Tiffany's Peds Cards Flashcards
Achondroplasia gene
FGFR-3, autosomal dominant
Pseudoachondroplasia gene
COMP, autosomal dominant
Multiple epiphyseal dysplasia (MED) genes
COMP, COL9A, autosomal dominant
Spondyloepiphyseal dysplasia (SED) gene
COL2A1,
Congenita - autosomal dominant
Tarda - X-linked recessive
Kniest dysplasia gene
COL2A, autosomal dominant
Apert syndrome gene
FGFR-2, autosomal dominant
Charcot Marie Tooth gene
PMP22, autosomal dominant
Marfan gene
Fibrillin-1 (FBN1), autosomal dominant
Multiple hereditary exostosis (MHE) gene
EXT, autosomal dominant
Neurofibromatosis gene
NF1, autosomal dominant
Osteogenesis imperfecta type gene
COL1A1 and COL1A2
Types 1+4 - autosomal dominant
Types 2+3 - autosomal recessive
Ehlers-Danlos gene
COL5A - found in 40%, autosomal dominant
Other gene involved, but COL5A is for the classic type
Diastrophic dysplasia gene
DTD, sulfate transport gene, autosomal recessive
Friedreich’s ataxia gene
Frataxin, autosomal recessive
Gaucher disease gene
B-glucocerebrosidase deficiency, autosomal recessive
Spinal muscular atrophy gene
SMN, autosomal recessive
Vitamin D resistant (familial hypophosphatemic) rickets gene
PHEX gene, X-linked dominant
Becker’s muscular dystrophy gene
dystrophin, X-linked recessive
Duchenne muscular dystrophy gene
dystrophin, X-linked recessive
Hunter syndrome gene
Sulpho-iduronate-sulphatase, autosomal recessive
Hurler syndrome
Alpha-L iduronidase, autosomal recessive
At what age does puberty start, reach peak growth velocity + finish? What physeal closure marks peak velocity?
Girls 10 - 12 - 14
Boys 12 - 14 - 16
Peak growth velocity marked by olecranon closure*
*RC question
When does the triradiate cartilage close?
Midway during ascending phase of puberty
RC: What corresponds to peak growth velocity?
A. Closure of olecranon apophysis
B. Risser 1
C. Closure of triradiate
D. Menarche
Answer: A
List methods of estimating bone age (3)
- L hand XR - radiographic atlas of hand + wrist by Greulich + Pyle
- Sauvegrain method - elbow ossification
- Risser
What is the definition of skeletal maturity? (3)
- Risser 4
- <1cm height growth over 6mo
- 2yrs post menarche
What is the Risser classification?
Describes stages of iliac apophysis ossification. Useful for assessing spine bone age as the spine matures later than limbs. Ossifies from lateral to medial
1. 25%. Early spine puberty
2. 50%. Spine max velocity
3. 75%. Slowing spine growth
4. 100%. Slowing spine growth
5. Iliac apophysis fused to iliac crest. Growth finished
Describe how knee varus/valgus changes during childhood
Max varum at birth, becomes peak valgum by 3yo. Normalizes at 5yo to 5deg valgum
List the zones in the physis
Epiphysis
Reserve zone
Proliferative
Hypertrophic zone - subdivided into maturation, degenerative, provisional calcification
Metaphysis
RC question
Describe the percentage growth contributed by each physis to each bone
What pathologies are associated w the zone of provisional calcification?
Rickets/osteomalacia, hypophosphatasia
What pathologies are associated w the reserve zone of the physis?
Gaucher, diastrophic dysplasia, Kneist
What pathologies are associated w the proliferative zone of the physis?
Achondroplasia, MHE, gigantism
What pathologies are associated w the hypertrophic zone of the physis
SCFE, rickets, hypophosphatasia, enchondromas, mucopolysaccharide, fractures
What is the Heuter-Volkman law?
Compression across physis slows growth. Tension accelerates growth
Name some pediatric milestones
4mo - good head control
8mo - sits independently
10 - crawls
12 - walks independently. Must walk by 18mo!
% of #s due to NAT?
% of #s due to NAT
90% occur <5yo
50% <1yo
30% <3yo
Most common presentation of NAT?
Skin lesions
Most common #s in NAT?
Humerus > tibia > femur
Risk factors of NAT?
Child-related: 1st born, unplanned pregnancy, premature, disability, step-child
Parent-related: single parent, recent stressor, unemployed, drug use, personal hx of abuse as child, low socioeconomic status, lack of social support
DDx of NAT?
True accident, OI, osteopenia of prematurity, disuse osteopenia, kidney disease, liver disease
Red flags when suspecting NAT (4)
- Delay in seeking care
- Inconsistent hx
- Long bone # in nonambulatory kid
- Specific # types (later slide)
What are some # types associated with NAT?
s at metaphysis/physis junction
Corner #s
Bucket handle #s
Epiphyseal separations - esp distal humerus
What imaging do you need to order for NAT W/U?
Suspected bone XR
Skeletal survey or bone scan
What is the difference between skeletal survey XR for NAT and dysplasia?
Dysplasia - skull, spine, chest, pelvis, one side of arm, one side of legs
NAT - all of above, but need both sides of arms + legs
When suspect NAT, what must you do?
Admit for multidisciplinary evaluation
Appropriate imaging
Consult CPS + social service
Treat injury
What is congenital pseudarthrosis of the clavicle? Treatment?
Congenital failure of fusion between medial + lateral ossification centers. Due to subclavian artery compression. Sometimes mistaken for NAT
Nonop - if asymptomatic
ORIF w iliac crest bone graft if pain, impaired fxn or cosmesis
50% of pediatric septic hip is before what age?
2yo
Risk factors for neonatal septic hip? (2)
C-section
Prematurity
Routes of inoculation for septic hip? (3)
Direct trauma
Hematogenous
Extension from tissue
Describe the blood supply to the hip before 4yo (3)
- Ligamentum teres - posterior branch of obturator art
- Circumflexes
- Transphyseal metaphyseal branches (disappear between 4-17yo, then reappear)
What joints have intracapsular metaphyses? (4)
- Shoulder
- Elbow
- Hip
- Ankle
NOT KNEE
DDx of hip pain in kids of all ages? (6)
OM/septic hip
DDH
SCFE
Perthes
Psoas abscess
Transient synovitis
RC: 7yo presents w 5wk history of painless limp. On exam, he has decreased abduction and internal rotation. There is a trendelenburg gait. What is the diagnosis?
A. DDH
B. JRA
C. Transient synovitis
D. Perthes
Answer: D (Perthes)
DDH would not be acute
JRA and transient synovitis would be painful
Indicators of poor prognosis in pediatric septic joints? (4)
Age <6mo
Associated OM
Hip (instead of knee)
Delayed presentation >4d
What are the longterm sequelae of pediatric septic hip?
AVN
Physeal arrest - LLD, angular deformity
Physical exam findings in pediatric septic hip?
Refusal to WB
FABER position
Pseudoparalysis
Most common organisms in pediatric septic hip? (5)
GBS, GAS, S. aureus, N. gonorrhea, K. kingae
Most common organisms in neonatal septic hip? (2)
GBS - community acquired
S. aureus - nosocomial
Most common organism in pediatric septic hip >2yo?
S. aureus
Most common organisms in adolescent septic hip? (2)
S. aureus, gonorrhea
What are the signs and treatment of gonorrhea septic hip?
Migratory polyarthritis, red papules
Tx - penicillin alone. Don’t need I+D
What is the Kocher criteria? (4)
Fever >38.5
ESR >40
WBC >12
Unable to WB
All criteria met - 99% likely septic hip
3/4 - 93%
2/4 - 40%
CRP >2 is not apart of Kocher criteria. Independent risk factor of 74% probability
Pediatric septic hip - what is the order of sensitivity of the following factors - fever, WB status, ESR, CRP, WBC?
Fever > CRP > ESR > NWB > WBC
Findings on native joint aspiration that suggest infection?
> 50k cells w >75% PMNs
Approach to I+D native septic hip?
Bikini incision - Smith Pete approach
MRSA infections are associated w what complications?
DVT + septic emboli
What part of the bone is most susceptible to osteomyelitis?
Metaphysis. Slow flow in metaphyseal vessels due to sharp turns. Time for bacteria to lodge
Which joints are at risk of septic infection from OM? (4)
Shoulder, elbow, hip, ankle. NOT knee
What are the bone findings in chronic OM?
Periosteal elevation from abscess
Sequestrum - necrotic bone
Involucrum - outer layer of new bone
What is the most sensitive image modality to detect OM?
MRI w gadolinium
Which biochemical marker is best for monitoring treatment response in OM?
CRP
Elevated within 6hrs of infection. Decreases rapidly w treatment. Normal in a week
If doesn’t decrease after 48h, reconsider treatment
(ESRP peaks in 3d but decreases too slowly to guide tx)
RC: What is true regarding osteomyelitis?
A. High CRP >20 has a LOW sensitivity
B. High WBC has LOW sensitivity
C. Radiographs are appropriate for diagnosis
D. Bone scan is useful to follow long term
Answer: B
CRP is the most sensitive test. WBC is the least. XR is not the best for diagnosing OM because it takes weeks for changes to be seen. Secondly, in patients w neuro-arthropathy or Charcot, XR findings look similar.
RC: In the setting of chronic osteomyelitis that has malignant transformation, what is most true?
A. Wide excision reconstruction is preferred to amputation
B. Most commonly metastasize to lungs
C. Clinical presentation often involves worsening purulence, foul smell and drainage
D. Marjolin’s tumor does not commonly transform in squamous cell
Answer: C
Marjolin’s tumor classically results from aggressive squamous cell. Think of this whenever there is a chronic ulcer. Need a biopsy to confirm malignancy. Most common site of mets are lymph nodes. Most common clinical features are pain, foul smell and drainage. Best treatment is amputation. Can consider reconstruction if distal and non-metastatic. No evidence that reconstruction does better than amputation.
Indications for antibiotics alone for OM treatment?
Early disease
No subperiosteal or bone abscess
Improvement w antibiotics within 48H - follow CRP
Indications for I+D in OM?
Bone or subperiosteal abscess
Failure to respond to abx
Chronic infection
Technique - debride devitalized tissue, drill into intraosseous collections + remove sequestrum. Send for cx + bx
RC: In pediatric patients undergoing biopsy, when should samples also be sent for anaerobes, acid-fast bacilli and fungus?
A. All patients
B. Osteomyelitis w associated septic arthritis
C. Osteomyelitis following a penetrating injury
Answer: C
Always send for pathology and aerobic culture. Anaerobe, acid-fast and fungus should also be sent for
- Failed primary treatment (Failed initial abx tx?)
- immunocompromised
- Penetrating wounds
RC: A previously healthy kid presents w pain to the mid tibia w a fever a elevated ESR. Found to have MRSA tibial osteomyelitis. The child comes from an area w a high prevalence of MRSA. What is the best antibiotic?
A. Cefazolin
B. Rifampin
C. TMP-SMX
D. Clindamycin
Answer: D (clindamycin)
Antibiotics for serious MRSA: vancomycin, daptomycin, linezolid
Antibiotics for stable MRSA: clindamycin
2016
What is chronic recurrent multifocal osteomyelitis? Diagnostic criteria? (3)
Idiopathic inflammatory disease
1. Multiple sites of apparent OM
2. Pathology + culture neg
3. No response to antibiotics
What is the prognosis and treatment of chronic recurrent multifocal osteomyelitis?
Comes + goes, resolves in 3yrs. Treatment - NSAIDs + pamidronate, as per Rheum. Rarely causes growth disturbance
RC: You are seeing a patient that has a diagnosis of chronic recurrent multifocal osteomyelitis. What is the ideal plan regarding treatment?
A. Biopsy and cultures are negative in this condition and should be treated according to rheumatology
B. Arrange for percutaneous or open biopsy followed by antibiotics
C. Admit to hospital for 6wks for broad spectrum IV antibiotics
D. Can become a Brodie’s abscess
Answer: A
RC: What is true regarding chronic recurrent multifocal osteomyelitis?
A. After core biopsy, it is best treated w I+D, followed by antibiotics
B. Bone scan is needed in the workup
C. It is an inflammatory condition that behaves like osteomyelitis but has sterile cultures
Answer: C
Inflammatory process, don’t treat w antibiotics. Treat w NSAIDs and pamidronate. A bone scan can determine other sites but is not necessary
What are poor prognostic factors for physeal injuries?
Higher SH grade (3+4)
Higher energy trauma
Numerous reduction attempts
Poor final reduction
Distal femur + tibia #s
Greater initial displacement
What is the F/U protocol for physeal injuries?
Repeat XR q3mo until normal growth for 6mo
What are Harris lines?
Radiographic finding after physeal injury. Represents growth arrest + resumption. Represents physis position at time of injury
List management options for growth disturbance after physeal injury (4)
- Physeal bar resection
- Epiphysiodesis
- Chondrodiastasis
- Limb lengthening + deformity correction
What are the indications for physeal bar resection?
