Peds Orthopedic Disorders Flashcards
What are some peds skeletal differences
- preosseus cartilage
- physics 0- growth plate
- periosteum - thicker stronger more osteogenic
- Moore shock absorption - lower bone mineral content and greater porosity
What is the peds skeletal difference in callus formation
Periosteum - thicker, stronger, more osteogenic
- increased vascularity
Why does physis injury occur prior to ligament injury in peds
- 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)
What features helps bone remodel faster after a fracture
- 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)
How does overgrowth affect bone remodeling in peds after a fracture
- less than 10 year old, usually have a 1-3 cm overgrowth in the long bone
- bayonet apposition to compensate
What are the risk factors (5Fs) for hip dysplasia
- Female
- First born
- Feet (butt) first aka breech
- Family history
- Flexible (history of hyperlaxity)
What are some clinical signs of DDH
- 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)
What is the gold standard for diagnosing DDH
Diagnostic ultrasound
What is Hilgenrenier’s line
Radiographic measurement through the junction of ilium, ischium and pubic bones at the center of the acetabulum
What is Perkin’s line and where should secondary ossification of femoral head be
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
Where is the 3rd line drawn in radiographic evaluation of DDH and what should the intersection of this line and Hilgenrenier’s line be
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
What is Shenton’s line
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
What are the 3 things we’re looking for on radiographic evaluation of DDH
- 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
What is the intervention for DDH treatment for a neonate
Pavlik harness
What is the intervention for DDH for a 1-6 month old
Harness or Spica cast
What is the intervention for DDH in a 6-24 month old
CRIF or ORIF with Spica Cast
What is the intervention for DDH in a 24 mth -8year old
ORIF with spica cast or left alone
What is coxa varus
Angle between femoral shaft and neck less than 120 degrees
What is the normal femoral shaft/neck angle at birth
150 degrees
What is the typical femoral head/neck angle in the typical adult
120-130 degrees
What is the coxa vara angle
Less than 120 deg
What is coxa valgus angle
Greater than 135
Describe the femoral neck and proximal femoral physis/epiphysis in coxa vara
Femoral neck - more horizontal
Proximal femoral physis/ephysis - more vertical
What is slipped capital femoral epiphysis (SCFE)
Occurs when he growth plate of the proximal femur is weakened
What part of the femur is actually involved in SCFE
There is a superior and anterior displacement of the femoral shaft/neck
What is the most common hip problem in adolescence
SCFE
What are causes of SCFE
Growth plate weakness
Excessive force across growth plate
Femoral retroversion
growth plate obliquity
Testosterone and/or normal imbalance
What is the ideal view of x-ray for SCFE
Frog leg view
What is Klein’s line
The line along the superior aspect of the femoral neck
What is a normal Klein’s line
The superior border of the epiphysis projects superiorly to Klein’s line
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
What are the 3 classifications of SCFE
- Acute
- Acute-on-chronic
- Chronic
What is acute SCFE
Occurs immediately following significant trauma
What os Acute-on-chronic SCFE
Patient with c/o hip or knee pain prior to a traumatic incident
What is chronic SCFE
Child presents with h/o limp, pain
Decrease ROM —> hip abduction and hip IR
What is the most common classification of SCFE
chronic
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
Which ROM is increased in SCFE
Hip ER
Which ROM is decreased in SCFE
Hip abduction, hip IR
What motion strength is decreased in SCFE
Hip abduction strength
What is the surgical intervention for SCFE
Pinning in situ to prevent further epiphyseal displacement
What is femoral head-neck offset
The distance between lateral border of femoral head and neck less tan 8mm is abnormal
What are some complications of SCFE
Osteoarthritis —> decreased blood flow, AVN
Cartilage deterioration —> chondrolysis, degenerative joint disease
What is Legg-Calve-Perthes Disease
AVN of femoral head —> compromised medial femoral circumflex artery
What is the clinical picture for a LCP
-typically boys 4-10 years
Small stature
Active children
Bilateral in 10-20% of cases
Causes of LCP
Smaller arterial diameter
Reduced blood velocity
Reduced blood flow volume
Period of rapidly changing epiphyseal vascularity
Is Legg-Calve-Perthes self healing
Yes in 1-3 years
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
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
What is Herring Lateral Pillar Classification A
Normal height - good prognosis
What is Herring Lateral Pillar Classification B
50-100% of uninvolved height - fair prognosis
What is Herring Lateral Pillar Classification C
Less than 50% of uninvolved height - poor prognosis
What is the most common symptom of SCFE
Knee pain
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
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
What is the SCFE, the patient population, and imaging used
- femoral head malalignment relative to femoral neck
Adolescent - X-ray (CT, MRI)
What is the LCP, the patient population, and imaging used
Femoral head flattening with possible femoral neck broadening
- child
- X-ray (CT, MRi)
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
What is true length length inequality
> 2.5cm ie 1inch
How is true LLD diagnosed
Orthoradiography
Is hip/knee arthrosis likely with LLD
No
What is the anatomical effects of LLD
2-3 (abduction) femoral head uncovering occurs per 1 cm of increased LLI
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
What is the LLI treatment guidelines for <2cm
No treatment
Shoe lift
Heel-sole lift
What is he LLI treatment guideline for 2-5cm
Epiphysiodesis
Transphyseal screw implantation
Shortening procedure
What is he LLI treatment guideline for >5cm
Lengthening procedure
- osteotomy and distraction
- lengthening on nail (LON)
What is he LLI treatment guideline for >15-20cm
Staged lengthening
W/ epiphysiodesis
Amputation
Do you measure LLD correction while patient is lying down
