Exam 3 Flashcards
(137 cards)
1
Q
Unchanged or decreased frequency of BMs
Pebbly or cracked stools
Straining/painful stooling
A
Constipation S/S
2
Q
Constipation Contributing Factors
A
Stool withholding
Slow transit
Sensory (taste, smell) abnormalities
Diet
3
Q
Laxatives (Dosing)
A
PEG (0.4-0.8 g/kg/day max 17g or 1 tsp/full year of age max 4)
Lactulose/Sorbitol 70% (1 mL/kg q12-24 max 60/30 mL/day)
Mineral Oil (1-3 mL/kg/day max 45)
4
Q
Concomitant Symptoms of Abdominal Pain Suggesting Organic Etiology
A
Persistant vomiting, GI blood loss
Rashes, joint complaints, fever
Dysphagia, weight loss, stunting
5
Q
Categorized by timing & content:
Acute watery - hours - days
Acute bloody/Dysentery
Prolonged (7-14 days) or Persistent (>14 days)
A
Diarrhea Presentation
6
Q
Diarrhea Diagnostics & Management
A
Depends on Category:
Watery - rehydrate, observe
Bloody/Dysentery - Infection/allergy/autoimmune - get a stool sample
Persistent - Parasitic, bacterial, or enteroviral infection, or unmasking of a chronic condition
Malnutrition - refeed
7
Q
Low-grade fever
Watery diarrhea; vomiting
Respiratory symptoms
A
Viral Gastroenteritis Presentation
8
Q
Acute Gastroenteritis Management
Viral, Bacterial, or Malnutrition-related
A
Vaccination to prevent (Rotavirus); probiotics to shorten
Rehydration (low-os ORS)
Refeeding (2-4 hours post rehydration); zinc supplements (malnutrition-related diarrhea)
9
Q
Bacterial gastroenteritis
May not be bloody
Vomiting
A
Salmonella Infection Presentation
10
Q
Salmonella Infection Management
A
3 mo.+: Rehydration/refeeding
<3mo., imm. comp., SCD: Antibiotic dependent on susceptibility (PCNs, Bactrim, tetracyclines)
11
Q
Vomiting, poor feeding, poor growth, FTT, Tooth erosion Blood in the stools Coughing, breathing problems Irritability
A
GERD Presentation, Signs
“Disease” means complications/sequelae
12
Q
GERD Management
A
NUTRITION
Avoid upright position while feeding
<12mo: rice cereal
12mo+: H2RA (-tidines) or PPI (-prazoles)
13
Q
Bacterial GE+
potential for HUS (Pallor, fatigue/SOB, hemophilia/hematuria)
Bloody, watery, and dysenteric OR
1. Bloody, solid diarrhea
A
E. Coli
Diarrhea quality important in differentiating type of e. coli infection:
1. Shiga toxin producing e. coli
14
Q
E. Coli Management
A
Inpatient AGE therapy (aminoglycoside or 3rd-gen cephalosporin antibiotic –> susceptible antibiotic)
15
Q
High Fever (>40); CNS involvement Bloody Stool Severe abdominal pain
A
Bacterial Gastroenteritis Presentation
16
Q
Bacterial GE+
Malaise
Tenesmus
Cramping abd pain
A
Shigella Infection Presentation
17
Q
C Diff Infection Management
A
Discontinue antimicrobial agents if on them OR
IMMEDIATELY start PO metronidazole x 10-14 d if not
18
Q
Feeding dysfunction/dysphagia, esophageal food impaction, heartburn/GERD symptoms
Esophageal stricture
A
Eosinophilic Esophagitis Presentation
19
Q
Eosinphilic Esophagitis Management
A
Eliminate dietary allergens
Topical corticosteroids
20
Q
Painful swallowing, drooling, food refusal
Necrosis w/ ulceration, perforation, mediastinitis, or peritonitis
A
Caustic Esophageal Burns Presentation
21
Q
Caustic Esophageal Burns Management
A
Inpatient steroids, then endoscopy (48-72 hours postingestion) and go from there
22
Q
Dysphagia, odynophagia, drooling
Regurgitation, chest/abdominal pain
A
Foreign Body Ingestion Presentation
23
Q
Foreign Body Ingestion Management
A
Non-motile esophageal body - Removal in 24 hours
Button battery - emergent excision
Other - will pass spontaneously
24
Q
Recurrent pulmonary infections
Vomiting, dysphagia
Anemia, failure to thrive
A
Hiatal or Paraesophageal Hernia
25
Hiatal/Paraesophageal Hernia Management
Upper GI series or CT to confirm
| Surgery to repair
26
12- wks: Nonbilious/projectile vomiting, dehydration
| Avid nursing
Pyloric Stenosis
27
Pyloric Stenosis Management
BMP (hypochloremic alkalosis) & US to confirm
| Rehydration/electrolyte balance *followed by* pyloromyotomy
28
Epigastric pain, vomiting, and hematemesis/hematochezia/melena
Gastric/Duodenal Ulcer
29
Gastric/Duodenal Ulcer Management
Upper GI endo to confirm
| Culture to determine H. pylori involvement: treatment with amoxicillin, clarithromycin, & a PPI
30
Bile-stained vomiting
| Overt SBO
Intestinal Malrotation
31
Intestinal Malrotation Management
