Peds Ortho Flashcards
What is Gowers sign
- weakness of proximal hip muscles can limit child’s ability to rise from sitting position
- to stand pt uses hands and arms to “climb up” the body
Normal gait
- heel toe gait
- symmetric arm swing
Contractures–>
cerebral palsy
Decreased muscle tone–>
muscular dystrophy
Ligamentous laxity is greatest when
at infancy
What is ligamentous laxity associated with
- developmental dysplasia of the hip
- dislocating patella
- pes planus
- injury
Congential orthopedic problems in peds
- malformation (spina bifida)
- disruption
- deformation (torticollis)
- dysplasia (osteogenesis imperfecta)
Acquired orthopedic problems in peds
- infection
- inflammation
- trauma
- tumor
Where are the ossification centers in peds
at the ends of the long bones
What is responsible for longitudinal growth of long bones in peds
physis
What is responsible for circumferential growth of bones in peds
periosteum
Pediatric bones have more ___ than adults
cartilage
What does the high amount of cartilage allow for in peds
skeletally immature patients to withstand more force before deformation or fracture than adult bone
What part of the bone is thicker in kids than adults
periosteum
Acute limp in kids can be what things
- transient synovitis
- contusion
- foot foreign body
- fracture
- osteomyelitis
- arthritis (septic, reactive, lyme)
Chronic limp in kids can be what things
- rheumatic disease
- apophysitis
- slipped capital femoral epiphysis
- Legg Calve Perthes disease
Trendelenburg gait is what
normal stance phase, but excessive swaying of the trunk
*drop of the pelvis when lifting leg opposite to weak gluteus medius
Antaligic gait
- painful limp
- stance phase and stride of affected limb shortened to decrease discomfort of weight bearing on affected limb
Waddling gait
bilateral decrease in function of gluteus muscles
Kids are more likely to require internal fixation with what things
- displaced epiphyseal fractures
- displaced intra articular fractures
- fracture in child with multiple injury
- open fracture
- unstable fracture
Pedi fracture remodeling occurs through what two things
- periosteal resorption
- new bone formation
Complications of fractures
- overgrowth
- neurovascular injury
- compartment syndrome
Injuries to the physis can result in what
premature closure
Growth plate is most susceptible to what
torsional and angular force
If there is partial closure of growth plate what is the consequence? Complete closure?
partial–> angular deformity
complete–> limb shortening
Salter-Harris for what type of fracture
physeal fracture
Common sites of salter-harris fx
- distal radius
- dital tibia
- distal fibula
Most common salter-harris fx
type II
Salter-Harris type I
fracture through growth plate
Salter-Harries type II
fracture through metaphysis and growth plate
Salter-Harris type III
fracture though epiphysis and growth plate
Salter-Harris type IV
fracture through metaphysis and epiphysis
Salter-Harris type V
crushed through growth plate
Greenstick fracture results from what
bending force applied perpendicular to shaft
How does a toddlers fx present
limping and pain with weight bearing with minimal swelling
What is a toddlers fracture
minimally or undisplaced oblique/spiral fractures of tibia without fibula fracture
Buckle fracture occurs after what
compression of the bone
Does the bony cortex break in a buckle fracture
nope
Bowing fracture?
not a true fracture, bone appears to be bent on x-ray
Treatment of bowing fracture
reduction requires a lot of force, do under general anesthesia
What is helpful in identifying a bowing fracture
comparison view of the other extremity
Supracondylar elbow fracture
extra articular fracture of distal humerus at elbow
caused by fall on extension
Displacement with a supracondylar elbow fracture?