Existing or developing deformity w >2yrs growth left
<50% physis affected
>1yr without drainage if physeal bar secondary to infection
Describe the technique for physeal bar resection
Map physeal bar w MRI
Peripheral bar - approach direct + excise overlying periosteum
Central bar - make metaphyseal window or osteotomy
Remove bar completely w bar. Prevent thermal damage w irritation + suction
Dry scope to check complete resection
Interpositional graft
Insert metallic markers on either side of physis for F/U - to differentiate growth of affected vs other side
Interpositional graft options for physeal bar resection?
Fat graft - autologous but no support
Artificial dura
PMMA - don’t use. Generates heat + damages physis
Describes the types of epiphysiodesis
Permanent - drilling + curettage
Reversible - physeal staple, 8 plate, transphyseal screws
Indications for epiphysiodesis for physeal injury management?
Physeal bar >50%
Central physeal arrest - projected 2-5cm LLD at maturity. Do contralateral limb
Peripheral physeal arrest - do ipsilateral limb
List methods of predicting limb length at maturity (3)
- Arithmetic method
- Multiplier method
- Moseley straight line method
What is the arithmetic method of predicting leg length?
Girls stop growing at 14. Boys stop growing at 16.
Growth remaining at each physis = (yrs growth remaining) x (inches of growth from that physis/yr)
What is the multiplier method of predicting leg length?
Theory - leg growth is constant, based on age + sex
Current limb length x multiplier = predicted length at maturity
Multiplier based on current bone age
Describe the indication + technique of chondrodiastasis for physeal injury management
Indication - adolescents approaching maturity
Ex-fix applied above + below physis
Distract physis to lengthen + correct angular deformity (Heuter Volkman law)
Intraop - can over distract + twist to break physeal bar
RC: 12yo has a 4.5cm LLD. Bone age is 14.5. Scanogram shows equal deficit from tibia and femur. What should be done?
A. Delayed epiphysiodesis of femur and tibia
B. Immediate epiphysiodesis of femur and tibia
C. Epiphysiodesis of femur
D. Lengthening w Ilizarov
Answer: B
Question stem didn’t specify which physes would be treated. Assume it’s distal femur and proximal tibia
Use the arithmetic method: growth of femur and tibial physes are 3/9/6/5
If boys stop growing at age 16, this child has 1.5yrs of growth left.
If you close the distal femur and proximal tibia physes of the long leg now, the 4.5cm discrepancy + 1.2cm growth from the remaining physes = 5.7cm LLD at maturity
Remaining growth of the short leg is 1.5 x (3+9+6+5) = 3.45
Final LLD would be 2.25, which can be treated w a heel lift
Technically, if his growth rate remained the same and the end deficit was 4.5, could also treat this w a shoe lift. But this wasn’t an option
2017
Acceptable alignment for peds trauma
What structures are at risk w posterior displacement of medial clavicle physeal fractures?
Brachiocephalic art + v
Internal jugular v
Phrenic n
Vagus n
Trachea
Esophagus
Describe the serendipity XR view for medial clavicle physeal #
40deg cephalic tilt
Anterior displaced - clavicle above other side
Posterior displaced - clavicle below other side
Describe the management options and indications for medial clavicle physeal #s
- Observation - anterior displacement. Posterior displacement w/o mediastinal injury
- Closed reduction under anesth - posterior displacement w mediastinal injury
- ORIF - failed closed reduction or chronic symptomatic posterior displacement
What is the contraindication to closed reduction of posteriorly displaced medial clavicle physeal #s?
Late presentation. May be adherent to mediastinal structures
Describe the closed reduction technique for anterior displaced medial clavicle physeal #
Longitudinal traction to both arms
Posterior pressure to medial fragment
Can grasp medial fragment w towel clip
Describe reduction + fixation technique for posterior displaced medial clavicle physeal #
Longitudinal traction to affected arm w shoulder adducted
CT after to confirm stability
Grasp medial fragment w towel clip + pull anterior
If unsuccessful, do open. Fix w sutures. Don’t fix w pins - will migrate
Regarding % of physeal growth contribution, which bone has the largest proximal : distal growth difference? Which bone is 2nd largest?
Humerus - proximal physis contributes 80% growth + distal contributes 20%. 2nd is femur - proximal is 30%, distal is 70%
What is the Neer-Horwitz classification for pediatric proximal humerus #s?
Type 1 - minimally displaced
2 - displaced <1/3 shaft width
3 - displaced 1/3 - 2/3 width
4 - displaced >2/3 width
What are the acceptable alignment parameters for pediatric proximal humerus #s?
<5yo: <70deg angulation, 100% displaced
5-12yo: <45-70deg
>12yo: <45deg angulation or <2/3 displaced
*RC question
RC: Proximal humerus # in a 14yo girl. 45deg angulation and 60% translation. What is the best treatment?
A. ORIF
B. Hanging cast
C. CRPP
Answer: C
Describe the deformity in proximal humerus #s.
Describe the reduction maneuver for proximal humerus #s.
Deformity: proximal fragment is varus + apex anterior from rotator cuff. Distal fragment is anterior, adducted + shortened from pec major + deltoid
Reduction maneuver:
- Traction
- Shoulder flexion + abduction to 90deg
- ER
If unable to reduce a proximal humerus # closed, what structures may be blocking reduction?
Long head of biceps - most common
Joint capsule
Periosteum
Deltoid
For pediatric proximal humerus #s, what are fixation options? (4)
- Perc pinning - avoid axillary n, musculocutaneous n + posterior circumflex (ER arm to avoid). Smooth pins can be removed in clinic. Threaded need OR to remove
- Retrograde flexinails. Avoid physis
- Cannulated screws
- Plate
Proximal humerus #s may fall into varus malunion. How would this affect function?
Glenohumeral impingement
In pediatric humeral shaft #s, what are acceptable alignment parameters?
Young (?8yo): <45deg angulation
Older: 20deg varus/valgus, 20deg procurvatum, 15deg rotation, 2cm shortening
RC: All are true regarding the use of flexible nails for humeral shaft #s in pediatrics, except:
A. Low risk of radial n injury
B. Low risk of delayed union
C. Should not be used in OI
D. Shortening is well tolerated in the upper extremity
Answer: C
2cm shortening is acceptable
Surgical management in OI should include intramedullary fixation
What are common mechanisms of injury for distal humerus physeal separations?
Birth trauma - shoulder dystocia, traumatic delivery, excessive traction during c-section
NAT
FOOSH
What are the treatment options for distal humerus physeal separation?
Casting - limited role. Most are displaced. Only for late presentation for comfort. Osteotomy later for deformity
CRPP - most cases, to maintain reduction
Describe the technique for CRPP of distal humerus physeal separation
- Elbow arthrogram: 50/50 saline + contrast
- Reduction. Flex elbow for pinning
- 2-3 k-wires, divergent at #. Bicortical
- Check ROM on fluoro
What complications are associated w distal humerus physeal separation? (3)
- cubitus varus. 70% incidence. Due to medial condyle AVN, malunion or growth arrest
- Fish tail deformity. Medial or lateral condyle AVN
- Growth disturbance, causing length discrepancy or angular deformity
At what age do the pediatric elbow ossification centers ossify and fuse?
Ossification: CRITOE
Fusion: CTE-ROI
When viewing a pediatric elbow XR, what are you looking for? (7)
- Anterior humeral line - should pass through middle third of capitellum
- Humerocapitellar angle: normal is 65-80deg. Lateral XR. Angle between humeral shaft + line along capitellum physis. Important for supracondylar #s. Sometimes called lateral Baumann’s angle
- Baumann’s angle: normal is 70-75deg. AP XR. Angle between humeral shaft + capitellum physis.
- Radiocapitellar line - radial shaft should align w center of capitellum. Important for Monteggia
- PUDA
- Anterior sail sign
- Posterior fat pad - occult #
What is the most common type of pediatric supracondylar #?
Extension type
What are common nerve injuries associated w pediatric supracondylar #s?
Extension type: AIN most common (posterolateral displacement), radial n 2nd most common (posteromedial displacement)
Flexion type: ulnar n
What is the Gartland classification?
Pediatric supracondylar #s
1: nondisplaced
2: displaced but posterior cortex intact
2A: posterior tilt, no rotation
2B: there is rotation or medial impaction
3: complete displaced
4: complete periosteal disruption. Unstable in flexion + extension. Diagnosed intraop w EUA
Also: medial comminution type + flexion type
What complications are associated with supracondylar #s? (7)
- Operative related - pin migration, infection, stiffness
- Cubitus valgus malunion - tardy ulnar n palsy
- Cubitus varus malunion - gunstock deformity. Causes elbow instability
- Recurvatum - due to nonop tx of extension types
- Nerve palsies - AIN, radial, ulnar
- Vascular injury
- Compartment syndrome, Volkmann contracture
In what elbow position do you cast/splint a supracondylar #?
Nonop or CRPP w only lateral pins: neutral rotation, don’t flex beyond 90deg to decrease risk of compartment syndrome
If cross pinning: splint in extension to prevent ulnar n subluxing over medial pin
Kid presents w type 3 supracondylar #. Well perfused, good pulses, neuro intact. What is your plan?
Splint for elective surgery same day OR. Type 3 can wait 21h without increased complications as long as NVI
Kid presents w supracondylar # that is pulseless but well perfused. What is your plan? What is your DDx?
Pink + pulseless. Urgent same day OR.
DDx - vascular injury, thrombosis, spasm
Do not reduce bedside, only reduce in OR. Reduction may lacerate brachial artery + causing expanding hematoma (causing compartment syndrome)
If continues to be pink + pulseless after reduction - monitor vascular + neuro status x24h
Pulses can return in 3wks
In a kid w a supracondylar # and a pink/pulseless hand, when would you open the #?
- Reduction attempt (in OR!) causes expanding hematoma
- AIN palsy preop (sometimes)
- Unable to reduce closed
Kid presents w supracondylar # that is pulseless + poorly perfused. What is your plan?
White + pulseless. Emergent OR now.
- Ask when injury happened. May need prophylactic fasciotomy
- Bring to OR
- Call vascular (or plastics if hospital doesn’t have vascular)
- Closed reduction + R/A
- Open if unable to reduce closed, continues to be poorly perfused, or expanding hematoma
Describe the incision used to open a supracondylar when suspecting a vascular injury?
Anterior, S shaped incision. Proximal arm starts medial on humerus, cross antebrachial fossa + bring distal arm lateral on forearm
Describe the closed reduction technique for an extension-type supracondylar #
- Longitudinal traction
- Correct varus/valgus. Thumb points towards direction of displacement. Pronate if fragment displaced medially. Supinated if fragment displaced laterally
- Flex elbow + place pressure on fragment to correct extension
- Assess w fluoro + pin
RC question
Describe how to use crossed pins when fixing pediatric supracondylar #s
- Mini open incision medially
- Place pin w elbow extended, after placing lateral pins
- Don’t cross pins at # site (very unstable)
- Splint arm in extension
What is the danger of using a medial pin when fixing pediatric supracondylar #s?
Ulnar n
Highest risk when pin placed w elbow in flexion. Ulnar n may sublux anterior over the medial epicondyle in some kids.
In pediatric supracondylar #s, what is most stable: 3 lateral pins vs crossed pins?
No difference in stability
RC: Type 3 supracondylar #, which of the following is true?
A. Splint in 120deg flexion to maintain reduction
B. Equivalent outcomes w lateral and crossed pinning
C. Require emergent surgical management
D. There is limited remodeling for translational deformity
Answer: B
Do not splint beyond 90deg flexion, otherwise increases compartment syndrome risk. Type 3 can wait as long as NVI
Translational deformity remodels
2017, 2019
In kids, what type of # is most commonly associated with elbow dislocations?
Medial epicondylar #
In what direction are pediatric medial epicondylar #s usually displaced?
Anteriorly. Avulsion injury from flexor-pronator mass
What XR views is most helpful in assessing medial epicondyle #s?
Internal oblique + axial view.
AP + lateral may not be accurate. The medial epicondyle is a posteromedial structure. Fragment is displaced anterior
RC: Which accurate describes the anatomy of the distal humerus?
A. 30deg anterior angulation, 6deg valgus, IR
B. 30deg anterior angulation, 6 varus, IR
C. 10deg anterior angulation, IR
D. 10deg anterior angulation, 6deg varus, ER
Answer: A
Distal humerus has 30 anterior angulation, 6deg valgus and 5deg IR
What are the indications for nonoperative treatment of pediatric medial epicondyle #s? What are the outcomes compared to surgery?
Indication: <5mm displacement.
Controversial: 5-15mm displacement
Outcomes: 9x more osseous union with surgery. Nonop leads to more fibrous union, which doesn’t affect function + is asymptomatic
What are the indications for ORIF for pediatric medial epicondyle #s?
Absolute indications:
- Open #
- Fragment incarcerated in joint
- Post reduction ulnar neuropathy when assoc w elbow dislocation
- Medial condyle involved (articular surface)
Relative indications:
- Ulnar n neuropathy
- >5-15mm displacement
- High level athlete (thrower, gymnast)
- Associated w elbow dislocation
Describe the surgical technique for ORIF of pediatric medial epicondyle #s
- Medial approach between brachialis + triceps
- Isolate ulnar n
- Screw or k-wire fixation
RC: 12yo girl presents 6mo after being treated nonoperatively for a minimally displaced medial epicondyle fracture. There is a non-union, but she has full ROM and no pain. What now?
