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Pediatric Orthopedics > Peds Orthopedic Disorders > Flashcards

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
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2
Q

What is the peds skeletal difference in callus formation

A

Periosteum - thicker, stronger, more osteogenic
- increased vascularity

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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)
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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)
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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
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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)
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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)
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8
Q

What is the gold standard for diagnosing DDH

A

Diagnostic ultrasound

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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

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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

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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

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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

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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
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14
Q

What is the intervention for DDH treatment for a neonate

A

Pavlik harness

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15
Q

What is the intervention for DDH for a 1-6 month old

A

Harness or Spica cast

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16
Q

What is the intervention for DDH in a 6-24 month old

A

CRIF or ORIF with Spica Cast

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17
Q

What is the intervention for DDH in a 24 mth -8year old

A

ORIF with spica cast or left alone

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18
Q

What is coxa varus

A

Angle between femoral shaft and neck less than 120 degrees

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19
Q

What is the normal femoral shaft/neck angle at birth

A

150 degrees

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20
Q

What is the typical femoral head/neck angle in the typical adult

A

120-130 degrees

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21
Q

What is the coxa vara angle

A

Less than 120 deg

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22
Q

What is coxa valgus angle

A

Greater than 135

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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

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24
Q

What is slipped capital femoral epiphysis (SCFE)

A

Occurs when he growth plate of the proximal femur is weakened

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25
Q

What part of the femur is actually involved in SCFE

A

There is a superior and anterior displacement of the femoral shaft/neck

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26
Q

What is the most common hip problem in adolescence

A

SCFE

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27
Q

What are causes of SCFE

A

Growth plate weakness
Excessive force across growth plate
Femoral retroversion
growth plate obliquity
Testosterone and/or normal imbalance

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28
Q

What is the ideal view of x-ray for SCFE

A

Frog leg view

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29
Q

What is Klein’s line

A

The line along the superior aspect of the femoral neck

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30
Q

What is a normal Klein’s line

A

The superior border of the epiphysis projects superiorly to Klein’s line

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31
Q

What is an abnormal Klein’s line and what does it mean

A

The superior border of the epiphysis lies on Klein’s line, more advanced cases, the epiphysis projects inferiorly to it
Means SCFE

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32
Q

What are the 3 classifications of SCFE

A
  • Acute
  • Acute-on-chronic
  • Chronic
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33
Q

What is acute SCFE

A

Occurs immediately following significant trauma

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34
Q

What os Acute-on-chronic SCFE

A

Patient with c/o hip or knee pain prior to a traumatic incident

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35
Q

What is chronic SCFE

A

Child presents with h/o limp, pain
Decrease ROM —> hip abduction and hip IR

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36
Q

What is the most common classification of SCFE

A

chronic

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37
Q

What are the grades of SCFE

A

-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

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38
Q

Which ROM is increased in SCFE

A

Hip ER

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39
Q

Which ROM is decreased in SCFE

A

Hip abduction, hip IR

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40
Q

What motion strength is decreased in SCFE

A

Hip abduction strength

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41
Q

What is the surgical intervention for SCFE

A

Pinning in situ to prevent further epiphyseal displacement

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42
Q

What is femoral head-neck offset

A

The distance between lateral border of femoral head and neck less tan 8mm is abnormal

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43
Q

What are some complications of SCFE

A

Osteoarthritis —> decreased blood flow, AVN
Cartilage deterioration —> chondrolysis, degenerative joint disease

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44
Q

What is Legg-Calve-Perthes Disease

A

AVN of femoral head —> compromised medial femoral circumflex artery

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45
Q

What is the clinical picture for a LCP

A

-typically boys 4-10 years
Small stature
Active children
Bilateral in 10-20% of cases

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46
Q

Causes of LCP

A

Smaller arterial diameter
Reduced blood velocity
Reduced blood flow volume
Period of rapidly changing epiphyseal vascularity

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47
Q

Is Legg-Calve-Perthes self healing

A

Yes in 1-3 years

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48
Q

What determines the prognosis of LCP

A
  • 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
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49
Q

What is herring lateral pillar classification

A

Femoral head deformity
Comparing the height of lateral 1/3 of the proximal femoral epiphysis
During the fragmentation stage

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50
Q

What is Herring Lateral Pillar Classification A

A

Normal height - good prognosis

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51
Q

What is Herring Lateral Pillar Classification B

A

50-100% of uninvolved height - fair prognosis

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52
Q

What is Herring Lateral Pillar Classification C

A

Less than 50% of uninvolved height - poor prognosis

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53
Q

What is the most common symptom of SCFE

A

Knee pain

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54
Q

What is the clinical sign of LCP

A
  • Trendelenburg**
  • decreased ROM of him AB and IR
  • decreased MMT hip AB
  • hip AD, flexor muscle spasm
  • Limp
  • pain groin, hip, knee
55
Q

What is Shriner’s protocol for LCP

A
  • Adductor tenotomy to achieve 35-40 deg abduction from casting
  • 6 weeks Petrie casting
  • A-frame orthosis
  • Hip ROM
  • 93% good hip congruency
56
Q