No
How do you measure correction for LLD
Measure functionally
- patient standing
- Equal iliac crest heights
- Reduction in symptoms
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
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
Wha type of PT is occurring during latency phase of lengthening
- gait, WB training, pin care
Wha type of PT is occurring during distraction phase of lengthening
ROM and strengthening- all LE joints are at risk
Wha type of PT is occurring during consolidation phase of lengthening
Strengthening and tissue mobilization
1 months for every 1 cm of distraction
Wha type of PT is occurring during ex fix removal and healing phase of lengthening
Casted and HEP (home exercise program)
Wha type of PT is occurring during rehabilitation phase of lengthening
Aggressive stretching and functional training
What are the 5 phases of LLD lengthening
- Latency
- Distraction
- Consolidation
- Ex fix removal and healing
- Rehabilitation
What is the proximal focal femoral deficiency (PFFD)
Absence or hypoplasia of the proximal a femur
Varying involvement - acetabulum, femoral head, patella, tibia, fibula
How often is bilateral involvement with PFFD
15% bilateral
Describe the thigh and foot in PFFD
Shortened flexed thigh - hip/knee flexion contractures
Foot at “knee” level
What is the natural angular position of the the knees of a new born
Moderate genu varus
What is the natural angular position of the the knees of a 1.5-2 yo
Approximately straight
What is the natural angular position of the the knees of 2-4 yo
Genu valgus
What is the natural angular position of the the knees of a 5-7 yo
Legs straight - achieved adult alignment
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
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
What are the treatment options for Blount disease
- surgical correction via osteotomy
- conservative treatment
Is bracing effective for Blount disease
No, unloading is unsuccessful
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
What is rickets
Results from Vit D deficiency
What is Rickets characterized by
Decreased bone mineral density
Genu varus/valgum —> deformity of femur and/or tibia
How is vitamin D metabolized
Sun —> vitD3 —> liver; 25D —> kidney:125D
What form of vit d is responsible for absorption of. Calcium and ionic phosphate
125D
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
How much calcium can be absorbed at a time
500mg
What are some signs of rickets
- nodular enlargements on the ends of long bones**
- muscle pain
- enlargement of liver and spleen
- profuse sweating**
What is exercise induced compartment syndrome
Increased intramuscular pressure within a tight fascia compartment
- ischemia
- neurovascular compression
How is exercise induced compartment syndrome resolved
With rest
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
What are the common connective tissue diseases
- hypermobility spectrum disorders
- ehlers danlos syndrome
- Marfan syndrome
What is benign joint hypermobility syndrome?
Generalized joint laity with musculoskeletal complaints in the absence of a specific genetic, musculoskeletal or rheumatic disorder
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
What are some related musculoskeletal physical traits of hypermobility spectrum disorders
- peds planus
- valgus deformities
- scoliosis
- excessive thoracic kyphosis
- excessive lumbar lordosis
- deformational plagiocephaly
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
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
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
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
What is Ehlers Danlos Syndrome
A clinically and genetically heterogenous group of connective tissue disorders characterized by 3 classic signs
What are the 3 classic signs Ehlers Danlos Syndrome characterized by
- join hypermobility
- skin hyperextensivility
- tissue fragility
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
What are he methods of inheritance for EDS
Autosomal dominant inheritance
Autosomal recessive inheritance
What type of EDS cases are most common
Classic or hypermobility types (>90%)
What are he major criteria for classic EDS
- skin hyperextendibility and atrophic scarring
- generalized joint hypermobility
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
What are common complaints in HSD and EDS
- joint pain
- pain with handwriting
- joint hypermobility
- excessive fatigue
- hamstring tightness
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
What is Marfan Syndrome
A genetic CT disease resulting in musculoskeletal, cardiovascular, respiratory, opthalmologic and integumentary compromise
What is the major component contributing to CT structural integrity in Marfan syndrome
FBN1 gene - fibrillin-1
What is the diagnostic criteria for Marfan syndrome
Revised Ghent Criteria
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
What is pectus carinatum
Ghent criteria - external defrmation of chest
Pectus excavated
Ghent criteria internal deformity of chest
In torsional profiles, what contributes to static in toeing
- anteversion
- internal tibial torsion
- met adductus, club foot, pes cavus
In torsional profiles, what contributes to dynamic in toeing
Medial hamstring
Lateral Gastroc
In torsional profiles, what contributes to static outtoeing
Hip ER contracture
Retroversion (rare)
External tibial torsion
Calcaneoalgus
In torsional profiles, what contributes to dynamic out-toeing
Muscle tightness of lateral hamstring, and medial gastroc
What is pronation in open chain
Calc: eversion, AB, DF
What is supination in open chain
Calc: inversion, AD, PF
What is pronation in closed chain
Calc: eversion
Talar, AD, PF
What is supination in closed chain
Calc: inversion
Talar: AB, DF
What is the movement of the entire LE during closed chain pronation
Talar adducts
Tibia IR
Femur IR, ad
Patella lateral movement
What is the entire motion of the LE in closed chain supination
Talus abduction
Tibia ER
Femur ER, AB
Patella medial movement
Excessive pronation that isn’t manage can lead to
Medial instability
Medial balance loss
Valgus positioning
Hip IRAD
Patella pain syndrome
MCL, ACL injury
Excessive supination can lead to what
Lateral instabilty
Lateral balance loss
Varus positioning
LCL injury
Lateral ankle injury
