Peds Orthopedic Disorders Flashcards
1
Q
What are some peds skeletal differences
A
- preosseus cartilage
- physics 0- growth plate
- periosteum - thicker stronger more osteogenic
- Moore shock absorption - lower bone mineral content and greater porosity
2
Q
What is the peds skeletal difference in callus formation
A
Periosteum - thicker, stronger, more osteogenic
- increased vascularity
3
Q
Why does physis injury occur prior to ligament injury in peds
A
- ligaments often attach to epiphyses therefore transferring force to physis
- ligaments are shorter and continuous tissue type (greater tensile strength)
- physis is sandwiched between epiphysis and metaphysis of growing bone - relatively soft tissue between relatively hard tissue
- histologically, metaphyseal trabecular are initially oriented vertically in long bones, progress to horizontal orientation with skeletal maturity (more mechanical strength)
4
Q
What features helps bone remodel faster after a fracture
A
- age - younger = better
- proximity to a joint - closer to a physis
- joint axis - deformity in the plane of “primary” osteokinematic motion eg if fracture of the knee is set to flexion or extension to each other because this is in the sagittal plane (ie primary motion of the knee) as opposed to frontal plane (not primary motion of the knee)
5
Q
How does overgrowth affect bone remodeling in peds after a fracture
A
- less than 10 year old, usually have a 1-3 cm overgrowth in the long bone
- bayonet apposition to compensate
6
Q
What are the risk factors (5Fs) for hip dysplasia
A
- Female
- First born
- Feet (butt) first aka breech
- Family history
- Flexible (history of hyperlaxity)
7
Q
What are some clinical signs of DDH
A
- decreased or asymmetric ROM
- Galeazzi sign -uneven knee heights
- asymmetric thigh folds
- pistoning - joint not intact, because hip is dislocated, can lift hip up and down
- Barlow maneuver - posterior dislocation with adduction
- Ortolani maneuver - anterior reduction with abduction (reduces hip)
8
Q
What is the gold standard for diagnosing DDH
A
Diagnostic ultrasound
9
Q
What is Hilgenrenier’s line
A
Radiographic measurement through the junction of ilium, ischium and pubic bones at the center of the acetabulum
10
Q
What is Perkin’s line and where should secondary ossification of femoral head be
A
Radiographic measurement, perpendicular to hilgenrenier’s line at the outer border (superior lateral edge) of the acetabulum
- secondary ossification of the femoral head should be in the inner inferior quadrant
11
Q
Where is the 3rd line drawn in radiographic evaluation of DDH and what should the intersection of this line and Hilgenrenier’s line be
A
Intersecting Hilgenrenier’s line along he superior aspect of the acetabulum;
- intersection of these lines should be less than 30 degrees, more than 30 is indicative of acetabulum hypoplasia
12
Q
What is Shenton’s line
A
Radiographic measurement, along the inferior borders of the femoral neck and superior pubic ramus
- should be smoot and unbroken
- DDH results in superior femoral movements and breaking of the line
13
Q
What are the 3 things we’re looking for on radiographic evaluation of DDH
A
- secondary ossification of femoral head in the inner inferior quadrant
- intersection of 1st and 3rd line less than 30 degrees
- shenton’s line is smooth and unbroken
14
Q
What is the intervention for DDH treatment for a neonate
A
Pavlik harness
15
Q
What is the intervention for DDH for a 1-6 month old
A
Harness or Spica cast
16
Q
What is the intervention for DDH in a 6-24 month old
A
CRIF or ORIF with Spica Cast
17
Q
What is the intervention for DDH in a 24 mth -8year old
A
ORIF with spica cast or left alone
18
Q
What is coxa varus
A
Angle between femoral shaft and neck less than 120 degrees
19
Q
What is the normal femoral shaft/neck angle at birth
A
150 degrees
20
Q
What is the typical femoral head/neck angle in the typical adult
A
120-130 degrees
21
Q
What is the coxa vara angle
A
Less than 120 deg
22
Q
What is coxa valgus angle
A
Greater than 135
23
Q
Describe the femoral neck and proximal femoral physis/epiphysis in coxa vara
A
Femoral neck - more horizontal
Proximal femoral physis/ephysis - more vertical
24
Q
What is slipped capital femoral epiphysis (SCFE)
A
Occurs when he growth plate of the proximal femur is weakened
25
What part of the femur is actually involved in SCFE
There is a superior and anterior displacement of the femoral shaft/neck
26
What is the most common hip problem in adolescence
SCFE
27
What are causes of SCFE
Growth plate weakness
Excessive force across growth plate
Femoral retroversion