A. ORIF w pins
B. Place in above elbow cast
C. Followup in 6mo
D. Get MRI to investigate for fibrous nonunion
Answer: C
Nonoperative management of medial epicondyle #s lead to more fibrous unions. But this doesn’t affect function and is asymptomatic.
2017
In peds, why do lateral condyle #s have worse outcomes than supracondylar #s?
- Articular
- Often missed
- Higher malunion/nonunion risk
What is the Milch classification?
Pediatric lateral condyle #s
Type 1: # is lateral to trochlear groove
Type 2: # extends into trochlear groove
Not as useful as Weiss classification
What is the Weiss classification?
Pediatric lateral condyle #s. Describes displacement to guide treatment
- Type 1: <2mm, intact cartilage hinge. Cast
- Type 2: 2-4mm. Intact articular hinge on arthrogram (thus, more stable). CRPP
- Type 3: >4mm. Articular hinge not intact. Likely need to open to reduce before pinning
Describe the pin or screw configuration when fixing pediatric lateral condyle #s
1 pin in lateral column, 1 pin in transverse column parallel to joint. Divergent. This is a different configuration than supracondylar #s. Direction should be from posterolateral to anteromedial
List complications associated w pediatric lateral condyle #s
- Stiffness: self resolving
2: Nonunion - Capitellum AVN: assoc w posterior dissection
- Trochlear AVN: fishtail deformity from growth arrest. Causes pain, limited ROM, proximal ulnar migration (overloads radiocapitellar joint) and arthritis. Does not cause humeral length deficiency
- Lateral overgrowth/prominence
- Cubitus valgus: tardy ulnar n
- Growth arrest
RC: All of the following are true regarding a fishtail deformity of the distal humerus, except
A. Associated w supracondylar humerus #
B. Results from central physeal growth arrest
C. Predisposes to early ulnohumeral degenerative changes
D. Results in significant humeral length deficiency
Answer: D
Fishtail deformity associated with all distal humerus #s (almost usually mentioned w lateral condyle or medial epicondyle #s). Results from central physeal arrest and can cause arthritis. Only 20% physeal growth from distal physis.
Definition of Monteggia injury?
Radial head dislocation + proximal ulna # (or plastic deformity in kids)
True or false: in Monteggia injuries, the ulnar # apex and radial head dislocation are always in the same direction
True!
RC question gave you the direction of the ulnar # apex. You had to indirectly know the direction that the radial head was dislocated. They asked if you had to increase or decrease the PUDA to reduce the head.
What is the Bado classification? In what position are each splinted?
Monteggia #
1: anterior radial head dislocation. Splint in flexion + supination
2: posterior radial head dislocation. Full extension
3: lateral radial head dislocation. Full extension + valgus mold
4: anterior radial head dislocation, radial head # + ulna #
What are signs associated w congenital radial head dislocation? (6)
- Bilateral
- Posterior dislocation
- Convex head (usually radial head is concave)
- Enlarged head
- Atraumatic
- Associated w syndromes
What are the indications for nonoperative management of pediatric Monteggia #s?
Types 1-3, as long as ulnar # + radial head dislocation stable after reduction
What are the indications for ORIF of pediatric Monteggia #s?
- Types 1-3 w unstable ulnar # or radial head
- Type 4
- Open #
- Older kids may be treated like adults?
Technique: plate ulna, ORIF radial head w screws like in adults
RC: 16yo is assaulted and presented w a type 1 Monteggia #. What is the most appropriate treatment?
A. Closed reduction and cast
B. Flexible nail of the ulna and reduction of radial head
C. Resect radial head
D. ORIF ulna and closed reduction of radial head
Answer: D
Apparently we are to treat a 16yo like an adult. Adult Monteggia are treated w ulna ORIF and radial head closed reduction
Should not treat w flexible nails. Not rigid enough to keep ulna aligned
Don’t resect the radial head in acute cases
Describe the management options of chronic Monteggia #s
Radial head reduction vs resection
- Radial head reduction, order of procedure: closed reduction > open reduction via Boyd approach for ulnar osteotomy + open radiocapitellar joint reduction
- Radial head resection: after skeletal maturity
Describe the Boyd approach
No internervous plane: approach is between anconeus
- Posterolateral incision along lateral epicondyle + extend along ulnar shaft
- Incise anconeus tendon along its attachment on the ulna
- Elevate anconeus flap anteriorly
- Detach supinator from ulnar origin
- Pronate forearm to protect PIN (within substance of supinator)
- Retract anconeus + supinator anteriorly to expose capsule
In both bone forearm #s, describe how to determine rotational alignment radiographically. (4)
- AP view: bicipital tuberosity + radial styloid should be 180deg apart
- Lateral view: coronoid + ulnar styloid should be 180deg apart
- Diameters of proximal + distal fragments should match
- Cortical thickness of proximal + distal fragments should match
What are acceptable alignment parameters for pediatric both bone forearm #s?
Controversial
Younger than 10yo
- <15deg angulation
- <30deg malrotation
- <100% translation
- bayonet is ok, <1cm short
Older than 10yo
- <10deg angulation
- <30deg malrotation
- <50% translation
- No bayonet, no shortening
Despite all this, rotation does not remodel and some say no malrotation is acceptable
True or false: in both bone forearm #s, using an above elbow cast (as opposed to below elbow) decreases the risk of loss of reduction
False. No difference in loss of reduction w short vs long arm cast.
(I would still use a long arm cast in practice, but this is the new literature)
Define “cast index”
What sort of fractures is this term most often associated with?
Cast index = lateral width / AP width
Goal is cast index <0.8
You want the AP width to be > than lateral width
This helps you maintain reduction
Cast index is often used when discussing both bone forearm and distal radius #s
RC question
RC: What is true of the cast index?
A. Measured from cast to skin and versus soft tissue shadow
B. Width of sagittal plane compared to width of coronal plane of the inner cast at the fracture site
C. Can predict functional outcome
Answer: B
In pediatric both bone forearm #s, what are the indications for flexinail vs plate fixation?
Flexinails:
- Unacceptable alignment
- >13yo (thus, near maturity)
Plate fixation: same as flexinail indications but w additional indications
- Open #
- Refracture
- Highly comminuted
Describe the technique for flexinailing pediatric both bone forearm #s
Can start w either radius or ulna, whichever is easiest
1. Ulnar nail inserted through olecranon. Avoid ulnar n
2. Radial nail can be inserted through either:
- Radial styloid between compartments 1 and 2. Risk superficial radial n
- Lister’s tubercle. Risk EPL attritional rupture
3. Open starting points w awl
4. Reduce bone. Up to 3 unsuccessful passage attempts allowed before opening #. Otherwise risk compartment syndrome
How do the outcomes for pediatric both bone forearm flexinailing compare to ORIF?
Flexinailing has
- Shorter OR time
- Less blood loss
- Equal union rates, ability in restoring radial bow, ability in restoring rotation
When flexinailing pediatric both bone forearm #s, what is the risk of using a radial styloid start point?
Superficial radial nerve neuroma
When flexinailing pediatric both bone forearm #s, what is the risk of using a Lister’s tubercle start point? When does this complication usually occur?
EPL attritional rupture. 6-12wks postop
What is the treatment for EPL attritional ruptures?
EIP to EPL tendon transfer
What are the risk factors for compartment syndrome in pediatric both bone forearm #s? (2)
- High energy trauma
- Multiple attempts (>3) at reduction + passing flexinail
What are some complications associated w pediatric both bone forearm #s?
- Refracture: assoc w plate removal or green stick patterns
- Malunion leading to loss of prosupination. Treat w corrective osteotomy
- Compartment syndrome
- Synostosis: assoc w high energy trauma and head injury
RC: Which of the following is true: both bone forearm # w 10 deg rotational malunion
A. A midshaft malunion will result in more decreased pronation
B. A midshaft malunion will result in a more decreased supination
C. A distal malunion will result in more decreased pronation
D. A distal malunion will result in a more decreased supination
Answer: B
Pronation losses were similar for both distal and middle forearm deformities. However, supination loss is more affected w midshaft deformities than distal ones.
2017
What percentage of growth do the proximal and distal radial physis contribute?
Proximal: 25%
Distal: 75%
What is the most common site of pediatric distal radius #s?
Metaphysis
What are the acceptable alignment parameters for pediatric distal radius #s?
Controversial
<9yo
- <20deg angulation
- <50% translation
>9yo
- >10deg angulation
Rotation does not remodel. No malrotation acceptable for any age
RC question
RC: 8yo presents to your clinic 10d after a distal radius # (no XR, no mention of physeal injury). He has been splinted and has 20deg apex volar angulation. He has a well molded cast. What do you do next?
A. Followup in 4-5wks
B. Hematoma block and repeat closed reduction
C. Drill osteoclasis and fixation
D. Open reduction and plate
Answer: A
True or false: there is no difference in loss of reduction w short arm vs long arm cast for distal radius #s
True. Can use either. Goal is for cast index <0.8
What is the risk of re-displacement w pediatric distal radius #s?
30% incidence
Most important risk factor: initial complete displacement. 7x more likely to redisplace
Anatomic reduction reduces risk for re-displacement
RC question
RC: Regarding entirely metaphyseal distal radius fractures in children treated w closed reduction and casting, which of the following is true about re-displacement?
A. 30% incidence
B. More common if younger than 10yo
C. An above elbow cast prevents re-displacement
D. Transverse patterns are more unstable
Answer: A
No difference in stability in above elbow vs below elbow cast. Transverse patterns are more stable.
(JPO 2015: Distal radius fractures in children: risk factors for redisplacement following closed reduction)
What is the indication for CRPP in pediatric distal radius #s? Describe the technique
Unstable pattern - unable to maintain reduction in cast
Radial styloid pins, just proximal to physis
If need transphyseal pin, use smooth wires
If intra-articular #, pin transversely across epiphysis
Dorsal pin may restore volar tilt
Dangers: superficial radial n
For physeal injuries to the distal radius, what are the management principles for acute vs late presentations?
Acute presentation: gentle reduction, NO re-manipulation
Chronic presentation: NO late reductions. Do not attempt reduction after 3ds even if unacceptable alignment. May cause growth arrest. Just well moulded cast to prevent further displacement. Hopefully remodels
RC question
RC: 12yo comes in 10days after a SH2 distal radius # with 15deg radial inclination on AP XR and 50deg apex volar on lateral XR. What is the best treatment option?
A. ORIF w plate
B. ORIF and perc pinning
C. Repeat closed reduction and cast
D. Cast with appropriate molding and observe
Answer: D
SH2 and 10days after injury. Therefore, physeal injury w delayed presentation. Don’t reduce as it could cause growth arrest. Just cast with a mold to prevent further displacement.
What is a Galeazzi fracture? In pediatrics, what is a Galeazzi equivalent?
Distal third radius # and DRUJ disruption
Galeazzi equivalent: distal third radius # and displaced ulnar physeal injury
What is the Walsh classification?
Galeazzi fractures
Type 1: Radius displaced dorsally, due to supination force
Type 2: Radius displaced volarly, due to pronation force
What is the closed reduction technique for Galeazzi injuries?
- Supinate if ulna displaced dorsally
- Pronate if ulna displaced volarly
In an irreducible DRUJ injury, what is tissue is most likely interposed?
ECU
How would you surgically manage a pediatric Galeazzi injury?
Radius: fix w volar plate or flexinail
DRUJ pinning:
- Dorsal approach if unable to reduce DRUJ due to interposed tissue
- PIN ulna to radius in supination
- If large ulnar styloid fragment, pin that too
Splint in supination
What are the entry points for radius flexinails? (2)
- Radial styloid between compartments 1 and 2
- Lister’s tubercle
True or False: in pediatric traumatic hip dislocations, associated acetabular #s are common
False. Less common than in adults due to cartilaginous acetab. Most common type: posterior wall #
In pediatric traumatic hip dislocations, what increases the risk of AVN?
Not reduced within 6hrs
Describe the leg position upon presentation in patients w anterior or posterior hips dislocations
Anterior: FABER
Posterior: FADIR
What is the management of pediatric traumatic hip dislocations?
Reduction within 6hrs of injury. Options after reduction include
- Spica cast
- <10yo: bedrest + abduction splint x4wks
- >10yo: bracing + protected WB x 6wks
Regarding the greater trochanteric apophysis, what deformity results from growth arrest? What deformity results from overgrowth?
Growth arrest causes a short GT and coxa valga
Overgrowth causes coxa vara
Describe the blood supply to the proximal femur in a pediatric patient
- Ligamentum teres: main blood supply at birth. Decreases after 4yo
- Metaphyseal vessels: contributes at birth but disappears ages 4-17 because blocked by physis. Reappears after 17yo
- Lateral femoral circumflex: contributes at birth but regresses later in childhood
- Medial femoral circumflex: posterosuperior and posteroinferior branches. Become main blood supply at 4yo
What is the Delbet classification?
Proximal femur fracture classification
Type 1: transphyseal. 100% AVN risk.
2: transcervical. 30% risk.
3: basicervical. 20% risk
4: intertrochanteric. 10%
All displaced #s or kids >4yo need surgery.