Upper GI series to diagnose (DJJ/Jejunum R of spine)
| Surgery; volvulus is emergent
32
Diarrhea, dehydration
Electrolyte or micronutrient deficiency states
Growth failure
Short Bowel Syndrome
33
Short Bowel Syndrome Management
Continuous formula through gastrostomy tube
Acid suppression, antimotility and antidiarrheal agents
Antibiotics to treat small bowel bacterial overgrowth
34
Recurring abdominal pain+screaming+knee-drawing
Vomiting, Diarrhea, Bloody stools
Tender, distended abdomen w/ sausage-shaped mass
Intussusception
35
Intussusception Dx & Tx
Confirm with abdominal ultrasound > AXR
| GI referral - Air Enema Reduction or surgery
36
Painless swelling to small area of groin
May abate when the infant is active, cold,
frightened, or agitated
Singular, depressible
Inguinal hernia
37
Maroon/melanotic rectal bleeding
Meckel Diverticulum
38
Meckel Diverticulum Management
```
Meckel Scan (special nuclear dye) to confirm
Refer for surgery
```
39
Fever and periumbilical/RLQ abdominal pain
Anorexia, bilious post-pain vomiting
Constipation, diarrhea
Acute Appendicitis
40
Acute Appendicitis Management
CRP & WBC elevation specific, not sensitive
Confirm with ex-lap
Refer for appendectomy
41
Newborn failing to pass meconium, emesis
Abdominal distention and reluctance to feed
Enterocolitis
Hirschsprung Disease
42
Hirschsprung Disease Management
Confirm with biopsy
| Refer for surgical repair
43
Crying with defecation; holding back stools
| Red bleeding outside of stool following defecation
Anal fissure
44
Anal Fissure Management
Confirm visually
Stool softener
Sitz baths for comfort
45
Initiation of Antibiotic Treatment 1-14 days prior
Persistent Watery Diarrhea
Abdominal Pain, Fever
C. Diff infection
46
Upper vs Lower GI Bleed Management
Saline gastric lavage vs not
| EGD vs Colonoscopy: ID site of bleed
47
Three or more recurrent episodes of stereotypical vomiting in children usually older than 1 year; the
emesis is forceful and frequent, occurring up to six times per hour for up to 72 hours or more
Cyclic Vomiting Syndrome
48
Cyclic Vomiting Syndrome Management
Trigger avoidance (re: migraine triggers)
Sleep (Diphenhydramine, Lorazepam)
Antimigraine, antiemesis Rx
49
Recurrent attacks of abdominal pain or discomfort at least once per week for at least 2 months
Little relationship to bowel habits and physical activity
Functional Abdominal Pain
50
Functional Abdominal Pain Management
Reassurance
Restriction of various sugars/sweeteners?
Peppermint Oil?
51
Diarrhea, vomiting
Failure to thrive, anorexia, poor weight gain
Abdominal pain, distention, edema, ascites
(bulky, foul, greasy, pale stools)
[Repeated infections]
Malabsorption Syndromes
(Fat malabsorption)
[Carbohydrate malabsorption]
52
Management of Malabsorption Syndromes
```
Nutrition replacement (albumin, hi protein, low fat)
Diuretics
```
53
6 - 24 mo
Chronic diarrhea, vomiting
Abdominal distention, irritability
Anorexia, poor weight gain
Celiac Disease
54
Celiac Disease Management
Strict dietary gluten restriction
| Supplemental calories, vitamins, and minerals (acute)
55
Adolescents & Children
Delayed puberty/short stature/delayed menarche
Anemia, decreased bone density, arthritis
Epilepsy
Intensely pruritic rash (elbows, forearms, knees)
Celiac Disease
56
6 - 24 mo
Rash on the extremities, around orifices, eczema
Profound FTT, immune deficiency
Fatty, greasy diarrhea
Acrodermatitis Enteropathica
6-24 mo: weaning from breast-feeding
57
Acrodermatitis Enteropathica Management
Zinc supplment (symptoms are caused by zinc deficiency)
58
```
Uveitis
Recurrent oral aphthous ulcers, rash
Arthritis
Growth and pubertal delay
[Abdominal pain, diarrhea, bloody stools]
Fever
Anorexia, anemia, fatigue, weight loss
(Stricturing process, abscess)
```
Inflammatory Bowel Disease
[(Chron Disease)]
[Ulcerative Colitis]
59
Inflammatory Disease Management
(Chron)
[UC]
5-ASA Derivatives: sulfasalazine 50 mg/kg/day
Corticosteroids
Moderate-Severe: adalimumab IM
Severe/steroid-dependent: immunomodulators - AZA, 6MP, (MTX)
(Enteral liquid formula --> High pro, high carb, even fat diet)
[Total Colectomy if other treatments are ineffective/contraindicated]
60
Anaphylaxis Management
IM epinephrine: autoinjector kit prescribed after first incidence of anaphylaxis.