growth plate obliquity
Testosterone and/or normal imbalance
28
What is the ideal view of x-ray for SCFE
Frog leg view
29
What is Klein’s line
The line along the superior aspect of the femoral neck
30
What is a normal Klein’s line
The superior border of the epiphysis projects superiorly to Klein’s line
31
What is an abnormal Klein’s line and what does it mean
The superior border of the epiphysis lies on Klein’s line, more advanced cases, the epiphysis projects inferiorly to it
Means SCFE
32
What are the 3 classifications of SCFE
- Acute
- Acute-on-chronic
- Chronic
33
What is acute SCFE
Occurs immediately following significant trauma
34
What os Acute-on-chronic SCFE
Patient with c/o hip or knee pain prior to a traumatic incident
35
What is chronic SCFE
Child presents with h/o limp, pain
Decrease ROM —> hip abduction and hip IR
36
What is the most common classification of SCFE
chronic
37
What are the grades of SCFE
-grade I - development of femoral head up to 1/3rd of the width of the femoral neck, 0-33% slippage
- grade II - displacement of the femoral head more than 1/3rd but less than 1/2 f the width of the femoral neck, 33-50% slip[page
- grade III - displacement of the femoral head more than 1/2 the width of the femoral neck, >50% slippage
38
Which ROM is increased in SCFE
Hip ER
39
Which ROM is decreased in SCFE
Hip abduction, hip IR
40
What motion strength is decreased in SCFE
Hip abduction strength
41
What is the surgical intervention for SCFE
Pinning in situ to prevent further epiphyseal displacement
42
What is femoral head-neck offset
The distance between lateral border of femoral head and neck less tan 8mm is abnormal
43
What are some complications of SCFE
Osteoarthritis —> decreased blood flow, AVN
Cartilage deterioration —> chondrolysis, degenerative joint disease
44
What is Legg-Calve-Perthes Disease
AVN of femoral head —> compromised medial femoral circumflex artery
45
What is the clinical picture for a LCP
-typically boys 4-10 years
Small stature
Active children
Bilateral in 10-20% of cases
46
Causes of LCP
Smaller arterial diameter
Reduced blood velocity
Reduced blood flow volume
Period of rapidly changing epiphyseal vascularity
47
Is Legg-Calve-Perthes self healing
Yes in 1-3 years
48
What determines the prognosis of LCP
- age (less than 6 = good, 6-8 = fair, more than 8 = poor)
- duration of disease
- femoral head deformity and deterioration
- congruity between femoral head and acetabulum
49
What is herring lateral pillar classification
Femoral head deformity
Comparing the height of lateral 1/3 of the proximal femoral epiphysis
During the fragmentation stage
50
What is Herring Lateral Pillar Classification A
Normal height - good prognosis
51
What is Herring Lateral Pillar Classification B
50-100% of uninvolved height - fair prognosis
52
What is Herring Lateral Pillar Classification C
Less than 50% of uninvolved height - poor prognosis
53
What is the most common symptom of SCFE
Knee pain
54
What is the clinical sign of LCP
- Trendelenburg**
- decreased ROM of him AB and IR
- decreased MMT hip AB
- hip AD, flexor muscle spasm
- Limp
- pain groin, hip, knee
55
What is Shriner’s protocol for LCP
- Adductor tenotomy to achieve 35-40 deg abduction from casting
- 6 weeks Petrie casting
- A-frame orthosis
- Hip ROM
- 93% good hip congruency
56
What is the SCFE, the patient population, and imaging used
- femoral head malalignment relative to femoral neck
Adolescent
- X-ray (CT, MRI)
57
What is the LCP, the patient population, and imaging used
Femoral head flattening with possible femoral neck broadening
- child
- X-ray (CT, MRi)
58
What is DDH, the patient population, and imaging used
Displacement of femoral head and neck relative to acetabulum
Infant
Ultrasound less than 6 mths, X-ray greater than 6 mths
59
What is true length length inequality
>2.5cm ie 1inch
60
How is true LLD diagnosed
Orthoradiography
61
Is hip/knee arthrosis likely with LLD
No
62
What is the anatomical effects of LLD
2-3 (abduction) femoral head uncovering occurs per 1 cm of increased LLI
63
What are the functional effects of LLD
- gait asymmetry and alteration in kinematics requires a LLI of >2cm or 3% variation in length
- LLI >2cm are associated with greater mechanical work and equalizing limb length improves the symmetry of gait
64
What is the LLI treatment guidelines for <2cm
No treatment
Shoe lift
Heel-sole lift
65
What is he LLI treatment guideline for 2-5cm
Epiphysiodesis
Transphyseal screw implantation
Shortening procedure
66
What is he LLI treatment guideline for >5cm
Lengthening procedure
- osteotomy and distraction