Types 1-3 are treated w pin/screws if displaced or in kids >4yo. Type 4 is treated w DHS if displaced or kids >4yo
Any type can be treated w spica if undisplaced in kids <4yo
What are the treatment options for proximal femur #s?
- Closed reduction + spica
- Emergent ORIF + capsulotomy
- Closed vs open reduction internal fixation
- ORIF w sliding hip screw
What are the indications for emergent ORIF and capsulotomy in pediatric proximal femur #s? Why is capsulotomy or hip aspiration suggested?
Indications include
- Open #
- Vascular injury requiring repair
- Associated hip dislocation
- Type 1 w epiphyseal dislocation
- Fractures w significant displacement (may increased AVN risk)
Capsulotomy or aspiration may decrease AVN risk
What are the indications for closed reduction + spica in pediatric proximal femur #s?
Only if acceptable alignment in kids <4yo, any type
Kids w displaced #s or >4yo, need surgery that is dependent on # type
What are the indications for pin/screw fixation vs DHS for pediatric proximal femur #s?
DHS is for type 4 that are either displaced or kids >4yo
Pin/screw fixation are for types 1-3 that are either displaced or kids >4yo
What complications are associated w pediatric proximal femur #s? (6)
- AVN
- Coxa vara
- Coxa valga
- Nonunion
- Physeal arrest
- Chondrolysis
What are the risk factors for AVN in pediatric proximal femur #s? (4)
- Increasing age
- Fracture type (Delbet classification)
- Delayed reduction >24h
- Unstable reduction
In pediatric proximal femur fractures, which # patterns are associated w coxa vara? Coxa valga?
Coxa vara - types 1-3
Coxa valga - type 4
What are the treatment options for coxa vara after pediatric proximal femur #s? What are the indications? (3)
- Observation: kids <3yo will remodel
- Trochanteric apophysis surgical arrest. Mild coxa vara in kids <8yo
- Subtroch or intertroch valgus osteotomy: associated nonunion, severe Trendelenburg gait, FAI or older patients
RC: What is true regarding femoral neck #s?
A. Rate of osteonecrosis is 5%
B. It is ok to cross the physis w fixation
C. Capsular decompression (?)
D. Age <11yo is a risk factor for osteonecrosis
Answer: B
Rate of osteonecrosis is at least 10%, depending on Delbet classification
Increasing age is a risk factor
Question stem didn’t mention anything further regarding capsular decompression.
In pediatric femoral shaft #s, what are the treatment options and indications for each? (6)
List 5 implant-related principles of femur shaft flexinails
- Nail size: 2 nails together must fill 80% canal
- Pre-bend the nails to contact the canal walls at the # site. Bend 30deg. Nails should bend in opposite directions
- End caps stabilize the nails
- Titanium nails are better than stainless steel: better strength. Steel nails are stiffer and have higher reoperation rates
- Insert 2 nails retrograde. Starting points is 2cm above distal physis
What are the advantages and disadvantages of using flexinails for pediatric femoral shaft #s?
Advantages:
- Small incision, minimal soft tissue damage
- Don’t need to immobilize
- Early WB at 6wks
- Decreased hospital stay
Disadvantages:
- Irritation at tip
- Risk shortening/angulation if length unstable
- Risk malunion if very proximal or distal #s
What are the advantages and disadvantages of using anterograde IM nailing in pediatric femoral shaft #s?
Advantages
- Immediate stability + WB
- Known technique for many surgeons
Disadvantages
- AVN associated w piriformis entry. Use GT or lateral entry to avoid. Medial femoral circumflex lies near piriformis fossa
What are the indications for anterograde IM nail in the management of pediatric femoral shaft #s?
- Near skeletal maturity (>11yo)
- Length unstable
RC: 54kg 10yo w a midshaft femur #. What is the treatment?
A. Ex-fix
B. Rigid IM nail
C. Flexible IM nail
D. Submuscular plate
Answer: D
With that body weight, flexible nails are not appropriate. Rigid IM nail or plate would be possible treatments, except the stem specifies that the pt is 10yo
Rigid IM nail is appropriate if the pt is >11yo
Plating is okay for pretty much all ages
2015
What SH type # is most common in pediatric distal femur physeal injuries?
SH2
What is a Thurston Holland Fragment?
Distal femur physeal injury, SH2. Triangular portion of metaphysis remaining w epiphysis
What is the incidence of physeal injury causing LLD or angular deformity in distal femur physeal injuries? What are the risk factors?
30-50% incidence. Risk factors:
- SH type
- # displacement
- Surgical HW invading physis
What are the treatment options and indications for pediatric distal femur physeal injuries? (3)
- Long leg cast for nondisplaced #s
- CRPP - SH 1 +2. Some SH 3 + 4 if anatomic reduction possible
- ORIF - Most SH 3 + 4. Irreducible SH 1 + 2 due to interposed periosteum on tension (lateral) side
Smooth k-wires if crossing physis. Otherwise, use screws
True or False: in pediatric ACL injuries, they are classically due to tibial eminence #s
True. There is increasing incidence of ACL ruptures now but classically associated w eminence #s
Risk factors for pediatric ACL tears? (5)
- Increased posterior tibial slope
- Increased Q angle
- Decreased intercondylar notch width
- Stronger quads then hamstrings
- Landing position: hip IR + knee valgus
Indications for nonoperative management of pediatric ACL tears? (3)
- Younger (<11yo)
- <50% tear
- Anteromedial bundle
Why is it better to fix pediatric ACL tears acutely, rather than delay until skeletal maturity?
Delaying found to increase incidence of:
- Irreparable meniscal tears
- Chondral damage
This is due to repeated episodes of instability
In pediatric ACL reconstruction, what are the general types of reconstruction techniques? (4)
- Extra articular
- Physeal sparing
- Partial transphyseal (in tibia)
- Complete transphyseal
Describe the concept of extra-articular ACL reconstruction in kids
No tunnels made. Autograft IT band fixed to femur and brought intra articular, then fixed to tibia. Good stability but may be over constrained
Describe the concept of physeal sparing (all epiphyseal) ACL reconstruction in kids
Indicated when >2yo growth left. Tunnels made in femur and tibia epiphyses. Hamstring autograft used. Best restores normal knee kinematics
Describe the concept of partial transphyseal ACL reconstruction in kids
Indicated when modest growth left. Spares femur physis and transphyseal tibial tunnel
List risk factors during ACL reconstruction in kids that may cause growth disturbance? (3)
- HW across physis
- Bone across physis (BPTB graft)
- Large tunnels in physis
True or False: autograft is best in pediatric ACL reconstruction
True. Autograft is best. Usually quadrupled hamstring used. Bone blocks increase risk of growth arrest.
Allograft associated w 4x revision rate.
In patella dislocations, list what you should examine or workup to determine the cause of recurrent instability
- Standing alignment
- Axial alignment: TT-TG
- Rotational alignment: rotational profile
- Trochlear groove morphology: patellar tilt, lateral femoral condyle dysplasia
- Generalized ligamentous laxity
- Soft tissue: MPFL tears, tight lateral retinaculum
Which is better in recurrent pediatric patella dislocations, MPFL reconstruction or repair?
Reconstruction is better (5% recurrence). Repair alone does poorly (60%) recurrence.
In pediatric MPFL reconstruction, where is the femoral origin?
Between medial epicondyle and adductor tubercle. About 5mm distal to physis
In pediatric patella dislocations, what are risk factors for recurrence? (6)
- Age <18
- Trochlear dysplasia
- Patella alta
- Increased TT-TG
- Miserable malalignment: femur anteversion, genu valgum and external tibial torsion
- Female
True or False: autograft is best for pediatric MPFL reconstruction
False. Equal results with autograft or allograft for MPFL reconstruction.
This is unlike with ACL, where autograft is always best for kids
RC: In a 10year old boy w recurrent patella instability and a TTTG measuring 26mm, what of the following is the least recommended:
A. Medial patellofemoral soft tissue reconstruction
B. Supra-patellar soft tissue realignment procedure
C. Tibial tubercle osteotomy
Answer: C
Do not do tibial tubercle osteotomy in skeletally immature
In patellar sleeve fractures, what is most common: superior pole or inferior pole fractures?
Inferior pole is most common
What are some clinical findings in kids w patellar sleeve #s? (4)
- Unable to WB
- High-riding patella (if inferior pole #, which is most common)
- Palpable gap at either proximal or distal end of patella due to disrupted extensor mechanism (depends on location of #)
- Difficulty w active knee extension
What are XR findings w patellar sleeve #s?
Flecks of bone near superior or inferior poles
Patella baja or alta depending on where the # is
What is the treatment of patella sleeve #s?
2 options
1. Cast x6wks: rare. Only if undisplaced w intact extensor mechanism
2. ORIF: displaced, articular stepoff, disrupted extensor mechanism
Medial parapatellar approach. Repair retinaculum and extensor mechanism with sutures, tension band, suture anchors, screws, etc
Cast in extension after
What structure attaches to the medial tibial spine?
ACL
Why are kids more prone to tibial eminence #s?
Not completely ossified. More prone to eminence #s than cruciate ligament tears
What is the Meyers and McKeever classification?
Pediatric tibial eminence fractures
Type 1: nondisplaced
Type 2: minimally displaced w intact posterior hinge
Type 3: completely displaced. Type 3+ is completely displaced and rotated
Type 4: completely displaced, rotated and comminuted
What are the clinical findings in kids w tibial eminence #s?
Knee flexed
Positive anterior drawer
What are the treatment options and indications for pediatric tibial eminence #s? (2)
- Closed reduction and full extension cast: type 1 and type 2 (if reducible)
- Fixation: Types 3 + 4, and irreducible type 2
What are common blocks to reduction in tibial eminence #s?
Meniscus and intermeniscal ligament
Most common: medial meniscus
Describe the fixation technique for pediatric tibial eminence #s
Arthroscopic vs open
Debride # and disengage entrapped soft tissue
Reduce and fix with either suture or screws
What are the advantages and disadvantages of suture or screw fixation in treating pediatric tibial eminence #s?
Suture fixation
- Advantage: use for smaller fragments. Minimal physeal damage
- Disadvantage: more technically demanding arthroscopically
Screw fixation
- Advantage: less technically demanding, possibly earlier mobilization
- Disadvantage: for larger fragment, HW irritation, may impinge ROM, iatrogenic comminution, physeal injury
True or False: surgically treated pediatric tibial eminence #s are associated with ACL laxity
True. ACL laxity after tibial eminence # is more common after surgical treatment. Laxity is noted on Lachman. However, usually functionally stable
ACL reconstruction later in 15-25%
RC: What is the most important factor in causing arthrofibrosis in tibial eminence injuries in kids?
A. Open fixation, instead of arthroscopic
B. Length of immobilization
C. Screw fixation, rather than suture
D. Injury to meniscus
Answer: B
Early ROM decreases the risk of arthrofibrosis
What are risk factors associated w tibial tubercle #s?
Jumping shorts: basketball, football, sprinting, high jump
Describe how the ossification centers of the proximal tibia close
2 ossification centers: physis and tubercle apophysis
Closes from posterior to anterior, proximal to distal
In tibial tubercle fractures with associated compartment syndrome, what else may be injured?
Anterior tibial recurrent artery
True or False: tibial tubercle #s may be associated w popliteal artery injury
True. Passes posterior over metaphyseal fragment. CTA if suspect injury
What is the Ogden classification?
Tibial tubercle #
1: through apophysis
2: between physis and apophysis
3: through apophysis and extends posterior to cross physis
4: through entire physis
5: proximal sleeve avulsion
What are the treatment option for tibial tubercle #s?
- Cast in extension: type 1, minimally displaced or acceptable displacement
- ORIF: types 2-5 displaced. Fix with smooth K-wires, screws and sutures
What deformity may result from tibial tubercle #s?
Recurvatum deformity. More common than LLD
Due to anterior growth arrest but posterior growth continues. Results in decreased tibial slope
RC: What is a complication of tibial tubercle #s?
A. Compartment syndrome
B. Something
C. Something
D. Something
Just know that compartment syndrome is a complication. Due to tear of recurrent anterior tibial artery
2017
What are acceptable alignment parameters for pediatric tibial shaft #s?
<5-10deg angulation. Accept 10deg angulation if <8yo
<1cm shortening
50% translation
What are treatment options for pediatric tibial shaft fractures?
- Long leg cast: acceptable reduction
- Ex-fix: DCO, extensive soft tissue injury
- Flexinails: unacceptable alignment, near maturity
Describe the order of closure of the distal tibial physis
Central > anteromedial > posteromedial > latera.
What is a triplane #?
Transitional # due to distal tibial physeal closure. Typically metaphyseal # on coronal plane, physeal # on axial plane, epiphyseal # on sagittal plane
Can be different # patterns but this is the classic
With triplane #s, which components of the # would you see on AP and lateral XR views?
AP: epiphyseal # as it is a sagittal plane #. SH3 type
Lateral: metaphyseal # as it is a coronal plane #. SH2
With triplanar #s, what radiologic sign may be seen on CT?
