Peds Ortho Flashcards
1
Q
What is Legg-Calve-Perthes Disease? Age range?
A
- idiopathic osteonecrosis of the femoral head in kids
- sequence of femoral head fragmentation and repair
- age range: 4-8 commonly (2-12)
- 2-5x more common in boys than girls
- 10% cases are bilateral
2
Q
Clinical presentation of Legg-Calve-Perthes disease?
A
- prolonged limping or waddling gait w/ pain in thigh, groin or knee
- 90% have delay in bone age and short stature
- bilateral LCPD both hips usually don’t become sx at same time
3
Q
Dx LCPD?
A
- AP and lateral view of hip
- wrist and hand films for bone age
- AP pelvis w/ hips abducted to determine containment
- bone scan w/ pinhole collimation
- MRI
4
Q
Etiology of LCPD?
A
- anterolateral portion of head is commonly involved
- the ascending lateral cervical vessels from medial femoral circumflex artery
- circulation is less developed in 3-10 yo boys
5
Q
Prognosis of LCPD?
A
- if disease begins b/f 6 and tx begins b/f 8yo then you have favorable prognosis
- adolescents fxn well in spite of poor radiographs
- 70-80% develop arthritis in long term studies
6
Q
Tx of LCPD?
A
- goals: reduce pain, impove fxn, and minimize femoral head deformity
- revascularization of femoral head
- traction, bed rest
- bracing: not proven to alter natural hx
- surgery
7
Q
What is a SCFE?
A
- disorder in which epiphysis becomes posterior displaced on the femoral neck
- this may lead to OA in adults or result in chondrolysis or avascular necrosis in the adolescent
8
Q
Epidemiology of SCFE?
A
- prevalence of 0.2/100,000 in Japan, 10/100,000 in connecticut
- tends to occur in boys 10-17, girls 8-15, males to females 2:1
- obesity 50% weigh more than 90% of the kids in their age group
- bilaterally 37% for the sx slips
9
Q
Clinical findings of SCFE?
A
- abrupt onset of groin pain
- longer duration of sxs, medial thigh and knee pain
- acute: sxs less than 3 wks
- chronic: sxs for longer than 3 wks
10
Q
Clinical findings in SCFE?
A
- stable: no independent movement on fluoroscopy
- unstable: independent movement on fluoroscopy
- pain is ocalized to anterior hip, groin or medial thigh and knee
- child walks w/ antalgic gait w/ leg in external rotation. Passive hip flexion results in obligatory external rotation
11
Q
Imaging studies for SCFE?
A
- AP and lateral radiographs are most impt imaging studies
- AP on pre-slip will show slight widening and fuzzy irregularity of the physis
- lateral views gives the most info the percent epiphyseal displacement and the lateral head/shaft angle
12
Q
Etiologies of SCFE?
A
- hypothyroidism (may also be cause of obesity)
- hypogonadism
- parathryorid adenoma w/ growth hormone abnormality
13
Q
Tx of SCFE?
A
- stabilize slipping process and achieve premature closure of physis
- single screw fixation under fluoroscopic conrol. Screw generally needs to be placed anteriorly on the femoral neck
14
Q
What is club foot?
A
- congenital foot deformity characterized by 4 components: plantar flexion of ankle inversion of heel high arch at midfoot adduction of forefoot - idiopathic - males 2x that of females - familial
15
Q
Clinical presentation of club foot?
A
- look like they could walk on top of foot
- plantar flexion is most severe, drawn up position of heel and inability to pull calcaneus down
- high arch difficult to see
- forefoot adduction
16
Q
Tests for club foot?
A
- R/O neuromuscular disorders
- xrays not needed unless dx unclear
17
Q
Tx of club foot?
A
- manipulation and casting should be started immediately
- 2-4 months of manipulation and casting are reqd to correct club foot
- surgery if conservative fails
- surgery lengthens tendons and ligaments so that bones can be positioned in normal alignment
- child can run and play after
18
Q
What is metatarsus adductus?
A
- common congenital deformity characterized by medial deviation of forefoot
- 25% preterm infants
- 13% term infants
- often resolves spontaneously
19
Q
Exam findings of metatarsus adductus?
A
- convex lateral border of foot w/ palpable prominence at base of 5th metatarsal
- hindfoot is in neutral or increased valgus
- normal ankle dorsiflexion
- pigeon toe
20
Q
Dx of metatarsus adductus?
A
- serial photocopies
- heel bisector line
21
Q
Tx of metatarsus adductus?
A
- supine sleeping position
- delay tx until 6 mo old
- serial casting
22
Q
Genu Varum presentation?
A
- tibia adducted in relation to femur
- 10-15 degrees is normal
- straighten by 12-18 mo of age
- after 30-36 months, bracing or surgery
23
Q
Genu Valgus presentation?
A
- alignment of knee w/ tibia abducted in relation to femur
- knock knees
- observation is TOC
24
Q
Variants of Developmental dysplasia of the hip?
A
- teratologic: fixed dislocation, occurs prenatally, usually assoc w/ NM disorder
- unstable hip: femoral head reduced, can be fully dislocated or partially subluxated
- dislocated hip: femoral head doesn’t articulate and may not be reducible
- subluxated hip: femoral head contacts portion of true acetabulum
- acetabular dysplasia: acetabulum is shallow, femoral head is subluxated or normal
25
Q
How common is DDH?
