal breakthrough of infection?
Ankle
Hip
Elbow
Shoulder
NOT KNEE***
Sequestrum vs involucrum?
Sequestrum: necrotic bone walled off from blood supply that is nidus for chronic osteomyelitis ***
Involucrum: outer layer of new bone formed by periosteum***
Risk factors for DVT after osteomyelitis in peds pt?
CRP >6
Pt >8 y/o*
MRSA*
Surgical tx of osteomyelitis***
NOT TEMPERATURE**
Most common bug for osteomyelitis following varicella infxn?
Group A beta hemolytic strep***
NOT MRSA**
Risk factor for neonatal septic arthritis?
Risk factors for poor prognosis?
Neonatal septic arthritis:
Prematurity (relatively immunocompromised)*
C-section*
Pts in NICU
Poor prognostics: Age <6 months*** Ass'd osteomyelitis** Delay >4 days until presentation*** hip (vs knee)*
Kocher criteria for septic arthritis in peds?
WBC >12k
Inability to bear weight
Temp >38.5 C
ESR >40
If all 4 –> 99.6%
Fever most sensitive > CRP > ESR > refusal to bear weight > WBC**
What is most likely aspirate from 17 y/o with likely septic hip arthritis?
Normal joint fluid***
Neiserria gonorrhoeae presents with negative synovial fluid aspiration in >50%***