Mercedes-Benz sign
Describe the technique for closed reduction and casting of triplanar #s
Indication: <2mm displaced
Reduce the fibula first
Lateral triplanar #s: most common type. Reduce w IR
Medial triplanar #s: reduce w ER
Long leg cast to control rotation x4wks, then short leg cast x2wks
Describe the technique for operative treatment of triplanar #s
Indication: >2mm displaced
CRPP vs ORIF
Approach for ORIF depends if lateral or medial triplanar #
Lateral triplanar: anterolateral approach
Medial triplanar: anteromedial approach
Fixation: smooth k-wires or cannulated screws
RC: What is true of a triplanar # on XR?
A. SH3 # seen on AP view, SH2 # seen on lateral view
B. SH2 seen on AP, SH3 seen on lateral
C. SH4 on AP view
D. SH4 seen on mortise view
Answer: A
SH3 # line seen on AP view. # is in the sagittal plane
SH2 # line seen on lateral view. # is in the coronal plane
What is a tillaux fracture?
SH3 # of anterolateral tibial epiphysis due to AITFL avulsion. Occurs within 1yr of physis closure, older then triplanar group
What does the AITFL connect to?
Chaput tubercle on tibia and Wagstaffe tubercle on fibula
What is the best XR view to visualize a tillaux #?
Mortise view
Describe the technique for closed reduction and casting in tillaux #s?
Indication: <2mm displaced
Reduction technique: IR foot
Long leg cast x4wks then short leg x2wks
Describe the operative technique for tillaux #s
Indication: >2mm displaced
CRPP: k wire to joystick reduction then fix w k wire or cannulated screws
ORIF: anterolateral approach. Visualize joint for reduction.
Transphyseal fixation is OK as physis almost closed
Postop: long leg cast x4wks for rotational stability, then short leg cast x2wks
What is juvenile idiopathic arthritis?
Autoimmune inflammatory arthritis lasting >6wks in kids <16yo
Must R/O infection
Diagnostic criteria: must have one of the following
- Rash
- RF positive
- Iridocyclitis
- C-spine involved
- Pericarditis
- Tenosynovitis
- Intermittent fever
- Morning stiffness
True or False: juvenile idiopathic arthritis is often RF positive
False. <15% are RF-positive
RF positive is included in the diagnostic criteria though
What is iridocyclitis and why is it important to R/O in JIA?
Type of anterior uveitis. Needs immediate ophtho consult for slit lamp exam. Can cause rapid vision loss.
Higher risk if ANA positive
ANA+: requires slitlamp exam q4mo
ANA-: slitlamp exam q6mo
What is Still’s disease?
Acute onset JIA presenting with
- Multiple joint involvement
- Fever
- Rash
- Splenomegaly
Usually 5-10yo
What are the 3 types of JIA? Which is most common and which has the worse prognosis?
Pauciarticular: most common (50%)
Polyarticular
Systemic: worse prognosis
What is the difference between pauciarticular and polyarticular JIA?
Pauciarticular
- <5 joints involved
- Large joints
- Asymmetric: causes LLD. Involved limb is longer
- Early onset is more common in girls x4 and associated w iridocyclitis
Polyarticular
- >5 joints involved
- Small joints (hand/wrist)
What is the prognosis of JIA?
Pauciarticular: 70% remission
Polyarticular: 60% remission
Systemic: worst. Most likely to become adult RA
What systemic findings are associated w systemic JIA?
- Rash
- Fever
- Multiple joints
- Hepatosplenomegaly
- Lymphadenopathy
- Pericarditis
- Heme: anemia, high plts/WBC
- Stills disease
What must be done preop for JIA?
Flex/ex XR for atlantoaxial instability
RC: What are radiographic findings in the c-spine in JIA?
- Atlantoaxial instability
- Basilar invagination
- Odontoid erosion
- Facet (apophyseal) joint ankylosis
- Subaxial instability
- Small cervical vertebrae (hypotrophy): most common at C4/5
What is the treatment for JIA?
DMARDS and slitlamp exams
Ortho-wise: treat LLD and deformities. May need arthrodesis or arthroplasty
What is the O’Brien classification of pediatric radial head #s?
Type 1: <30deg angulation
Type 2: 30-60
Type 3: >60 deg
What XR view should you order to better assess radial head #s?
Radiocapitellar view. Oblique later XR performed by placing arm on table w elbow flexed 90deg. Thumb pointing upwards
What are the indications for nonoperative management of pediatric radial head #s?
Able to achieve acceptable alignment w closed reduction.
- <30deg angulation
- <3mm translation
Describe closed reduction techniques for pediatric radial head #s (3)
Patterson maneuver: elbow in extension/supination. Traction + varus force. Direct pressure over head
Israeli: elbow flexed to 90 and pronation. Direct pressure over head
Esmarch: tightly apply Esmarch from wrist to above elbow. May spontaneously reduce
Describe CRPP techniques for pediatric radial head #s (3)
- K-wire push technique: use blunt head to push against fragment
- K-wire lever technique: kwire into fracture site to lever
- Metaizeau technique: pin/nail retrograde across # site. Rotate pin/nail to reduce #
Pin # if unstable
Describe the open reduction technique for pediatric radial head #s
Kocher approach. Internal fixation only if grossly unstable
True or False: in pediatric radial head #s, loss of pronation is a much more common complication than loss of supination
TRUE
True or false: in pediatric radial head #s, the incidence of osteonecrosis is increased w open reduction
True. 70% incidence w open reduction. Radial head is mostly cartilage in kids. Blood supply from metaphysis
RC: What are poor prognostic factors in radial neck #s in kids?
- Older (>10yo)
- Associated injuries, comminution
- Requires open reduction
- Delayed treatment
- Poor reduction (>30deg angulation, 3mm translation)
What is a Nursemaid’s elbow and what age group is it found in?
Annular ligament subluxation after sudden traction on extended and pronated elbow
Found in kids 1-4yo
When suspected Nursemaid’s elbow, what position is the patient’s arm usually held? What is the physical exam like?
Arm held in slight flexion and pronation
Pain to lateral aspect of elbow. Full flexion and extension
Pain w supination
Describe the closed reduction techniques for Nursemaid’s elbow (2)
-Supination technique: supinate forearm and flex elbow maximally. Put pressure on radial head to reduce
- Hyperpronation: elbow flexed to 90deg and hyperpronate forearm
In pediatric elbow dislocations, what is the most commonly associated #?
Medial epicondyle #
True or False: elbow dislocations are common in kids <3yo
False. Most common in 10-15yo. “Elbow dislocation” in kids <3yo, suspect physeal separation from NAT
What is Sprengel’s? Describe the associated deformity
Congenitally small + undescended scapula
High-riding
Medially rotated scapula (glenoid faces inferior)
Triangle shape
What motion is typically limited in Sprengel’s?
Shoulder abduction. Due to loss of scapulothoracic motion
True or False: Sprengel’s is the same as scapular winging
False. Sprengel’s is a congenitally small and undescended scapula. It may be associated w winging but not necessarily. Winging is from injury to the long thoracic n or serratus anterior
What is an omovertebral bone?
Present in 50% of Sprengel’s deformity. Forms a connection between the scapula and C-spine. Restricts shoulder motion
What conditions are associated w Sprengel’s? (3)
- Congenital scoliosis: most common
- Klippel-Feil
- Spinal dysraphism: spina bifida, split cord, etc
For operative management of Sprengel’s, name the 2 procedures that can be performed and general principles of each. What are your options in regards to protecting the brachial plexus?
- Green procedure
- Woodward procedure - more popular
Both procedures are similar. Position prone. Incision over Cspine spinous processes. In Green procedure, detach muscles from scapula for exposure. In Woodward, detach muscles from spinous processes for exposure. Excise omovertebral bone. Externally rotate scapula and move inferior. Reattach muscles
Options to protect the brachial plexus
- Clavicle resection
- Clavicle osteotomy
What are the outcomes of operative management for Sprengel’s?
Both Green and Woodward procedures improve abduction by 45deg
What nerves innervate pec major? Where do they branch off of on the brachial plexus?
Medial and lateral pectoral n. From medial and lateral cords, respectively
What are the risk factors for obstetrical brachial plexopathy? (6)
- Large for gestational age
- Multiparous pregnancy
- Difficult presentation (breech)
- Shoulder dystocia
- Forceps delivery
- Prolonged labor
Define preganglionic brachial plexus injury vs postganglionic
Preganglionic: lesion is proximal to sensory (dorsal root) ganglion
What are the implications of preganglionic brachial plexus injuries?
Preganglionic injuries involve root avulsions and will not spontaneously recover. Require nerve transfer
In obstetrical brachial plexopathy, certain nerve injuries suggest preganglionic injury. List them (5)
- Horner’s syndrome: sympathetic chain
- Phrenic n: elevated hemidiaphragm on XR
- Long thoracic n: winged scapula from serratus anterior
- Dorsal scapular n: rhomboids
- Suprascapular n: supra and infraspinatus
What nerve roots are involved in Erb’s, Klumpke’s, and total obstetrical brachial plexopathy? Which is most common
Erbs: C5-6 (sometimes C7)
Klumpke: C8-T1
Complete: with or without Horner’s
Erbs is most common > complete > Klumpke
Note: these terms are outdated. Now, we use the Narakas classification
What is the Narakas classification?
Obstetrical brachial plexopathy. Eponym classification (Erb’s, Klumpke) is outdated
Group 1 (Duchenne-Erb’s): C5-6
Group 2 (Intermediate): C5-7
Group 3 (Total): C5-T1 without Horner’s
Group 4 (Total w Horner’s)
What major nerves are involved in Erb’s palsy? What is the typical deformity?
C5-6. C7 involved in 50%
Suprascapula, musculocutaneous, axillary, and radial n
Waiter’s tip deformity
- Adducted and IR shoulder
- Extended and pronated elbow
- If C7 involved, no wrist extension. Will be fixed in flexion
What neonatal reflexes should be examined in obstetrical brachial plexopathy?
- Moro: sudden loss of support. Spread out arms (abduction) and then pull back in (adduction)
- Tonic neck reflex: aka fencing reflex. When face turned to one side, arm/leg on that side become extended. Opposite arm/leg flex
Describe the general principles of managing obstetrical brachial plexopathy
- R/O pseudoparalysis from trauma, meaning is this true plexopathy?
- Neonatal reflexes
- Determine roots involved. R/O Horner’s. Don’t need EMG/NCS (unlike adults)
- PT to maintain ROM. Don’t need splinting (unlike in adults)
- Serial exams over first 3-6mo of life. Monitor biceps recovery w cookie test
- If no biceps recovery by 3-6mo, send to plastics for microsurgery. If preganglionic, can send at 3mo. If not preganglionic, can wait until 6mo to refer
- After recovered from nerve surgery (wait at least 2yrs), assess remaining functional deficits for tendon transfers, etc
List 2 motor grading systems developed to assess obstetrical brachial plexopathy
- Active Movement Scale. Use to track neuro recovery. Motor graded from 0-7. Grades 0-4 if gravity eliminated, grades 5-7 if movement possible against gravity
- Mallet classification. Assesses 5 functions: shoulder abduction, shoulder ER, hand to neck, hand to mouth, hand to sacrum
What is the cookie test?
Assess biceps recovery in obstetrical brachial plexopathy. Place cookie in hand of affected side. Hold elbow adducted. If able to bring cookie to mouth, then has biceps function
What are good prognostic factors for obstetrical brachial plexopathy? (2)
- Erb’s palsy
- Biceps activity by 2mo. Specifically, antigravity activity
What are poor prognostic factors for obstetrical brachial plexopathy? (4)
- Klumpke’s or complete palsy
- No biceps activity by 3mo
- Preganglionic injury
- Horner’s syndrome
What is Horner’s syndrome?
Ptosis, miosis, anhidrosis
How do you workup phrenic n involvement in obstetrical brachial plexopathy?
Chest fluoro or US
What are the indications for nerve transfer in obstetrical brachial plexopathy? Indications for nerve grafting?
Nerve transfer for preganglionic
Nerve grafting for postganglionic
How long should you wait after microsurgery for obstetrical brachial plexopathy before proceeding to tendon transfer?
Wait at least 2yo to ensure no more recovery after nerve surgery
What is the overall prognosis for obstetrical brachial plexopathy without intervention?
90% will resolve without intervention
What is the most common nerve graft used for obstetrical brachial plexopathy?
Sural n
Describe the principles of nerve grafting for Erb’s palsy
Indications - postganglionic. No biceps return after 6mo
- Cable graft w sural n
- Resect neuroma
- Graft C5 to suprascapular and posterior division of superior trunk (axillary n)
- Graft C6 to the anterior division of superior trunk (musculocutaneous)
Describe the principles of nerve transfer for Erb’s palsy
- Spinal accessory n (CN 11) transferred to suprascapular n
- Thoracic intercostals (T2-4) transferred to lateral and posterior cords
Describe the principles of nerve surgery for total obstetrical brachial plexopathy
Priority is hand function
Graft C5 and C6 nerve roots to medial and ulnar n
Transfer spinal accessory n (CN 11) to suprascapular n
Transfer thoracic intercostals (T2-4) to lateral and posterior cord
What shoulder deformities result from Erb’s palsy? (2)
- IR contraction
- Dislocation from posterior subluxation and glenoid retroversion
In Erb’s palsy, what are the treatment options for shoulder subluxation and glenoid deformity? (2)
- Minimal glenoid deformity: open reduction, subscap release. Possible lat dorsi transfer
- Retroverted glenoid deformity: humeral derotational osteotomy
In Erb’s palsy, what are the treatment options for shoulder IR contracture? What are the indications? (4)
- Subscap release: failed PT (<30deg ER) by 1yo, no glenoid dysplasia
- Pec major release +/- lat dorsi transfer: failed PT by 2yo, no glenoid dysplasia
- Humeral derotational osteotomy: persistent contracture + glenoid dysplasia
- Arthrodesis: nonfunctional deltoid but good hand/wrist fxn
Describe the principles of humeral derotational osteotomy
Indication: persistent IR contracture with glenoid dysplasia
Deltopectoral approach
Transverse osteotomy just proximal to deltoid insertion on humerus. Protect radial n just posterior
Position distal humerus in 30deg ER
Plate fixation
Shoulder arthrodesis: what is the position of fusion?