< 15 kg: 0.1 mg
15-30: .15
>30: .3
61
Diarrhea, abdominal pain, vomiting, fever
Dehydration
Bloody stools
Seizures, meningismus (stiff neck, photophobia, confusion), encephalopathy
```
Campylobacter Gastroenteritis
(Bacterial Gastroenteritis: high fever, CNS involvement, severe abdominal pain, bloody stools)
```
62
Campylobacter Infection Management
```
Supportive care (HYDRATION, nutrition)
Severe: azith 10 for 3, or eryth 40 for 5
```
63
```
From childhood: asymptomatic
Epigastric or stomach pain/tenderness
Nausea, vomiting
Bloody stool/vomit
Gas
```
H. Pylori Infection
Epigastric pain: PUD
Stomach pain, gas: gastritis
64
```
Vague GI symptoms with:
Dysphagia, odynophagia
Weight loss, linear growth deceleration
Delayed puberty
Family history of IBD, CD, PUD
```
Red flags for H. Pylori Infection: refer to GI
65
H. Pylori Diagnosis & Management
Upper GI Endo (biopsy) to confirm (GI referral)
| PPI w/ Amoxicillin (or Clarithromycin if PCN allergy) & Metronidazole until susceptibility is established
66
voluminous, nonbloody, and watery diarrhea
| 1. malaise, N/V
cryptosporidiosis
| 1. C. hominis
67
Cryptosporidiosis Management
Confirm with microscopic stool analysis (oocysts)
Supportive therapy, self-resolves in 2 weeks
Immunocompromised (suff. CD4 count): Nitazoxanide
68
Watery, nonbloody, foul-smelling, greasy diarrhea
Abdominal distention
Anorexia, maybe fever
Giardiasis
69
Giardiasis Diagnosis & Management
Trichrome stain to confirm
Metronidazole x 5-7d or
Tinidazole x 1 or
Nitazoxanide x 3 days
70
Dysentery w/ any of
1. Rectal bleeding, N/V, abdominal distention
2. Tachycardia, fever, abd pain/distention, dehydration
3. Fever, abdominal pain, hepatomegaly
```
Amebiasis
90% of cases are asymptomatic
1. Necrotizing colitis
2. Toxic megacolon
3. Liver abscess
```
71
Amebiasis Diagnosis & Management
Confirm with stool antigen test
Tinidazole (or metronidazole)
Followed by an intraluminal agent (Paromomycin*, Iodoquinol, or diloxanide furoate)
72
Flulike illness
Nontender, nonsuppurative cervical lymphadenopathy
Up to 6 weeks
1. Eye pain, reduced vision, floaters, strabismus,
leukocoria
2. encephalitis, myocarditis, pneumonitis, hepatitis
Toxoplasmosis
1. Congenital/post-natal acquired
1 & 2. Immunocompromised/HIV
73
Toxoplasmosis Diagnosis & Management
Confirm with PCR, isolation, histology
Observation if immunocompetent
Immunocompromised//pregnant w/ infected or 18+ week fetus: pyrimethamine, sulfadiazine, and leucovorin x 4-6 weeks after symptoms resolved --> prophylaxis
Pregnant w/ uninfected <18wk fetus: spiromycin
74
Growth Stunting & Cognitive/Intellectual Deficits +
| Pruritis Ani
Enterobiasis (pinworm)
75
Enterbiasis (pinworm) Management
```
Albendazole 400 (off label) OR
Mebendazole 100
```
76
Patho/Etiology of GER/D
Relaxation of esophageal sphincter w/o swallowing
H. Pylori --> spontaneous increase of gastric acids/ulceration
Infantile contributory factors:
Small stomach capacity, large-volume feedings, short esophageal length, supine
positioning, slow swallowing response
77
Best course of treatment for infant w/ GERD
Feeding techniques, volumes, frequency
Trial of hydrolyzed protein formula
Increase in calorie density if weight loss
78
Etiology, patho of UTI/Pyelonephritis
Bacterial (e. coli) infection of:
urethra - asymptomatic bacteriuria
bladder - cystitis
kidneys - pyelonephritis - severe --> kidney damage