- lengthening on nail (LON)
67
What is he LLI treatment guideline for >15-20cm
Staged lengthening
W/ epiphysiodesis
Amputation
68
Do you measure LLD correction while patient is lying down
No
69
How do you measure correction for LLD
Measure functionally
- patient standing
- Equal iliac crest heights
- Reduction in symptoms
70
What are the 5 biologic principle and law of tension stress
- corticotomy - keeps periosteum and nutrient artery intact
- delaying distraction 5-10 days allows initiation of osteogenesis
- distraction 1mm/day - broken into 0.25mm segments every 6 hours
- corticotomy better the metaphyseal region
- 2 simultaneous corticotimies ok if necessary in the tibia but NOT the femur
71
What are some consideration of ex fix placement
- decreased knee flexion
-distal placement closer to the knee
- lateral vs posterior/lateral placement
- lengthening process
- if you maintain the available knee flexion, you are actually increasing muscle length
- patella mobilization
- important to maintain proper knee flexion and extension
72
Wha type of PT is occurring during latency phase of lengthening
- gait, WB training, pin care
73
Wha type of PT is occurring during distraction phase of lengthening
ROM and strengthening- all LE joints are at risk
74
Wha type of PT is occurring during consolidation phase of lengthening
Strengthening and tissue mobilization
1 months for every 1 cm of distraction
75
Wha type of PT is occurring during ex fix removal and healing phase of lengthening
Casted and HEP (home exercise program)
76
Wha type of PT is occurring during rehabilitation phase of lengthening
Aggressive stretching and functional training
77
What are the 5 phases of LLD lengthening
1. Latency
2. Distraction
3. Consolidation
4. Ex fix removal and healing
5. Rehabilitation
78
What is the proximal focal femoral deficiency (PFFD)
Absence or hypoplasia of the proximal a femur
Varying involvement - acetabulum, femoral head, patella, tibia, fibula
79
How often is bilateral involvement with PFFD
15% bilateral
80
Describe the thigh and foot in PFFD
Shortened flexed thigh - hip/knee flexion contractures
Foot at “knee” level
81
What is the natural angular position of the the knees of a new born
Moderate genu varus
82
What is the natural angular position of the the knees of a 1.5-2 yo
Approximately straight
83
What is the natural angular position of the the knees of 2-4 yo
Genu valgus
84
What is the natural angular position of the the knees of a 5-7 yo
Legs straight - achieved adult alignment
85
What is Blount disease
Tibia vara
- abnormal or inhibited growth of the proximal medial physis, epiphysis and metaphysis of the tibia
- results in progressive varus deformity below the knee
86
Describe Blount radiographic features
- sharp varus angulation of the metaphysis
- beaking of the medial metaphysis
- wedging of the medial epiphysis
- widening of the growth plate
- cartilage islands in or near beaking
87
What are the treatment options for Blount disease
- surgical correction via osteotomy
- conservative treatment
88
Is bracing effective for Blount disease
No, unloading is unsuccessful
89
What are some complications of LLI and Blount
Malalignment
- deformity
- poor axis of movement
Physis and normal growth interruption
- angular deformities
- LLI
Overgrowth
- LLI
Recurrent fracture
90
What is rickets
Results from Vit D deficiency
91
What is Rickets characterized by
Decreased bone mineral density
Genu varus/valgum —> deformity of femur and/or tibia
92
How is vitamin D metabolized
Sun —> vitD3 —> liver; 25D —> kidney:125D
93
What form of vit d is responsible for absorption of. Calcium and ionic phosphate
125D
94
Difference between vit D3 and D2
D3 = cholecalciferol, more effective form resulting in higher circulating levels of 25D
D2 - ergocalciferol - typical form found in supplements
95
How much calcium can be absorbed at a time
500mg
96
What are some signs of rickets
- nodular enlargements on the ends of long bones**
- muscle pain
- enlargement of liver and spleen
- profuse sweating**
97
What is exercise induced compartment syndrome
Increased intramuscular pressure within a tight fascia compartment
- ischemia
- neurovascular compression
98
How is exercise induced compartment syndrome resolved
With rest
99
What are the clinical signs off compartment syndrome
Lower leg pain
Parasethesia in the lower leg and foot
Tightness in lower leg tissue
Shiny skin and hair loss
100
What are the common connective tissue diseases
- hypermobility spectrum disorders
- ehlers danlos syndrome
- Marfan syndrome
101
What is benign joint hypermobility syndrome?