30-30-30
Abduction 30 deg
Forward flexion 30deg
IR 30deg
Goal: hand to mouth
In Klumpke’s palsy, what are the treatment options for elbow flexion contracture? (2)
- Splinting
- Night time extension splint to prevent progression
- Elbow extension casting when contracture >40deg - Biceps and brachialis lengthening
In Klumpke’s palsy, what are the treatment options for forearm supination contracture? What is the goal? (2)
Goal: 20deg supination. Allows gravity assisted wrist flexion, which aids in digit extension via tenodesis
1. Biceps tendon rerouting transfer: distal insertion rerouted around radial neck and sutured to itself, to act as pronator instead of supinator. Indications: intact passive pronation.
2. Forearm osteotomy and biceps rerouting: when passive pronation is limited
RC: Which of the following is true of obstetric brachioplexopathy?
A. Phrenic n injury is indicative of root avulsion
B. Horner’s is usually associated w upper plexus injury
C. Limited biceps flexion at 3mo is indicative of neurotmesis
D. Neurotmesis is usually repairable
Answer: A (phrenic n is indicative of root avulsion)
Root avulsion is preganglionic
Horner’s is associated w lower trunk injuries
2017
What are the risk factors for DHH? (5)
- First born
- Female
- Frank breech
- Family hx
- Oligohydramnios
What is a teratologic hip? What is the treatment?
Related to DDH. Dislocated in utero and irreducible. Have pseudoacetabulum
Treatment: open reduction. Don’t use Pavlik or closed reduction
What conditions are associated w a teratologic hip?
- Arthrogryposis
- Lumbosacral agenesis
- Diastrophic Dwarfism
- Larsen’s
- Chromosomal abnormalities
What is the typical acetabular deficiency in DDH? In CP?
DDH: anterolateral
CP: Posterosuperior
List the soft tissue blocks to reduction in DDH (7)
LLLPPCT
1. Labrum
2. Limbus
3. Ligamentum teres
4. Pulvinar
5. Psoas tendon
6. Capsule
7. Transverse acetab ligament
RC question
List common packaging disorders (7)
- Congenital torticollis
- DDH
- Congenital knee dislocation
- Posteromedial tibial bowing
- Calcaneovalgus foot
- Club foot
- Metatarsus adductus
After what age are Barlow and Ortolani tests no longer useful?
3mo
After this, soft tissue tighten. These tests will not be useful
After 3mo, what is the most sensitive physical exam test for DDH?
Decreased hip abduction.
Cannot use Ortolani or Barlow tests after 3mo due to soft tissue tightening
Regarding imaging modalities for DHH, at what age range should you use US? When should you start using XR instead?
US useful at 4wks to 4mo
>4mo, use XR. Head ossifies. Can’t see through ossified head on US
What are the treatment options for DDH when the child is <6mo?
Pavlik harness is the only option
What are 3 parameters you should measure on US for DDH?
- Alpha angle: between acetab and ilium. Should be >60deg
- Beta angle: between labrum and ilium. Should be <55deg
- Head coverage %
RC question: List 6 XR findings of DDH before 6mo old
Acetabulum
1. Acetabular Index >25deg
2. Widened teardrop
3. Rounded acetabular corners
Head
4. Delayed femoral head ossification
5. Head not inferomedial to Hilgenreiner and Perkin’s lines
6. Disrupted Shenton’s line
Bonus - coxa valga
What is the Tonnis classification in DDH?
XR classification based on femoral head displacement relative to Perkin’s line and superior acetab rim
In DDH, head displaces laterally and superiorly
Grade 1: Head is reduced. Medial to Perkin’s
Grade 2: Lateral to Perkin’s but below acetab rim
Grade 3: Level w acetab rim
Grade 4: above acetab rim
In DDH, what are the implications of increasing Tonnis grade?
Each increase in Tonnis grade doubles the likelihood of failing nonop
What is a Pavlik Harness and what movements does it restrict?
Dynamic abduction brace. Prevents extension, adduction and IR
What are the indications for using a Pavlik Harness in DDH?
<6mo and reducible head
How often should the Pavlik Harness be worn for DDH and what is the duration of treatment?
Controversial. Some say wear for 23h/d for 6wks. Then wean out for another 6wks. During treatment, F/U q2mo w repeat exam and US. Continue F/U until maturity for recurrent instability or acetab dysplasia
Describes the straps involved in a Pavlik Harness and how to use them
Chest strap: at nipple line
Anterior strap: flexion
Posterior strap: abduction
Describe the ideal positioning of the legs in a Pavlik Harness. What complications are associated w its use?
90-100deg flexion, 45deg abduction
Complications include
- Transient femoral n palsy: from hyperflexion. Won’t see kid kicking (knee extension)
- AVN: from hyperabduction >60deg due to impinging on medial femoral circumflex
- Brachial plexus palsy: from shoulder straps
When using a Pavlik Harness, what is the stable zone? What is the safe zone? What can you do to increase them?
Stable zone: degrees of abduction between dislocation and max abduction possible
Safe zone: degrees of abduction between dislocation and safe amount of abduction
Can increase your zone w adductor tenotomy to increase abduction
After starting a Pavlik Harness of DDH, when should you followup next and why?
Should followup after a week to make sure family is using the harness correctly and see if hip reduced. If hip is not reduced after 3wks, need to stop the harness. Otherwise, risk Pavlik Harness disease
What is Pavlik Harness disease?
Develops if harness is worn but hip is not reduced. Dislocated hip causes posterosuperior acetab wear.
RC: A child w DDH is treated in a Pavlik harness and develops femoral n palsy. What is not true?
A. Can present bilaterally
B. Leads to increased need for open procedure
C. 60% resolve spontaneously
D. 2.5% incidence
Answer: C
100% resolve spontaneously
Most occur within 1wk. Indeed 2.5% incidence
Risk factors: older kid, larger kid, more severe dysplasia
In DDH, what should you do if the hip remains dislocated with Pavlik Harness?
Discontinue if not in hip after 3wks to prevent Pavlik Harness disease. Plan for closed reduction when kid is 4mo (safe for anesthesia)
If the Pavlik Harness is successful in keeping DDH hip reduced, what are some radiographic signs suggesting acetab remodeling? (3)
- Acetab Index decreases
- Smooth horizontal sourcil
- U-shaped tear drop
Describe the bony abnormalities in DDH hips (4)
- Shallow anteverted acetab
- Excessive femoral anteversion
- Delayed head ossification
- Coxa valga
What gait patterns are associated with DDH? (2)
- Trendelenburg: abductor insufficiency from dislocated hip
- Toe walking: compensate for shortened affected side
What are Hilgenreiner’s and Perkin’s lines? Where should the head normally sit in relation?
Hilgenreiner: horizontal line through triradiate
Perkin’s line: perpendicular to floor, along lateral acetab edge
Head should be inferomedial to these lines
In the hip, what is Shenton’s line?
Arc along femoral neck and obturator foramen. It is discontinuous if hip is dislocated
What is the acetabular index? What does it mean?
Angle formed between
- Hilgenreiner’s line
- Line from triradiate to lateral acetab margin
Normal is <25deg
Measures inclination of acetab roof
What is the center edge angle? What does it mean?
Angle between
- Vertical line through head
- Line from head center to lateral acetab margin
Normal >20deg
Measures acetab coverage
How does the teardrop sign change in DDH?
If subluxed/dislocated, widened. Becomes U-shaped when hip is reduced
What are the treatment options for DDH in kids after failing Pavlik or late presentation?
- Closed reduction + spica
- Open reduction +/- femoral shortening derotational osteotomy +/- pelvic osteotomy
What are the indications and contraindications of closed reduction/spica for DDH?
Indications
- Failed Pavlik (Do closed reduction >4mo when safe for anesthesia)
- Presented too late for Pavlik
Contraindication: teratologic hip (needs open reduction)
Describe the principles of closed reduction and spica cast for DDH
- Reduction technique: Ortolani
- Arthrogram
- Adductor tenotomy if too tight
- Spica
- MRI postop
Describe how to do a hip arthrogram for DDH closed reduction?
50/50 mix of radio-opaque dye and NS. Inject 2cc w 18gauge needle
Abduct hip and palpate adductor longus. Place needle inferior to adductor longus at head/neck junction. Aim for ipsilateral shoulder
Assess medial dye pool. If <5mm, likely reduced. If >7mm, not reduced
How is the spica cast positioned for DDH?
“Human position”
90deg flexion and 45 abduction. Neutral rotation
(Bonus fact: hip only rotated in spica for proximal femur #. Needs IR)
After successful closed reduction and spica cast application for DDH, what is the followup? How long should the spica be on for? What is the management after?
Change spica after 6wks
Should have spica cast on for 3mo
Then abduction brace for 2mo (1mo full time, 1mo night time)
On MRI, how do you determine if the hip is reduced in DDH?
Line from pubic rami should intersect w proximal femur metaphysis
Describe the principles of open reduction for DDH
- Bikini incision, Smith-Pete approach
- Identify the true acetabulum: iliopsoas will constrict capsule into hourglass shape. Cut iliopsoas. T capsulotomy
- Remove soft tissue blocks to reduction: limbus, lig teres, pulvinar, transverse acetab lig
- Reduce head. Should be deep and concentric
- If all good, do capsulorrhaphy
- If can’t unable to reduce or tight reduction: do femoral osteotomy
- If reduced but dysplastic acetab (so reduction is not deep and concentric), do pelvic osteotomy if kid >18mo
Describes the principles for femoral derotational shortening osteotomy in DDH. What are the indications?
Indications:
- Unable to reduce hip during open reduction
- Tight fit once reduced. Risk of AVN
- Also corrects excessive femoral anteversion
Technique
- Transverse intertrochanteric osteotomy
- Reduce head + remove overlapping bone
- Derotate anteversion by ER femur
- Fix w 4 hole plate
True or False: femoral shortening osteotomy in DDH reduces AVN rate
True. Decreases to 0-10% rate
What are the indications for a pelvic osteotomy in DDH? (2)
- > 18mo. Unlikely to remodel
- Severe dysplasia. High AI and deficient anterolateral coverage
Which pelvic osteotomies are commonly used for DDH? What are your considerations for each? (3)
- Salter: redirectional, for mild dysplasia. Provides anterolateral coverage but uncovers posteriorly. Don’t do for CP or shallow pelvis
- Dega: acetabuloplasty, so for shallow and large acetab. Global coverage, so can use for CP
- Pemberton: acetabuloplasty, so for shallow and large acetab. Anterolateral coverage
What are the 3 categories of pelvic osteotomies. Define each
- Redirectional. Shifts acetabulum but preserves its shape/volume
- Acetabuloplasty. Changes acetab shape/volume. Incomplete osteotomies, coverage is w own articular cartilage
- Salvage. Changes acetab shape/volume. Uses extra-articular bone to augment existing acetab, forms fibrocartilage
What are the contraindications for redirectional pelvic osteotomies? (2)
- Shallow acetab
- Non-concentric reduction
(If shallow acetab, better to do acetabuloplasty or salvage)
List the 3 pelvic osteotomies that rely on a cartilaginous hinge
- Salter: pubic symphysis
- Dega: triradiate
- Pemberton: triradiate
List the 3 types of redirectional pelvic osteotomies. At what age rage are each typically done and why?
- Salter: done before 8yo, because requires pubic symphysis as hinge. After 8yo, becomes too stiff
- Triple: done in adolescents. Pubic symphysis is too stiff for Salter. Triradiate is still open so can’t do PAO (Ganz)
- PAO: done after triradiate fusion because osteotomy goes through triradiate. This is why its a common non-salvage osteotomy done in adults
Which non-salvage pelvic osteotomy can be performed in adults and why?
Triple and Ganz
Don’t require mobile pubic symphysis (Salter) or open triradiate (Dega, Pemberton)
What are the indications and contraindications for a Salter pelvic osteotomy? What are the general techniques?
Indication: mild dysplasia in kids <8yo (mobile pubic symphysis)
CI: CP DDH due to deficient posterior coverage, shallow acetab
Osteotomy from sciatic notch to above AIIS. Iliac crest bone graft wedge into osteotomy site
What are the indications and contraindications for a Triple pelvic osteotomy? What are the general techniques?
Indications: adolescents and older
CI: shallow acetab
Technique: Salter osteotomy and cuts in superior and inferior rami
Which redirectional pelvic osteotomy does not violate the sciatic notch?
