Peds Ortho - MSK Flashcards
Developmental Dysplasia of the Hip
-Risk factors: Female, first born, breach, oligohydramnios, large body size, genetics
20% associated with congenital muscular torticollis, Cultures that strap babies with, hips in extension
-Examination - dislocatable vs dislocated hip
-Unequal knee heights w/ hips and knees flexed
-Asymmetric skin folds
-Barlow, Ortolani, and pistoning tests
-Ultrasound if less than 6 months
-AP pelvis x- ray if older than 6 months
-Hip ossification center not present until 3 to 6 months of age
-Tx: Pavlik harness if < 4 mos, Closed reduction and spica cast 4 to 18 mos, Open reduction with femoral or pelvic osteotomy if > 18 months
Congenital Idiopathic Clubfoot
- 1 in 1000 live births
- Males higher incidence
- Bilateral 50 %
- Genetic - 2nd born male 40 X inc. incidence
- Ankle in equinus down
- Hindfoot in varus tipped in
- Forefoot in supination and adduction
- Medial and posterior skin creases
- Ponseti serial casting method
- Serial long leg cast done every 1-2 wks
- 90% get heel cord tenotomy at 6th cast
- Foot abduction brace used until 3 yrs old
- 85% good or excellent results
Congenital Muscular Torticollis
- “Wry neck”
- Contracture of sternocleidomastoid muscle
- Head flexes and rot. away from affected side
- 30% breech and 20% have DDH
- Possible intrauterine compartment syndrome?
- Restricted motion with tight band
- Firm mass in SCM muscle for 6 weeks
- Face flattened on ipsilateral side
- Contralateral parieto-occipital skull flattened - plagiocephaly
- Frequent stretching of involved SCM muscle
- 85% correct by 18 months
- Helmet therapy for plagiocephaly
- Release muscle if older than 24 months
Septic Hip Arthritis
- Infantile: growth plate not formed, no barrier between metaphysis and epiphysis, easy transmission from metaphysis to hip joint
- Metaphyseal infection burst directly into hip joint, pressure builds in joint, hip may dislocate
- Infection involves growth plate and leads to deformity
- Avascularnecrosis can occur
- Direct cartilage injury
- Juvenile: growth plate acts a barrier between direct inoculation of infection from metaphysis through epiphysis into the joint
- Most commonly metaphysis site of infection, ruptures into periosteum and extends into joint
- Irritable and fussy
- Hip flexed, abducted, and externally rotated
- Increased pain with ext.
- Fever common except neonate
- Ultrasound documents effusion
- ESR, CRP, and WBC usually elevated
- Blood culture positive in 50%
- Hip aspiration by U/S or in operating room
- Pus = surgical emergency, must I and D
- Infants and young children placed in spica
- IV antibiotics targeted to organism recovered
Congenital Tibia Bowing
- Recognize at birth
- Posteromedial (PM) bow and anterolateral (AL) bow
- PM bow more benign, can improve over time, some will need lifts for leg length, some will need limb lengthening
- usually do stretching for PM bow
AL Tibia Bow
- More serious type of bowing
- One half have neurofibromatosis
- Very likely to fracture
- Once fractured, likely to go on to nonunion, dont heal
- Brace until skeletal maturity if bone intact
Idiopathic Toe Walking
- Concerning to parents when child first walks
- Usually resolves over time
- Full ROM but up on tiptoes when child walks
- DDx: cerebral palsy, muscular dystrophy, congenital short heel cord
- Treatment: stretches, AFO braces, serial casts
Flexible Flatfoot
- Medial arch flattens during weight bearing
- Arch forms when feet dangle or stand on tiptoe
- Normal arch develops until age 8 to10
- No disability as an adult
- Arch supports do not change natural history
- Flexible flatfoot is a variation of normal
- Any kind of treatment will succeed but not needed
- If have tight heel cord do stretches
- Prescribe arch support only if painful
Transient Synovitis of Hip
- Most common hip disorder of childhood
- Acute onset of painful limp, resist weight bearing
- Age 4 to 10
- Pain in area of thigh or knee
- Pain with hip rotation and extension
- M/F ratio 2/1
- 2/3 of cases had previous recent URI
- Temperature mildly elevated
- WBC and ESR typically mildly elevated
- X-rays normal, U/S shows effusion
- Hip aspiration if done show nl WBC count
- Hip and blood culture negative