What is the SCFE, the patient population, and imaging used

A
  • femoral head malalignment relative to femoral neck
    Adolescent
  • X-ray (CT, MRI)
57
Q

What is the LCP, the patient population, and imaging used

A

Femoral head flattening with possible femoral neck broadening
- child
- X-ray (CT, MRi)

58
Q

What is DDH, the patient population, and imaging used

A

Displacement of femoral head and neck relative to acetabulum
Infant
Ultrasound less than 6 mths, X-ray greater than 6 mths

59
Q

What is true length length inequality

A

> 2.5cm ie 1inch

60
Q

How is true LLD diagnosed

A

Orthoradiography

61
Q

Is hip/knee arthrosis likely with LLD

A

No

62
Q

What is the anatomical effects of LLD

A

2-3 (abduction) femoral head uncovering occurs per 1 cm of increased LLI

63
Q

What are the functional effects of LLD

A
  • 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
Q

What is the LLI treatment guidelines for <2cm

A

No treatment
Shoe lift
Heel-sole lift

65
Q

What is he LLI treatment guideline for 2-5cm

A

Epiphysiodesis
Transphyseal screw implantation
Shortening procedure

66
Q

What is he LLI treatment guideline for >5cm

A

Lengthening procedure
- osteotomy and distraction
- lengthening on nail (LON)

67
Q

What is he LLI treatment guideline for >15-20cm

A

Staged lengthening
W/ epiphysiodesis
Amputation

68
Q

Do you measure LLD correction while patient is lying down

A

No

69
Q

How do you measure correction for LLD

A

Measure functionally
- patient standing
- Equal iliac crest heights
- Reduction in symptoms

70
Q

What are the 5 biologic principle and law of tension stress

A
  • 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
Q

What are some consideration of ex fix placement

A
  • 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
Q

Wha type of PT is occurring during latency phase of lengthening

A
  • gait, WB training, pin care
73
Q

Wha type of PT is occurring during distraction phase of lengthening

A

ROM and strengthening- all LE joints are at risk

74
Q

Wha type of PT is occurring during consolidation phase of lengthening

A

Strengthening and tissue mobilization
1 months for every 1 cm of distraction

75
Q

Wha type of PT is occurring during ex fix removal and healing phase of lengthening

A

Casted and HEP (home exercise program)

76
Q

Wha type of PT is occurring during rehabilitation phase of lengthening

A

Aggressive stretching and functional training

77
Q

What are the 5 phases of LLD lengthening

A
  1. Latency
  2. Distraction
  3. Consolidation
  4. Ex fix removal and healing
  5. Rehabilitation
78
Q

What is the proximal focal femoral deficiency (PFFD)

A

Absence or hypoplasia of the proximal a femur
Varying involvement - acetabulum, femoral head, patella, tibia, fibula

79
Q

How often is bilateral involvement with PFFD

A

15% bilateral

80
Q

Describe the thigh and foot in PFFD

A

Shortened flexed thigh - hip/knee flexion contractures
Foot at “knee” level

81
Q

What is the natural angular position of the the knees of a new born

A

Moderate genu varus

82
Q

What is the natural angular position of the the knees of a 1.5-2 yo

A

Approximately straight

83
Q

What is the natural angular position of the the knees of 2-4 yo

A

Genu valgus

84
Q

What is the natural angular position of the the knees of a 5-7 yo

A

Legs straight - achieved adult alignment

85
Q

What is Blount disease

A

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
Q

Describe Blount radiographic features

A
  • 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
Q

What are the treatment options for Blount disease

A
  • surgical correction via osteotomy
  • conservative treatment
88
Q

Is bracing effective for Blount disease

A

No, unloading is unsuccessful

89
Q

What are some complications of LLI and Blount

A

Malalignment
- deformity
- poor axis of movement
Physis and normal growth interruption
- angular deformities
- LLI
Overgrowth
- LLI
Recurrent fracture

90
Q

What is rickets

A

Results from Vit D deficiency

91
Q

What is Rickets characterized by

A

Decreased bone mineral density
Genu varus/valgum —> deformity of femur and/or tibia

92
Q

How is vitamin D metabolized

A

Sun —> vitD3 —> liver; 25D —> kidney:125D

93
Q

What form of vit d is responsible for absorption of. Calcium and ionic phosphate

A

125D

94
Q

Difference between vit D3 and D2

A

D3 = cholecalciferol, more effective form resulting in higher circulating levels of 25D
D2 - ergocalciferol - typical form found in supplements

95
Q

How much calcium can be absorbed at a time

A

500mg

96
Q

What are some signs of rickets

A
  • nodular enlargements on the ends of long bones**
  • muscle pain
  • enlargement of liver and spleen
  • profuse sweating**
97
Q

What is exercise induced compartment syndrome

A

Increased intramuscular pressure within a tight fascia compartment
- ischemia
- neurovascular compression

98
Q

How is exercise induced compartment syndrome resolved

A

With rest

99
Q

What are the clinical signs off compartment syndrome

A

Lower leg pain
Parasethesia in the lower leg and foot
Tightness in lower leg tissue
Shiny skin and hair loss

100
Q

What are the common connective tissue diseases

A
  • hypermobility spectrum disorders
  • ehlers danlos syndrome
  • Marfan syndrome
101
Q

What is benign joint hypermobility syndrome?