A
- 2.7-17/1000 live births
- 1/1000 est dislocation
- 0.4-.0.6/1000 late dislocation
26
Q
Etiology of DDH?
A
- physiology: ligamentous laxity (CT disorder), hormonal and familial
- mechanical:
prenatal, breech, oligohydramnios, primigravida, congenital knee recurvatum w/ dislocation, congenital muscular torticollis, metatarsus adductus - Post-natal factors:
swaddling, strapping - genetic: fender is femal, left hip 3:1
27
Q
Dx of DDH?
A
- all cases may not be detectable at birth
- late cases aren’t always misdx cases
- screening programs must be dynamic
- sonography for routine screening isn’t cost effective or practical
28
Q
PE findings of DDH?
A
- neonate
- barlow test: hip that is reduced but is dislocateable
- ortolani’s test: hip that is dislocated but reducable
29
Q
Imaging for DDH?
A
- xray is diff to interpret in the very young child
- US is useful in kids under 6 mo of age and can be effective up to 1 yo
- arthrogram demonstrates soft tissue impediments to reduction and concentricity and stability of reduction
- CT isn’t for routine screening but can be useful in reconstruction
30
Q
Tx of DDH?
A
- closed reduction
- pavlik harness can be used for up to 6 mo:
- hip is dislocateable or dislocated and capable of being reduced
- reduction of hip should be confirmed by 3 wks
- this is effective 90% of time
- AVN rate is low, less than 5%
31
Q
When is closed reduction TOC for DDH?
A
- for pts up to 24 months of age
- this needs general anesthesia and arthrogram guidance
- spica cast is worn 3 months
32
Q
When is open reduction TOC for DDH?
A
- for older kids
- anterior and medial approach is MC
- anterior approach is most versatile and commonly used
33
Q
Complications of DDH?
A
osteonecrosis MC complication:
- there is a failure of appearance of ossific nucleus for period of over 1 yr following reduction
- broadening of femoral neck over similar period
- residual deformity of femoral head and neck
- there is increased radiographic density followed by fragmentation
failed reduction
one needs to repeat reduction
34
Q
What is Osgood-Schlatter disease?
A
- condition results from repetitive injury and small avulsion injuries at bone-tendon junction where patellar tendon inserts into secondary ossification center of tibial tuberosity
- sports
- males
35
Q
Clinical sxs of Osgood-schlatter?
A
- pain exacerbated by running, jumping, and kneeling
- most continue all activities
36
Q
Exam and dx of Osgood schlatter?
A
- exam reveals tenderness and swelling at insertion of patellar tendon into tibial tubercle
- often bilateral
- jt stable
- xrays show soft tissue swelling, maybe small spicules of heterotopic ossification anterior to the tibial tuberosity
37
Q
Tx of osgood schlatter?
A
- Ice, NSAIDs, protective knee pad
- decreased activity for around 2-3 months
38
Q
Diff spreads of septic arthritis?
A
- jt infections most commonly affect kids at hip, knee, and ankle
- hematogenous spread (staph)
- contiguous spread (from jt)
- direct inoculation (puncture wound)
39
Q
Sxs of septic arthritis?
A
- pain, malaise, loss of appetite, failure to use affected jt
- toddler refuses to walk
- temp above 102, but neonates may not have fever
- hip MC in kids younger than 2
40
Q
Exam and dx of septic arthritis?
A
- swelling, tender, warmth
- hip held in flexion, abduction, and external rotation
- knee and elbow in flexion
- pseudoparalysis (flacid limb) shoulder
- AP/lateral X-rays: takes 8-14 days to show up
- labs: CBC w/ diff, sed rate, CRP, and blood cultures
- jt aspiration
41
Q
+ jt aspiration results in septic arthritis?
A
- WBC greater than 50,000 mm^3
- PMNs 90%
- they eat sugar and protein would be increased
- lower WBCs w/ N gonorrhoeae
42
Q
Bad outcomes of septic arthritis?
A
- can lead to destruction of jt surface, secondary arthritis, scarring of capsule
- osteonecrosis of femoral head
- prognosis is good if surgical drainage and abx w/in 4 days of sxs
43
Q
Common bugs of septic arthritis?
A
- staph aureus MC
- GBS infants younger than 1
- H flu 6 months-4 yrs
- N. gonorrhoeae 12-18 yrs
- refer early: ID and ortho needs to be involved
44
Q
Pearls of ortho?
A
- examine jts above and below
- xray jts above and below
- xray opp side if unsure esp in kids/open growth plates
- everything in ortho takes 6 wks to heal
45
Q
Osteosarcoma presentation?
A
- 2nd most common primary bone tumor after myeloma. High risk of mets, 20% of all bone sarcomas, 2nd decade male = females, appendicular (50% knee), metaphyseal, xrays missed lytic/sclerotic w/ cortical destruction (codman’s triangle, star burst, periosteal rxn), MRI
- then worry about other cancers as well that may met to bone: breast, prostate