- Must exclude septic hip
- Transient : milder clinical findings, mild inc. sed rate, mild inc. WBC, nl. CRP, neg. aspirate, neg. blood culture
- Septic: more severe clinical findings, ESR > 50, inc. WBC, inc. CRP, pos. aspirate, pos. blood culture
- Treatment with bed rest or crutches and anti-inflammatories
- Resolves in a few weeks
- If does not resolve consider Perthes disease of rheumatoid arthritis
Perthes Disease
-Patient presents with painful limp
-Restricted hip motion, esp. IR and abduction
-AP and frog pelvis radiographs shows changes in 95% of cases
-Epiphyseal fragmentation, hip subluxation, reduction in epiphyseal height, wide medial clear space
-Avascular necrosis suspected etiology
-Generalized disorder of growth
-4 to10 year old age group
-Male, light hair, ADHD, shorter than normal stature
-90% show retardation in skeletal bone age
-End result can be relatively spherical head or highly deformed head
-Younger child has better prognosis
> age 7-8 worse prognosis
-Females worse prognosis (less growth remain)
-Disease process lasts 2-4 years
-Once hip extrudes in high risk patient, containment often offered
-Femoral osteotomy to tip “ball into socket” in order to keep femoral head inside of socket while femoral head is deformable during revacularization
Osteomyelitis
- Infection of bone, usually hematogenous
- Males 3 times higher incidence
- Incidence 1 in 5000
- Metaphysis of long bone most common
- Sluggish circulation leads to bacteria growth
- Present with bone pain, fever, malaise, chills
- Child does not want to move limb or bear wt.
- Pain to palpation of affected area
- Localized erythema and edema common
- X-rays show little first 7 to 10 days
- Lysis or periosteal new bone formation
- Late cases show dead, dense bone (involucrum)
- MRI most useful early imaging study
- CBC, ESR, CRP, blood culture
- Needle aspiration of affected bone
- Before bony changes seen, IV abx alone
- Once bony destruction seen, surgical debridement necessary
- Staph aureus most common
- Late complications: chronic osteomyelitis, growth plate injury leading to angulation or leg length difference, fracture
- Urgent diagnosis and treatment limits complications
Disc Space Infx
- Often seen younger than age 5
- Male = female incidence
- Intense back pain with fever
- Refuse to walk, sit, or change position
- Severe malaise and loss of appetite
- Any motion of back leads to splinting
- X-rays show loss of disc height and end plate irregularities
- MRI can be diagnostic before x-ray changes
- Disc space aspiration gets organism 50%
- Markedly elevated ESR
- Bracing alone with pain medicine can be successful
- Antibiotics directed against Staph aureus
- Affected disc space and surrounding vertebra typically contain infection
- Symptoms last 4 to 6 weeks
- Tuberculosis in immigrant population
Infantile Blount Dz
- Severe genu varus- bow leg
- Internal tibial torsion
- Radiographic changes medial tibia physis
- Early walker, more common African Americans
- Large body mass
- TX: surgical
Discoid Meniscus
- Age 1 to 8
- Clunking or clicking sensation of knee
- May or may not be painful
- Frequent falling
- Clunk or snap to knee while flexing and extending
- Lateral joint line tenderness
- Thickened and mal-shaped discoid meniscus
- If symptomatic, arthroscopic reshaping into a c-shaped structure is performed
- Refer to Ortho for surgery
Adolescent Idiopathic Scoliosis (AIS)
- Spinal bending with rotation, most common
- Curve measures over 10 degrees
- Commonly 10 to 15 yrs of age
- Right thoracic curve most common
- Females 2 to 3 x more common
- Progression correlates with maturity, curve location, and curve magnitude
- Thoracic curves over 30 in immature likely to progress
- Pulmonary compromise in curves over 70 deg
- Curves 25 to 40 consider bracing
- Curves over 40 or 45 deg get surgery
- Exam done standing with gown on patient
- Check to see level pelvis (no leg length diff)
- Shoulder asymmetry
- Rib rotatory prominence
- Asymmetric waist
- Surgery offered for curves over 40 to 45 degrees
- Prevent future curve progression and pulmonary compromise
- Bracing if not done growing, brace for at least 2 years after menarche in girls, have to wear 85%