A

Generalized joint laity with musculoskeletal complaints in the absence of a specific genetic, musculoskeletal or rheumatic disorder

102
Q

What are the 3 clinical groups of hypermobility spectrum disorders

A
  • asymptomatic joint hypermobility
  • specifically defined syndrome that includes joint hypermobility
  • symptomatic joint hypermobility not meeting diagnostic criteria for a specific syndrome
103
Q

What are some related musculoskeletal physical traits of hypermobility spectrum disorders

A
  • peds planus
  • valgus deformities
  • scoliosis
  • excessive thoracic kyphosis
  • excessive lumbar lordosis
  • deformational plagiocephaly
104
Q

What is the least to greatest symptomatic involvement for hypermobility spectrum disorder

A

As-LJH
As-PJH
As-GJH
L-HSD
P-HSD
G-HSD
HEDS
H-HSD

105
Q

What is a positive score for Brighton criteria for joint hypermobility

A

2 major
1 major + 1 minor
4 minor
2 minor + a confirmed 1st degree relative

106
Q

What are the major points for Brighton’s criteria for joint hypermobility

A
  • Brighton score 4/9 or more
  • joint pain >3 months in 4 or more joints
107
Q

What are some minor scores for brighton criteria for joint hypermobility

A
  • 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
Q

What is Ehlers Danlos Syndrome

A

A clinically and genetically heterogenous group of connective tissue disorders characterized by 3 classic signs

109
Q

What are the 3 classic signs Ehlers Danlos Syndrome characterized by

A
  • join hypermobility
  • skin hyperextensivility
  • tissue fragility
110
Q

How do the mutations in genes contribute to Ehlers Danlos Syndrome

A

All contribute to the processing, production and structure of fibrillation collagen proteins responsible for connective tissue structural integrity

111
Q

What are he methods of inheritance for EDS

A

Autosomal dominant inheritance
Autosomal recessive inheritance

112
Q

What type of EDS cases are most common

A

Classic or hypermobility types (>90%)

113
Q

What are he major criteria for classic EDS

A
  • skin hyperextendibility and atrophic scarring
  • generalized joint hypermobility
114
Q

What are the clinical criterion for skin hyperextensibility

A

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
Q

What are common complaints in HSD and EDS

A
  • joint pain
  • pain with handwriting
  • joint hypermobility
  • excessive fatigue
  • hamstring tightness
116
Q

What are some joint protection- neutral alignment for EDS

A
  • no standing on Y ligaments
  • limited hip IR
  • no genu recurvatum
  • control of pes planus
  • no shoulder/hip tricks
  • no elbow hyperextension
117
Q

What is Marfan Syndrome

A

A genetic CT disease resulting in musculoskeletal, cardiovascular, respiratory, opthalmologic and integumentary compromise

118
Q

What is the major component contributing to CT structural integrity in Marfan syndrome

A

FBN1 gene - fibrillin-1

119
Q

What is the diagnostic criteria for Marfan syndrome

A

Revised Ghent Criteria

120
Q

What is wrist and thumb sign

A

Ghent criteria - can take thumb and cross around palm and closed finger, thumb extends out
Wrapt pink and thumb around wrist

121
Q

What is pectus carinatum

A

Ghent criteria - external defrmation of chest

122
Q

Pectus excavated

A

Ghent criteria internal deformity of chest

123
Q

In torsional profiles, what contributes to static in toeing

A
  • anteversion
  • internal tibial torsion
  • met adductus, club foot, pes cavus
124
Q

In torsional profiles, what contributes to dynamic in toeing

A

Medial hamstring
Lateral Gastroc

125
Q

In torsional profiles, what contributes to static outtoeing

A

Hip ER contracture
Retroversion (rare)
External tibial torsion
Calcaneoalgus

126
Q

In torsional profiles, what contributes to dynamic out-toeing

A

Muscle tightness of lateral hamstring, and medial gastroc

127
Q

What is pronation in open chain

A

Calc: eversion, AB, DF

128
Q

What is supination in open chain

A

Calc: inversion, AD, PF

129
Q

What is pronation in closed chain

A

Calc: eversion
Talar, AD, PF

130
Q

What is supination in closed chain

A

Calc: inversion
Talar: AB, DF

131
Q

What is the movement of the entire LE during closed chain pronation

A

Talar adducts
Tibia IR
Femur IR, ad
Patella lateral movement

132
Q

What is the entire motion of the LE in closed chain supination

A

Talus abduction
Tibia ER
Femur ER, AB
Patella medial movement

133
Q

Excessive pronation that isn’t manage can lead to

A

Medial instability
Medial balance loss
Valgus positioning
Hip IRAD
Patella pain syndrome
MCL, ACL injury

134
Q

Excessive supination can lead to what

A

Lateral instabilty
Lateral balance loss
Varus positioning
LCL injury
Lateral ankle injury

Pediatric Orthopedics (18 decks)

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