Test 2 Ortho Review Flashcards
What are 90% of osteogenesis imperfecta caused by?
defect in gene producing type I collagen
what are the physical findings of osteogenesis imperfecta
1) fragility of the entire skeleton
2) ligamentous laxity
3) changes in dentin and sclerae
Are there varying degrees of OI
yes
- bowing, fracture, scoliosis, pes panus, laxity of joints, deafness
What’s the treatment for osteogenesis imperfecta?
1) bracing to support joints
2) growth hormones
3) calcitonin
4) biphosphates
What are the nursing implications for OI?
- need to promote parent/baby bonding b/ they’re scared to hold the baby
- safety concerns with fragile musculoskeletal
What is the medical term for clubfoot
talipes equinovarus
when should treatment begin for talipes equinovarus?
- within the first week or two after birth
What can most infants with talipes equinovarus be treated with?
younger than 9 months then with serial casting
How often do you change plaster casts?
every 5-7 days
How many cast changes does clubfoot usually require?
5-8
what do 90% of patients experiencing talipes equinovarus require? what does this cause?
percutaneous tenotomy of the Achilles tendon? extra 3 weeks in cast
What is DDH?
developmental dysplasia of the hip: abnormal relationship between the acetabulum and femoral head #1 cause of pediatric lawsuits
What can DDH lead to?
poorly formed hips, abnormal gait pain, hip damage, and osteoarthritis
What are the S/S of DDH?
- uneven gluteal folds
- asymmetric hip abduction
- uneven knee heights
- waddling gait
How many bones are in the body?
206
What is bone matrix made out of?
calcium phosphate and collagen
What’s the difference between cortical and cancellous bone?
cortical: outside of bone, most of the mass, haversian systems connected by Volkman’s Canal
cancellous: spongy bone, highly vascularized, long bones, near joints, lots of bone marrows
What happens in the embryo musculoskeletal-wise on weeks... 3 4-5 6-7 8 9-12 13-20 20-40?
3rd: organogenesis, neural tubes form
4-5: limb buds develop
6-7: digits
8: digits separate, basic organ systems
9-12: first bone (clavicle) the skull ossify, upper limbs become proportionate but lower limbs remain short
13-20: rapid growth, lower limbs become proportionate, most bones ossify
20-40: growth continues, fetus looks more infant-like
What’s the first bone to ossify?
clavicle
are xrays useful in seeing cartilage at birth? what are ultrasounds indicated for?
- no
- hips
What is metatarsus adductus?
foot curved inwards in middle of the foot
What percent of metatarsus adductus cases occur bilaterally?
50%
Is metatarsus adductus equal incidence in m/f?
yes
Most cases of metatarsus adductus resolve by what age?
90% by 4 years of age
how do they treat metatarsus adductus?
- passive stretching
- casting
What should you check for in an infant with metatarsus adductus?
DDH and torticollis
is metatarsus adductus associated with long-term pain/debilitation?
no
What is calcaneovalgus foot?
- another packaging disorder where the foot is excessively flexed back and up (dorsiflexed hindfoot)
Can calcaneovalgus foot be passively corrected?
yes, improves by 2 months
Why would you perform an xray on a calcaneovalgus foot?
to rule out vertical talus
What else do you need to rule out with calcaneovalgus foot?
DDH, torticollis
What is VT?
vertical talus, dislocation of navicular on talus
- fixed hindfoot equinus
- midfoot dorsiflexion
- forefoot dorsiflexed and abducted
- very rigid
What are 50% of vertical talus cases associated with
- NM or genetic disorders like a) spina bifida b) arthrogryposis
does vertical talus correct itself?
no, poor prognosis if not surgically treated
What is tibial torsion?
inward twisting of the shin bones
What ages is tibial torsion common?
1-3 years old
What is the normal foot thigh angle?
0 to -15 degrees
Does tibial torsion resolv spontaneously?
yes, usually by age 6 so don’t need shoes/orthotic/PT
when do you need to perform surgery for tibial torsion?
if > -15 degrees after 6 yo
what is femoral anteversion?
twisting of proximal femur so soles of feet point out b/c of internal rotation
- greater than 70 degrees of internal rotation
- less than 20 degrees external rotation
- can typically W sit
Do you need surgery for femoral anteversion?
rarely, usually improves up until 10 yo
What is genu varum?
bowlegged (think you see curve out of legs and ovular space)
When is genu varum greatest and when does it resolve?
greatest at age 2 but resolves by age 3
In what types of children is genu varum more common?
- earlier walkers
What is Blount’s disease?
- a progressive pathologic illness of medial proximal tibial growth plate, different than just bowlegged
What is genu valgum?
- knock knees
When is genu valgum the greatest and by what age should i resolve?
greatest by age 3 (typically up to 20 degrees), should resolve by age 6 (normal is 12 degrees)
what is indicated if the genu valgum is severe, painful, or pathologic?
- hemiepiphysiodesis: clamps or staples are put into bone around growth plate
or - realignment osteotomy: bone cut or shaved for straightening
What are some pathos with similar presentations?