posterior displacement of the distal component
Treatment for supracondylar elbow fracture
Conservative
- long arm cast
- analgesics
- serial radiographs q2wks
ORIF- two lateral pin technique with medial pin
Presentation of nursemaids elbow
pronated and painful elbow
Treatment for nursemaids
pressure on radial head and gentle supination while flexing the elbow
Galeazzi fracture dislocation
- fracture of distal radius
- dislocation of distal radioulnar joint
What causes a galeazzi fracture
FOOSH w/ flexed elbow
Monteggia fracture dislocation
- fracture of ulna shaft (displaced and overlapped)
- dislocation of radial head (anteriorly)
Standard of care for Monteggia fracture dislocation
ORIF
Mnemonics for Galeazzi/Monteggia
Grimus
G: Galeazzi
R: radius
I: inferior
M:Monteggia
U:ulna
S:superiorWhy is the blood supply to the hip unique in peds
blood vessels are extraosseous and lie on the surface of the femoral neck, entering epiphysis peripherally
What three things are under the category of developmental dysplasia of the hip
- hip that is dislocated and irreducible
- unstable (dislocatable and reducible)
- dysplactic, but withing the acetabulum
Risk factors for DDH
- first born
- female
- breech birth
- positive family history of hip dysplasia or early total hip replacement
Associated diagnoses with DDH
- congential knee dislocations
- congenital muscular totricollis
- metartarsus adductus and/or clubfoot
Presentation of DDH
- toe walking, can be unilateral
- limb length inequality
- waddling gait
- hyperlordosis
Tests for DDH
- galeazzi test
- barlow test
- ortolani test
Treatment of DDH
-pavlik harness
-abduction orthosis
-if all conservative measures fail of >6mnth at diagnosis:
closed reduction
open reduction if above failed
spica cast to hold hips in place
Legg-Calve Perthes
idiopathic osteonecrosis of capital femoral epiphysis
Presentation of LCP
- boy
- small for age
- delayed bone age
- very active or hyperactive
- pain may be non specific
- mild limp
- usu no hx of trauma
What are the four stages of LCP
Necrosis: initial period of ischemia/loss of blood supply to femoral head
Fragmentation: re-absorption of bone w/ femoral head collapse
Re-ossification: new bone re-growth to reshape the femoral head
Remodeling: femoral head reshapes itself into spherical shape
PE for LCP
- limp
- limited motion–> abduction and internal rotation
- atrophy of quad
- leg length inequality due to collapse of femoral head
Imaging for LCP
AP pelvis and frog lateral
Treatment of LCP
- reduce activities
- crutches, walker, wheelchair
- NSAIDs
- referral to peds ortho for surgical intervention
Slipped capital femoral epiphysis
disorder of proximal femoral physis that leads to slippage of epiphysis relative to femoral neck
Risk factors for SCFE
- obesity
- males more than females
- occurs during period of rapid growth
Clinical presentation of SCFE
- can be bilateral
- groin/thigh pain most common
- knee pain
- gait: external rotation or trendelenburg
- decreased hip motion
Xrays for SCFE
ap hip and frog lateral
Treatment for SCFE
- percutaneous in situ fixation
- stabilize epiphysis from further slippage
- promote closure of the proximal femoral physis
Most common cause of hip point in children
transient synovitis
What does transient synovitis of the hip typically follow
an URI =/- fever
Clinical presentation of transient synovitis of the hip
- rapid onset of limping and subsequent refusal to walk/bear weight
- limited ROM d/t pain and spasm, hip held in flexion
What must you exclude for a diagnosis of transient synovitis of the hip
septic arthritis
Hip aspiration for transient synovitis?
only when the ESR is >20mm/hr
Treatment of transient synovitis of the hip
- bed rest
- gradual increase of activity
- NSAIDs
Prognosis of transient synovitis of the hip
symptoms resolve and range of motion returns to normal
Osgood-Schlatter?
transient apophysitis in adolescents
Characteristic pain of Osgood-Schlatter
pain over the tibial tuberosity relieved with rest
can be bilaterally
PE for Osgood-Schlatter
-prominent tibial tubercle
+/- swelling, redness
Treatment of Osgood-Schlatter
- rest
- ice
- NSAIDs
- reassurance
Sever’s disease aka
calcaneal apophysitis
When does Sever’s disease occur
during adolescence particularly during a growth spurt
What causes pain in Sever’s disease
repetitive stress on the groth plate as foot strikes the ground
Clinical presentation of Sever’s
- heel pain bad enough to cause a limp
- usu first noticed after sports
- pt will often report new cleats or foot wear
Treatment of Sever’s
- RICE
- DC sports if sx severe
- gel heel pads or heel inserts
- NSAIDs
- stretching of Achilles’
Growth plate with physiologic genu varum?
normal
Worrisome clinical features of genu varum
- lateral thrust during gait
- short stature
- ligament laxity
- abnormal location of the deformity
- apparent enlargement of the elbow, wrists, knees and ankles
When do you do xrays with genu varum
- asymmetry
- atypical age
- worsening deformity
Pathological bow legs?
- osteochondral dystrophy
- rickets
- tibia varum
Risk factors for Blount’s disease
- early walking
- obesity
- family history
Signs of rickets
- short stature
- enlargement of elbow, wrists, knee, ankles
Genu valgus—>
knock knees
What should be considered if a child is walking on their toes
- cerebral palsy
- tethered cord
- achilles tendon contracture
- possible leg length discrepancy
Treatment of idiopathic toe walking
- physical therapy
- serial casting
- surgical heel cord lengthening
What must be ruled out before a patient can be diagnosed with idiopathic toe walking
- neuromuscular disorder
- cerebral palsy
- autism
Club foot is what kind of rotation
equinus, adductus, varus and medial rotation
Treatment of club foot?
surgery or serial casting
Diagnosis of club foot should prompt what
a search for other MS problems
3 types of scoliosis
- idiopathic: most common
- congenital: vertebral abn
- neuromuscular: underlying d/o
Cobb angle great than what = scoliosis
10 degrees
What should you observe for when doing a PE for scoliosis
-one shoulder being higher than the other
larger space from arm to side of body
-uneven waist crease
-uneven hip levels
What is the Risser staging used for
used to grade skeletal maturity based on level of ossification and fusion of iliac crest apophyses
Treatment for scoliosis
<25: observe
25-45: brace
>50: surgery