PAO
What are the indications and contraindications for PAO? What are the general techniques?
Indications: closed triradiate
CI: open triradiate. Shallow acetab
Technique: 4 cuts in superior and inferior rami, incomplete cut in ilium between ASIS/AIIS, and vertical in ischium. Doesn’t violate sciatic notch
What are the 2 types of acetabuloplasty?
Pemberton and Dega
What are the indications and contraindications for acetabuloplasty? What are the general techniques?
Difference between Pemberton and Dega: Pemberton involves only anterolateral roof, Dega involves whole acetab roof (so longer cut)
Indications: shallow acetab requiring shape/volume change
CI: closed triradiate (hinge)
Technique: Incomplete cut from just above AIIS towards sciatic notch, without violating. Wedges placed. No fixation needed
What are the 2 types of salvage pelvic osteotomies?
Shelf and Chiari
What are the general principles of a Shelf osteotomy?
Provides anterolateral coverage
Strips of bone graft taken from outer ilium. Length determined by desired CEA
Strips are wedged above acetab. Held together by repairing reflected rectus head
Complication: graft may resorb
What are the general principles of a Chiari osteotomy?
Provides anterolateral coverage
Osteotomy from sciatic notch to AIIS. Medialize acetabulum. Internal fixation.
What is the definition of coxa vara? What are possible causes?
Neck-shaft angle <120deg
3 main causes
- Congenital: associated w PFFD
- Acquired: trauma, infection, SCFE, Perthes
- Developmental: ossification defect in medial femoral neck
What is the cause of developmental coxa vara?
Due to ossification defect in medial femoral neck. Unknown etiology
- WB causes progressive varus deformity, which further increases compression at medial neck
- Deformity causes vertical proximal physis. Increases shear force across physis
Presents in early childhood after starting to WB
How do patients present w developmental coxa vara?
- Presenting after walking has begun
- Painless. Waddling, Trendelenburg gait (coxa vara decreases abductor tension and causes weakness)
- LLD
- Prominent (high riding) GT
- Restricted ROM
What are key XR findings for developmental coxa vara? (5)
- Neck shaft angle <120
- Short femoral neck
- Vertical physis
- Inverted Y sign - triangular metaphyseal fragment at inferior neck. Pathognomonic
- Hilgenreiner-epiphyseal angle. Normal <25. Coxa vara >25
What is the Inverted Y sign on hip XR?
AP view. Triangular metaphyseal fragment at the inferior femoral neck. Pathognomonic for developmental coxa vara
What is the Hilgenreiner-epiphyseal angle?
For developmental coxa vara
On AP XR. Angle between
- Hilgenreiner’s line
- Line through proximal femoral epiphysis
Normal <25deg
Coxa vara >25deg
How is the Hilgenreiner-epiphyseal angle used to prognosticate developmental coxa vara?
Correlates w risk of progression
<45deg: unlikely to progress
45-60: indeterminate
>60: likely to progress
What are the treatment options for developmental coxa vara? What are the indications for each? (2)
- Observation. Indications: H-E angle <60deg. Should closely follow H-E angles between 45-60deg as risk of progression is indeterminate
- VDRO (valgus derotation osteotomy). Indications
- H-E angle >60deg
- He angle 45-60 but with Trendelenburg gait, hip abductor fatigue or angle progression
Describe the general principles of valgus derotation osteotomy for developmental coxa vara
- Direct lateral approach
- Likely need adductor tenotomy
- Osteotomy: intertroch or subtroch. Do not do at neck (poor outcomes)
- Overcorrect varus to minimize recurrence
- Correct version
- Blade plate
- Can also do GT epiphysiodesis to prevent recurrence
- Hip spica x6wks
What is the rate of recurrence after VDRO for developmental coxa vara?
Up to 50%. Decrease w overcorrection
What is the rate of premature physeal closure after VDRO for developmental coxa vara?
Up to 90% within 2yrs
What is Legg-Calve-Perthes disease?
Idiopathic osteonecrosis of the femoral head. Mostly in boys, 5-8yo
Perthes is a diagnosis of exclusion. What is the DDx? (5)
- Septic hip
- Sickle cell
- Corticosteroid therapy
- Skeletal dysplasia - suspect of both hips at same stage of disease
- Mucopolysaccharidoses
What are risk factors and associated conditions of Perthes?
Risk factors
1. Famhx
2. Low birth weight
3. Abnormal birth presentation
4. 2nd hand smoke
Associated conditions
1. ADHD (30%)
2. Delayed bone age (90%)
What is the clinical presentation of Perthes?
- Insidious groin pain and limp
- Limited abduction and IR
- Mild LLD
What are key XR findings in Perthes? (9)
- Widened joint space: cartilage grows but no ossification
- Crescent sign
- Smaller head
- Head collapse (loss of height)
Head at risk signs - Gage sign: V-shaped lucency
- Lateral epiphysis calcification
- Lateral femoral head subluxation
- Horizontal physis
- Metaphyseal cyst
What is the Waldenström classification?
Radiographic stages of Perthes
1. Initial: sclerotic epiphysis. Widened joint space. Cartilage grows but no ossification
2. Fragmentation: lasts 1yr. Crescent sign from subchondral #. Collapse. Bisphosphonates may help here
3. Reossification
4. Remodeling
RC: What are prognostic factors for Perthes? (10)
- Age of onset: worse if >8
- Gender: worse if female
- Extent of head involved. Catterall classification. Extensive = bad
- Extend of deformity and joint incongruity. Stulberg classification. Aspherical, noncongruous = bad
- Extent of subchondral resorption. Salter-Thompson classification. Crescent sign >50% of head = bad
- > 2 Catterall head at risk signs
- Lateral pillar height (aka Herring classification). Herring C = bad
- Premature physeal closure
- Stiff ROM
- > 20% hip extruded
What is the Stulberg classification?
For Perthes disease. There is a relationship between femoral head shape and early OA risk.
1: normal
2: minor head change
3: aspherical head
4: Flattened head, congruous acetab
5: Collapsed head, noncongruous acetab
Poor interobserver reliability. Can’t determine until skeletal maturity
What is the Salter-Thompson classification?
Based on radiographic crescent sign
Class A: crescent sign involves <50% femoral head
Class B: crescent sign involves >50%
What is the Catterall classification?
Extent of head involvement at fragmentation stage. Classified as groups
1: anterior epiphysis only
2: anterior and central epiphysis
3: most of epiphysis, sparing posteromedial corner
4: total head
What are the Caterall head at risk signs? (5)
- Gage sign: v-shaped lucency at lateral epiphyseal/metaphyseal junction
- Lateral epiphysis calcification
- Lateral femoral head subluxation
- Horizontal physis
- Metaphyseal cyst
What is the lateral pillar (Herring) classification?
Height of lateral third of epiphysis. Has best interobserver agreement
A: full height. Good outcome
B: 50 - 100% height. Poor outcome if >8yo
B/C: 50%
C: <50% height. Poor outcome in all
Which classification systems are to be used for the fragmentation stage of Perthes? (3)
- Salter-Thompson: crescent sign
- Caterall: head involvement
- Lateral pillar (Herring): height
The treatment for Perthes disease is for which stage?
Fragmentation. Reossification and remodeling stages don’t need treatment
What are the indications for nonoperative management of Perthes? General principles?
Indications: <6yo or lateral pillar A
Activity restriction
Protected WB until reossification
Bracing/orthotics are not helpful
What are the outcomes for kids <8yo with Perthes?
Kids <6yo do well without treatment if lateral pillar A, B or B/C
Most end up w Stulberg 1 or 2 at maturity. 80% good outcome
Did poorly if pillar C
Generally, what are the indications for operative management in Perthes? (3)
- > 8yo
- Herring B
- Herring B/C
Kids <8yo all do well w nonop except if Herring C
All kids w Herring C do poorly regardless of treatment
What are the operative options for Perthes? What are the indications? (2)
- Femoral varus osteotomy +/- pelvic osteotomy
Indications: head extrusion in kids >8yo or B, B/C
Make varus to reposition in acetab.
Pelvic osteotomies: salter, triple, Dega or Pemberton - Femoral valgus osteotomy +/- salvage pelvic osteotomy
Indications: head extrusion + painful hinging during abduction
Salvage osteotomies: shelf or Chiari
What femoral head deformities are associated with Perthes? (2)
- Coxa magna: wider head and bigger acetab. Due to overexaggerated healing
- Coxa plana: flat head
What is the epiphyseal slip-in index? How do you measure it?
Measure w arthrography. Used to determine if VDRO would be beneficial
Place hip in 40deg abduction to mimic hip position after varus osteotomy
Index is ratio between
- Horizontal distance from lateral acetab rim to tip of epiphysis
- Horizontal distance from tear drop to lateral acetab rim
ESI <20% = head won’t be well contained after VDRO. Poor outcomes w VDRO
ESI >20% = head will be contained. Good outcomes w VDRO
Well contained head after VDRO is important for remodelling into spherical head
RC: Which of these patients is least likely to benefit from a VDRO?
A. 8yo w Herring B
B. 7yo w lateralized hip
C. Epiphyseal slip index >20%
D. Performing the osteotomy during initial or fragmentation phase
Answer: B
This is the best answer but it depends on the situation. If it is a lateralized hip that causes hinge abduction, then the pt would benefit from a valgus osteotomy. If it is a lateralized hip that can be contained w a VDRO (check w arthrogram and hip in 40deg abduction), then VDRO would still be useful
The other choices would benefit more though
2018, 2016
What are the complications associated w Perthes? (6)
- Femoral head deformity: coxa magna and plana
- Lateral hip subluxation from extrusion. May cause hinge abduction
- Premature physeal arrest
- OA
- Acetab dysplasia
- FAI and labral injury
What is SCFE and in what direction is the slip?
Femoral neck metaphysis displaced anterior and superiorly compared to epiphysis
What is the leg position in SCFE? What motions are limited?
Leg is in extension, varus (adduction), ER
Limited FABIR (flexion, abduction, IR)
List risk factors for SCFE (11)
- Obesity: single greatest risk
- Male
- Ethnicity: Blacks, Pacific Islanders
- Peak growth velocity (12 in girls, 14 in boys)
- Younger age: risk factor for bilateral slip
Anatomic variants that increase shear force - Femoral anteversion
- Decreased neck-shaft angle
- Physeal obliquity. More vertical = bad
Other conditions - Previous radiation
- Endo disorders
- Down syndrome
What endocrine disorders are associated with SCFE? (6)
- Hypothyroidism
- Growth hormone
- Renal osteodystrophy
- Panhypopituitarism
- Hypo or hyperparathyroidism
- Hypogonadism
Who should have an endocrine workup for SCFE? (2)
- <10yo
- Weight <50 percentile
What zone of the physis does SCFE affect?
Hypertrophic zone
What are the classification systems for SCFE? (4)
- Traditional: based on duration. Pre-slip, acute, chronic, acute on chronic
- Loder: ability to WB
- % Displacement
- Southwick angle
What is the Loder classification?
For SCFE. Based on ability to WB and correlates w AVN risk
- Stable: able to WB, even if need crutches. 10% AVN risk
- Unstable. Unable to WB. 50% AVN risk
What is the % displacement classification for SCFE?
Displacement of epiphysis relative to metaphysis
Mild: <33%
Moderate: 33-50%
Severe: >50%
What is the Southwick Angle Classification for SCFE?
Difference in epiphyseal-shaft angle between both sides, on frog-leg latera XR
Normal: 12deg
Mild: <30deg
Moderate: 30-50deg
Severe: >50deg
What is the clinical presentation of SCFE?
- Pain: groin, knee
- Limited ROM in FABIR: flexion, abduction, IR
- Prefer sitting w affected leg crossed over the other
- Drehman sign: obligatory hip ER w passive flexion
- Foot is ER on foot progression
- Trendelenburg gait
- LLD
What is the best XR view to detect subtle SCFE slips?
Frogleg lateral
What are key XR findings in SCFE? (3)
- Klein’s line
- Physeal widening
- Blurred metaphysis: aka blanch sign of Steel. Due to overlapping metaphysis and epiphysis
What is Klein’s line?
For SCFE. Line along superior femoral neck should intersect the epiphysis. In SCFE, the epiphysis is flush or below line
What is the primary goal of SCFE treatment?
Prevent progression
Longterm followup shows that remodeling occurs after insitu fixation
For very severe slips, some may correct the slip, but still controversial
What are the treatment options for SCFE? Treatment for residual deformity later?
- In situ perc pinning
- Modified Dunn
- Contralateral prophylactic pinning
Residual deformity: proximal femur osteotomy
Describe the reduction maneuver for SCFE in situ pinning
None. Trick question. There is no closed reduction.
There is serendipitous reduction when positioning on table
For in situ pinning of SCFE, 1 screw is sufficient. Why are the advantages and disadvantages of using 2 screws?