- skeletal dysplasias
- renal rickets
When does spina bifida usually occur in the embryo? why?
week 3 b/c neural tube fails to close
When someone has a “bad limb,” what is that called?
dysmelia, just means there’s some degree of deformity of that limg
Who is dysmelia more common in?
- males, lower extremities are 2x as affected, 80% cases involve single limbs
What is amelia? hemimelia? phocomelia?
amelia: entire limb missing
hemimelia: partial limb
phocomelia: “seal limb”
What drug in the 60s caused a high incidence of phocomelia?
thalidomide, was being used in pregnant women because of morning sickness
When would a dysmelia start to develop?
weeks 6-8 of embryo
What is syndactyly? polydactyly?
syndactyly: webbing of digits
polydactyly: extra digits
When would cleidocranial dysplasia start to develop?
9-12 week of embryo development
What are the physical findings of cleidocranial dysplasia?
- delayed fontanel closure
- frontal bossing
- absence of clavicles
- abnormal dentition
- short stature
- anterior pelvis fails to close
What is cleidocranial dysplasia?
- usually have underdeveloped clavicle bones and so shoulders are shrugged in, also dentition problems
What is the medical term for clubfeet
talipes equinovarus
Are m/f more likely to be born with talipes equinovarus?
- boys 2x more likely
Are most cases bilateral for talipes equinovarus?
it’s even 50%
is talipes equinovarus associated with position in womb? can it be seen on ultrasound?
no, yes
when should treatment for talipes equinovarus be started?
- should start quickly, within the first week or two after birth
what is treatment for talipes equinovarus?
- most infants younger than 9 months can be successfully treated with serial casting
What type of serial casting is used for talipes equinovarus?
ponseti casting: plaster casts changed q5-7days; usually 5-8 casts total
What do 90% of patients with talipes equinovarus require? 10%?
- percutaneous tenotomy of the Achilles tendon which causes an extra 3 weeks in cast; 10% need tendon transfer
After a tenotomy in treating talipes equinovarus, what device is worn/used by the patient? How long must it be worn?
- the Denis-Brown Bar: until 9 months it’s worn 23 hrs/day and off for one hour to shower
- then from 9-18 months worn during nights and naps
What are the three nursing implication for treating clubfoot/talipes equinovarus?
1) educate to reduce anxiety
2) allow for bonding experiences
- bathing in-between cast removal
- hold/feed infant without casts
- decorate casts
3) cast care
- never get casts wet
- monitor for color/temp changes suggesting it’s too tight
- peet can slip in casts, parents should always be able to visualize toes and check cap refill
- wound care for minor skin breakdown
What are the two types of hip dysplasia?
1) developmental (DDH)
2) neuromuscular
What is DDH caused by? how prevalent?
DDH = developmental dysplasia of the hips
- abnormal relationship between the acetabulum and femoral head
- 1/1000
What are the risk factors for DDH?
- females > males
- breech position in last 4 weeks of pregnancy
- family hx
- oligohydramnios
What can DDH lead to?
- poorly formed hips
- abnormal gait
- pain
- hip damage
- osteoarthritis
what are the degrees of hip dysplasia?
1) dysplasia - mild, femoral head sits in shallow acetabulum
2) subluxation - moderate, incomplete dislocation
3) dislocation - severe, femoral head located outside acetabulum
hip dysplasia is the #1 cause of what?
pediatric lawsuits
What maneuver is used to test for hip dysplasia? When is this performed?
performed in infants less than 3 months old
- 1st perform the Barlow sign where the legs are bent to 90 degrees and brought to the midline then pushed posteriorly (dislocation of the femoral head from the acetabulum can be palpated if Barlow sign is positive)
- 2nd perform the Ortolani sign where the legs are abducted and thighs pushed anteriorly, if a click is heard the Ortalani sign is positive and the femoral head has clicked back into the socket
- > nonspecific findings
- > each hip done one at a time
If the client is greater than 3 months old, what can help indicate hip dysplasia upon physical exam?
- uneven gluteal skin folds
- asymmetric hip abduction (dislocated hip will not abduct)
- uneven knee heights (dislocated hip has shorter leg)
- waddling gait (dislocated hip causes uneven weight distribution)
What sort of imaging is used for DDH?
- if less than 4 months, do an ultrasound
- if greater than 4 months, do xray with an AP or frogleg view
What treatments are used for DDH?
1) if less than 6 months old and with reducible hips: Palvik harness - worn full time for 6 weeks
2) 6-18 months old: closed reduction with spica cast for 6 weeks
3) greater than 18 months or failed closed reduction
- open reduction with adductortenotomy and arthrogram
- spica cast for 6 weeks then cast change in OR with repeat arthrogram (total time in spica will be 12 weeks)
what happens in neuromuscular hip dysplasia?
- teratogenic dislocation occurs during 1st trimester r/t neuromuscular disease
ex: spina bifida, arthrogryposis - spasticity or increased muscle tension can sublux or dislocate hip over time (hips become painful and daily care like bathing/diaper changes is difficult)
What are surgical interventions for neuromuscular hip dysplasia (I think also hip dysplasia in general)?