Generalized joint laity with musculoskeletal complaints in the absence of a specific genetic, musculoskeletal or rheumatic disorder
102
What are the 3 clinical groups of hypermobility spectrum disorders
- asymptomatic joint hypermobility
- specifically defined syndrome that includes joint hypermobility
- symptomatic joint hypermobility not meeting diagnostic criteria for a specific syndrome
103
What are some related musculoskeletal physical traits of hypermobility spectrum disorders
- peds planus
- valgus deformities
- scoliosis
- excessive thoracic kyphosis
- excessive lumbar lordosis
- deformational plagiocephaly
104
What is the least to greatest symptomatic involvement for hypermobility spectrum disorder
As-LJH
As-PJH
As-GJH
L-HSD
P-HSD
G-HSD
HEDS
H-HSD
105
What is a positive score for Brighton criteria for joint hypermobility
2 major
1 major + 1 minor
4 minor
2 minor + a confirmed 1st degree relative
106
What are the major points for Brighton’s criteria for joint hypermobility
- Brighton score 4/9 or more
- joint pain >3 months in 4 or more joints
107
What are some minor scores for brighton criteria for joint hypermobility
- Beighton score 3/9 or less
- joint pain <4 joints
- dislocation or subluxation- multiple joints or episodes
- soft tissue inflammation
- marfan like symptoms
- skin abnormalities
- eye signs
- varicose veins, hernias
108
What is Ehlers Danlos Syndrome
A clinically and genetically heterogenous group of connective tissue disorders characterized by 3 classic signs
109
What are the 3 classic signs Ehlers Danlos Syndrome characterized by
- join hypermobility
- skin hyperextensivility
- tissue fragility
110
How do the mutations in genes contribute to Ehlers Danlos Syndrome
All contribute to the processing, production and structure of fibrillation collagen proteins responsible for connective tissue structural integrity
111
What are he methods of inheritance for EDS
Autosomal dominant inheritance
Autosomal recessive inheritance
112
What type of EDS cases are most common
Classic or hypermobility types (>90%)
113
What are he major criteria for classic EDS
- skin hyperextendibility and atrophic scarring
- generalized joint hypermobility
114
What are the clinical criterion for skin hyperextensibility
Measured by pinching and lifting skin:
- >1.5cm distal end of the anterior surface of dominant UE forearm
- >1.5cm dorsum of the hands
- >3.0cm at the neck elbows and knees
115
What are common complaints in HSD and EDS
- joint pain
- pain with handwriting
- joint hypermobility
- excessive fatigue
- hamstring tightness
116
What are some joint protection- neutral alignment for EDS
- no standing on Y ligaments
- limited hip IR
- no genu recurvatum
- control of pes planus
- no shoulder/hip tricks
- no elbow hyperextension
117
What is Marfan Syndrome
A genetic CT disease resulting in musculoskeletal, cardiovascular**, respiratory, opthalmologic** and integumentary compromise
118
What is the major component contributing to CT structural integrity in Marfan syndrome
FBN1 gene - fibrillin-1
119
What is the diagnostic criteria for Marfan syndrome
Revised Ghent Criteria
120
What is wrist and thumb sign
Ghent criteria - can take thumb and cross around palm and closed finger, thumb extends out
Wrapt pink and thumb around wrist
121
What is pectus carinatum
Ghent criteria - external defrmation of chest
122
Pectus excavated
Ghent criteria internal deformity of chest
123
In torsional profiles, what contributes to static in toeing
- anteversion
- internal tibial torsion
- met adductus, club foot, pes cavus
124
In torsional profiles, what contributes to dynamic in toeing
Medial hamstring
Lateral Gastroc
125
In torsional profiles, what contributes to static outtoeing
Hip ER contracture
Retroversion (rare)
External tibial torsion
Calcaneoalgus
126
In torsional profiles, what contributes to dynamic out-toeing
Muscle tightness of lateral hamstring, and medial gastroc
127
What is pronation in open chain
Calc: eversion, AB, DF
128
What is supination in open chain
Calc: inversion, AD, PF
129
What is pronation in closed chain
Calc: eversion
Talar, AD, PF
130
What is supination in closed chain
Calc: inversion
Talar: AB, DF
131
What is the movement of the entire LE during closed chain pronation
Talar adducts
Tibia IR
Femur IR, ad
Patella lateral movement
132
What is the entire motion of the LE in closed chain supination
Talus abduction
Tibia ER
Femur ER, AB
Patella medial movement
133
Excessive pronation that isn’t manage can lead to
Medial instability
Medial balance loss
Valgus positioning
Hip IRAD
Patella pain syndrome
MCL, ACL injury
134
Excessive supination can lead to what
Lateral instabilty
Lateral balance loss
Varus positioning
LCL injury
Lateral ankle injury