Advantage: slightly more stable
Disadvantages
1. Violates physis more
2. Difficult to assess joint violation
3. Increased AVN risk, as more likely to violate lateral epiphyseal vessels
4. Labral tear, seen when 2nd screw used and penetrates anterosuperior quadrant
Describe the technique for SCFE in situ pinning
- Serendipitous reduction while positioning on radiolucent table
- Start at anterior neck. Aim posterosuperior into epiphysis
- 6.5 or 7.3 cannulated screw
- Approach-withdraw on fluoro to assess joint penetration
- Postop: WB if stable, NWB if unstable
Describe ideal screw positioning w SCFE in situ pinning
Center of epiphysis
Perpendicular to physis
Cross physis w 5 screws
6.5 or 7.3 cannulated screws. Fully threaded easer to remove later
What are the goals and indications for the modified Dunn for SCFE management?
Goal: surgical hip dislocation for capital realignment. Severe slips may not remodel adequately. May lead to limited ROM and FAI
Indication: severe slips
Describe the technique for the modified Dunn procedure for SCFE
- Gibson approach
- Surgical hip dislocation w z-capsulotomy
- Develop retinacular flaps. Epiphysis will remain attached to posterior flap (blood supply)
- Starting anteriorly, free the epiphysis from the metaphysis
- Debride callus from along posterior metaphysis to allow reduction and prevent retinaculum from kinking
- Reduce epiphysis + fix
What is the main complications w the modified Dunn procedure for SCFE?
AVN
Indications for contralateral prophylactic pinning in SCFE? (6)
High risk patients or risk of loss to followup
1. Obese male
2. Endocrine disorder
3. Down syndrome
4. Initial slip at younger age (<10yo). Literature: younger kids more likely to have bilateral SCFE
5. Open triradiate: indicates younger
6. Unreliable followup (lives in remote area, etc)
Describe the management of residual deformity for SCFE. Indications? Procedure?
Need corrective osteotomy. Can be intertrochanteric or subtrochanteric. Avoid neck osteotomy as risk of AVN
Indications: painful or function-limiting deformity
Fix w blade plate
Correction needed (FABIR)
- Flexion
- Valgus (abduction)
- IR
What are the risk factors for AVN for SCFE? (3)
- High grade slips
- Attempts at reduction
- Hardware in posterosuperior neck
What complications are associated with SCFE? (5)
- Femoral head osteonecrosis
- Contralateral SCFE
- Residual hip deformity
- Slip progression
- Labral tear from additional 2nd screw during in situ fixation
What other conditions are associated w congenital knee dislocation? (4)
- Myelomeningocele
- Arthrogryposis
- Larsen’s
- Packaging disorders
What is the clinical presentation of congenital knee dislocation? What key physical examinations must be done?
Hyperextended knee at birth
Assess passive flexion as it determines treatment
R/O DDH
A bipartite patella is asymptomatic. In what situation may it cause persistent pain?
Trauma. Either direct, indirect or from jumping activities. Disrupts fibrocartilaginous zone between the accessory fragment and main patella. Zone can’t heal by bony union, so causes persistent pain
What is the Langenskiold Classification?
Stages of infantile Blount’s disease, based on XR
Stages 1-4: worsening medial metaphyseal beaking and sloping
Stages 5-6: physeal bar formation
True or False: infantile Blount’s disease can spontaneously resolve
True.
Common in Langenskiold stage 2
Possible in stage 4
What is the metaphyseal-diaphyseal (Drennan) angle?
Differentiate between physiologic varus vs infantile Blount’s
Angle between:
- Line perpendicular to longitudinal axis
- Line connecting metaphyseal beak
<10deg: physiologic. 95% resolve
10-16deg: indeterminate. Follow closely
>16deg: Blount. 95% progression
What are XR findings in rickets? (8)
- Physeal widening
- Metaphyseal cupping
- Poor bone density
- Genu varum
- Rachitic rosary: at osteochondral junction in ribs
- Codfish vertebra: biconcave vertebral body
- Cat back: kyphosis
- Looser’s zones: insufficiency # seen on compression side of bone. Common at proximal femur, ribs, ulna, rami
What are the types of rickets?
- Vitamin D resistant: familial hypophosphatemic
- VitD deficient: nutritional
- VitD dependent
What lab abnormality is seen in vitamin D resistant rickets?
Decreased PO4
What lab abnormality is seen in VitD deficient rickets?
Low Vitamin D, low Ca, Low PO4
Rationale: low vitD in take. The net effect of vitD is to increase Ca and PO4 absorption from the gut, but this does not happen
What lab abnormality is seen in type 1 vitamin D dependent rickets?
Low calcitriol, low Ca, Low PO4
Rationale: lack enzyme to convert vitD to calcitriol
The net effect of vitD is to increase Ca and PO4 absorption from the gut, but this does not happen
What lab abnormality is seen in type 2 vitamin D dependent rickets?
High calcitriol, low Ca, low PO4
Defective calcitriol receptor so the body makes more to have an effect. But no effect so gut doesn’t absorb Ca and PO4
What lab abnormality is seen in hypophosphatasia?
Low ALP, high Ca, high PO4
Poor ALP activity. So Ca and PO4 don’t form hydroxyapatite in bone
What are XR findings in hypophosphatasia? (3)
- Genu varum
- Physeal widening
- Deossification of bone next to physis
What are common XR findings in a spine w neurofibromatosis? (3)
- Vertebral scalloping: erosion due to dural ectasia or intraspinal neurofibroma
- Rib pencilling. Poor prognosis for scoliosis. Rapid curve progression if >3 ribs affected
- Enlarged foramina: due to neurofibroma
Why is a spine MRI always needed preop in neurofibromatosis? What are typical findings?
R/O tumors. Neurofibromas are vascular and present a bleeding risk
Findings:
- Dural ectasia: dural sac dilation that erodes bone. Vertebral scalloping
- Dumbbell lesion: neurofibroma that expands through foramina
What is the Jones classification?
For tibial deficiency
1A: no tibia. No extensor mechanism, hypoplastic distal femoral epiphysis
1B: tibial anlage present, delayed ossification. Intact extensor mechanism. Normal femoral epiphysis
2: proximal tibia only
3: diaphysis and distal tibia only
4: ankle diastasis at distal tib/fib joint. Short tibia
What is the Achterman and Kalamchi Classification?
Types of fibular deficiency
1A: nearly normal. Proximal fibula is distal to tibial physis. Distal fibula is proximal to talus
1B: partial absence. Unable to support ankle joint
2: complete absence
What is the Aitken classification?
For PFFD
Class A: femoral head present, normal acetab. Short femur
Class B: femoral head present but dysplastic acetab. No bony connection between head and shaft
Class C: no head, dysplastic acetab. No articulation between femur and acetab
Class D: no head, absent acetab
List all the components of assessing rotational profile
- Foot progression
- Hip IR and ER
- Thigh-foot angle
- Lateral foot border
- Heel bisector
How do you assess the rotational profile of the hip? What are normal values?
Test ROM in prone
- Increased IR if >70deg. Normal is 20-60deg
- Decreased ER if <20deg. Normal is 30-60deg
How do you assess the rotational profile of the tibia? What are normal values?
Thigh-foot angle in prone position
Abnormal >10deg IR
Normal in infants: 5deg IR
Normal in 8yo: 10deg ER
How do you assess the rotational profile of the foot?
- Lateral border of foot should be straight
- Heel bisector. Normally through 2nd/3rd webspace
What is the relationship between the talus and calcaneus on XR in a clubfoot compared to a normal foot?
Hindfoot parallelism. Talus and calc are parallel on AP and dorsiflexion lateral view
- AP view: talus and calc are normally divergent
- Dorsiflexion lateral: talus and calc normally convergent
Describe the normal alignment of the talus and calcaneus on an AP XR
- Axis of talus parallel to 1st MT axis
- Axis of calcaneus falls on 4th MT axis
- Talus and calcaneus are divergent. Angle between (talocalcaneal angle) is 20-40
Is the talocalcaneal angle increased or decreased in clubfoot?
Decreased. <20deg. Talus and calcaneus display hindfoot parallelism in clubfoot
Is the talocalcaneal angle increased or decreased in cavovarus feet?
Decreased. <20deg in hindfoot varus
What are the 3 common gait patterns seen in CP? Do they affect the stance or swing phase of gait?
Stance
1. Jump gait: true vs apparent equinus
2. Crouch
Swing
3. Stiff knee
What is jump gait?
Toe walking. No heel strike at initial contact.
2 types: true vs apparent equinus
What is true equinus jump gait?
Due to gastroc-soleus spasticity or contracture
Hips and knees may be
- Hyperextended: will resolve after equinus treated
- Hyperflexion knee/hip: due to spasticity or contracture
What is apparent equinus jump gait?
Foot appears in plantarflexion relative to the floor, but actually isn’t
Due to hyperflexion of knee/hip. Do not correct at the ankle!
What is crouch gait?
Flat foot at initial contact due to weak ankle plantar flexors. Develops other deformities as a consequence:
- Knee hyperflexion contracture - initially as compensation then becomes fixed
- Patella alta: quads tendon shortens, patella tendon lengthens due to knee hyperflexion
What is stiff knee gait?
Occurs during swing phase. Limited knee flexion . Difficult to clear foot
In a child w hip adduction contracture, what is the goal of adductor release? Describe how to do the release
Goal: 45deg abduction
Landmark: adductor longus
Incision: parallel to groin crease and 1cm distal
Order of release:
- Adductor longus. Avoid anterior branch of obturator n
- Gracilis
- Assess if abduction >45deg
- If not enough abduction, release adductor brevis
Describe the indications and principles of the SPOTT procedure for the management of equinovarus in CP patients
Indication: passively correctable equinovarus deformity due to spastic tib post
Transfer to peroneus brevis
- Medial incision over tib post
- Lateral incision over peroneals
- Split tib post. Reroute posterior to tib/fib to suture to peroneus brevis
Describe the indications and principles for the SPLATT procedure for the management of equinovarus in CP patients
Indication: passively correctable equinovarus deformity due to spastic tib ant
- Medial incision over tib ant
- Split tendon and release from 1st MT. Reroute laterally under extensor retinaculum
- Transosseous tunnel through cuboid. Tie sutures over button while foot dorsiflexed
What is Reimer’s migration index?
Width of uncovered head / total width
Hip at risk >25%
Subluxation >30%
Dislocation >100%
Most accurate method of identifying and monitoring hip stability
What spine abnormalities are associated w OI? (3)
- Scoliosis
- Codfish vertebrae: from compression #
- Basilar invagination
What are XR findings in osteopetrosis? (7)
- Thick cortical bone
- Increased bone density
- Lose medullary canal diameter: “bone on bone appearance”
- Erlenmeyer flask: proximal humerus, distal femur
- Rugger jersey spine
- Block femoral metaphysis
- Coxa vara
What are typical femur XR findings in achondroplasia?
Flared metaphysis
Inverted V distal femur physis
Normal distal epiphysis
Describe how the epiphyses appear on XR in MED
Multiple epiphyses affected (duh)
Delayed ossification
Fragmented
Flattened
Describe how to differentiate MED from bilateral Perthes?
When bilateral Perthes suspected, order skeletal survey to R/O MED
MED is different from Perthes in that:
- Symmetric and bilateral presentation. Perthes is not synchronous
- Early acetabular changes
- No metaphyseal cysts
Describe typical knee XR findings in MED (3)
- Valgus
- Flat femoral condyles
- Double layer patella
What are typical hip XR findings in SED?
- Horizontal acetab roof
- Coxa vara
- Delayed head ossification
What are nonorthopaedic manifestations of Kniest dysplasia?
- Flat facies
- Cleft palate
- Resp insufficiency
- Eyes: myopia and retinal detachment
- Ears: otitis media and hearing loss
What is epiphyseal bracket?
AKA delta phalanx. Congenital disorder of epiphysis affecting phalanx. Distal and proximal phalanx connect w extension of epiphysis along the diaphysis. Forms C-shaped curve. Diaphysis appears D-shaped
What are the treatment options for epiphyseal bracket?
Pre-op splinting - loosen soft tissues
1. Physiolysis and fat interposition: skeletally immature. Resect bracket. Leave normal epiphysis at ends
2. Corrective osteotomy: after epiphyseal bracket closure
What is the Bayne classification?
Types of ulnar deficiency
0: hand deficiencies only
1: smaller ulna and both physis present
2: part of ulna missing (usually distal end)
3: absent ulna
4: radiohumeral synostosis
What is the clinical presentation of madelung deformity?
- Asymptomatic until adolescent
- Ulnar impaction
- Medial n irritation
- Restricted prosupination
- Carpus dislocates radial and volar
What are typical XR findings in madelung deformity?
- Dorsal/volar bowing of radius
- Excessive radial inclination and volar tilt
- Positive ulnar variance
- DRUJ displaced dorsally
- V-shaped deformity at DRUJ with lunate herniated at apex
- Carpus subluxed radial and volar
Describe the finger syndactyly classification
- Simple: only soft tissue
- Complex: bony fusion
- Complications: accessory phalanges or abnormal bones
- Complete: skin extends to finger tips
- Incomplete: skin fusion doesn’t extend to tips
What is the Wassel classification?
Types of preaxial (thumb) polydactyly
1. Bifid distal phalanx
2. Duplicated distal phalanx
3. Bifid proximal phalanx
4. Duplicated proximal phalanx. Most common
5. Bifid metacarpal
6. Duplicated metacarpal
7. Triphalangia