1) femoral varus osteotomy
2) haas osteotomy
What is Legg-Calve-Perthes?
- damage to blood supply of femoral head
How long does it take to recover from Legg-Calve-Perthes?
- bone dies then grows back over two years
How does Legg-Calve-Perthes usually present/in what patient population?
boys 4-8 yo, unilateral
How do we treat Legg-Calve-Perthes?
NSAIDS, physical therapy, bracing
do most Perthes patients require surgery?
no, 60% do not
how long do patients with Perthes wear a brace?
wear abduction brace 20+ hours/day for years
what do 50% of Perthes patients develop? when does this usually present?
develop osteoarthritis in the 5th or 6th decade of life
What is damaged in a slipped capital femoral (SCFE) epiphysis?
- growth plate (can occur chronically or acutely)
What is the single greatest risk factor for a slipped capital femoral epiphysis? what are some others?
- single greatest: obesity others - males, african-american, PI - 12 yo girl or 13 yo boy - left hip most common - bilateral in 17-50%
What surgery is used for a SCFE?
- in situ pinning to stabilize epiphysis though sometimes prophylactic pinning of contralateral side is performed
is reduction used for an SCFE?
- controversial b/c high risk of avascular necrosis THOUGH may be warranted if large slip
What are the three types of scoliosis?
1) congenital
2) neuromuscular
3) idiopathic
How does the spine develop in scoliosis?
- born with C shaped spine which becomes S shaped with ambulation
What are the three treatment options for scoliosis?
1) observe (450)
What is VEPTR? hemivertebrae?
- verticle expandable prosthetic titanium rib, used to treat thoracic insufficiency syndrome or types of scoliosis that obstruct breathing
- hemivertebrae is where one half of the vertebral body doesn’t form for whichever reasons and this causes the spine to curve
What are the three types of idiopathic scoliosis?
- infantile:
What test is performed upon physical examination of idiopathic scoliosis and what does this determine?
the Adam’s test or forward bending test: as the patient to bend over forward and let arms dangle….if there is a large prominence on one side then the scoliosis is STRUCTURAL; if the posterior thorax displays symmetry then the scoliosis is considered FUNCTIONAL
What device is used to correct severe scoliosis?
halo traction
What are two examples of idiopathic scoliosis treatment?
- Boston Brace (TLSO) - the TLSO is for both the lumbar and thoracic regions whereas the LSO is just for the lower lumbar region
- posterior spinal fusion
What are the 5 types of sports injuries we studied?
1) Little league elbow - compression fracture of lateral elbow
2) Osgood Schlatters - irritation of growth plate behind tibial tubercle caused by repetitive stress
3) Severes disease - calcaneal growth plate irritation exacerbated by tight Achilles tendon
4) shin splints
5) spondylolysis/spondylolisthesis - types of low back pain
What are the two types of little league elbow?
1) in older patients: usually ulnar collateral ligaments are injured
2) in younger patients: often an injury to the epicondyle apophysitis or avulsion injury
What types of treatments are for little league elbow?
- rest
- limit movement/throwing
- PT
- surgery
In what groups do we often see Osgood-Shlatters Disease?
- jumpers and sprinters
What types of treatment is there for Osgood-Schlatters Disease?
- ice
- rest
- PT
- NSAIDS
- if severe, then cast x 6 weeks
Until when will Osgood-Schlatters likely persist until?
- will persist intermittently until growth plate is closed which happens between 14-18 yo
What types of treatment is there for Severe’s Disease?
- ice
- rest
- PT to stretch Achilles
- proper foot wear
- NSAIDS
- gel heel pad inserts in shoe
- cast if severe
Until when will Severe’s Disease persist?
- like other apophysises, will remain a problem until growth is complete
What are the risk factors for shin splints?
- running on hard surfaces like cement
- 20+ miles a week
- hill training when not in shape/deconditioned
What do you need to rule out before diagnosing a shin splint?
stress fracture
are shin splints more common in males or females?
females
What types of treatment is used for shin splints?
- activity and shoe modification
- PT
- phonophoresis
- corticosteroids
What is spondylolysis?
It’scaused by an anatomic malformation or defect of the pars interarticularis which is a bone that connects to the back of vertebrae and holes them in place; the defect is not present at birth but develops over time and caused improper shaping of the spine
What’s something that can lead to spondylolysis?
- repetitive hyperextension so we see it in gymnasts, weightlifters, football linemen
What can caused pain in a pt with spondylolysis?
- movements of minimal hyperextension or lateral flexion
What is spondylolistheis?
- it’s unstable spondylolysis where the spinal disk slip (usually anteriorly)
What are the most common vertebrae to slip in a pediatric patient with spondylolisthesis?
L5-S1
how many cases of spondylolysis develop a slip?
15%
Spondylolisthesis is likely to progress if the slip angle is greater than what?
50%
What sort of symptoms does spondylolisthesis in particular produce?
- neuro symptoms
- radicular symptoms like sciatica from nerve root compression
- tight hamstrings or spasms
What is the treatment for spondylolisthesis
- PT and lumbar brace 6-12 weeks