Most important risk factor in children: vesicoureteral reflux (VUR), also: congenital structural abnormalities, circumcision, sex, abuse, HTN, and hygeine/recurrent infection issues
79
1. Fever, irritability, vomiting
2. Fever, bacteriuria, vomiting, flank pain
3. Fever, toxicity, dehydration
Clinical manifestations of UTI
1. In infant
2. In children
3. Severe or in infants under 6 months
80
Diagnostic testing of UTI
Confirm with UA/UC:
- Opaque, foul, alkaline, proteinuria, bacteriuria,
hematuria, pyuria
> Blood cultures too if appears septic
> Hematuria & Proteinuria on dipstick: >1+ is abnormal
- 10k cells & symptoms or 100k cells & asymptomatic
> sensitivity study for toxic, pyelonephrotic, recurrent,
or unresponsive
-> Also a CBC, ESR, CRP, BUN/Cr for these & < 12mo
81
Management of UTI
Antibiotics (Bactrim, amox, Augmentin, cepha, cefix, cefpodox, nitrofur) as appropriate
Asymptomatic bacteriuria w/ no luekocytes: observe
F/U UC after initiating treatment
Phenazopyridine for dysuria (> 6yo)
82
Management of Pyelonephritis
Young children: cefix, ceftib, Augmentin
Adolescents: Augmentin, cipro
F/U UC after initiating treatment
83
Hematuria cut-off and differential for
1. Gross
2. Asymptomatic w/ proteinuria
5+ RBC/HPF x 3
1. Post-strep glomerulo, renal disease, UTI, IgA nephropathy
Trauma, coagulopathy, HSP, SCD
Crystalluria, nephrolithiasis
Rhabdomyosarcoma
2. Renal disease more likely
84
Proteinuria cut-off and types
30+ mg/dL (4+ mg/m^2?)
Glomerular - high levels
Isolated - asymptomatic & persistant or orthostatic
Functional - Exercise/fever-induced
Tubular/interstitial - high levels
85
Types of Enuresis
Primary (never potty-trained)
Secondary (6-12 mo of dryness)
Nocturnal/monosymptomatic nocturnal (MNE) - only at night
86
Management of Enuresis
CBT
Enuresis Alarms
Desmopressin - antidiuretic
Education: supportive, proactive, positive reinforcement of child
87
1. Phimosis (Px & Tx)
| 2. Paraphimosis (Px & Tx)
1. Cleanse/gently stretch to reduce; physiologic < 6 yo
| 2. Can be secondary to masterbation/sex; Lubricate to reduce, if unsuccessful, surgical emergency
88
Testicular torsion diagnostics & management
Doppler US, pyuria, bacteriuria
| SURGICAL EMERGENCY
89
Inguinal hernia management
Attempt to reduce
| If does not reduce, or continues to re-protrude after 1-2 weeks, refer to urology
90
Concerning findings for the scrotum
1. undescended, retractile, gliding
2. painless, translucent swelling; tense/blue or reducable; no testis movement
3. hard, painless, opaque mass
4. Painful swelling, ecchymosis
1. Cryptorchidism - risk for deterioration
2. Hydrocele - low risk, refer > 1 year
3. Malignant tumor
4. Scrotal trauma - cool comp, NSAIDs, refer if grows
91
Concerning findings for the testis
1. sudden, ipsilateral, severe, unrelenting pain
2. Gradual onset of pain; “Blue dot” sign on scrotum
3. Painful scrotal swelling; hard, tender mass above testis (sexually active patient)
1. Testicular torsion - ischemia after 6 hours
2. Appendix testis
3. Epididymitis (gonorrhea, trachomatic infection) - support, ceftri & doxy
92
For what are chordee or torsion of the penis is concerning?
Hypospadias: assess urethral opening location
93
Testicular torsion - patho
Twisting of spermatic cord – compromised blood supply
94
Testicles feel like a “bag of worms” (Px, Dx, Tx)
Varicocele - Benign enlargement of testicular veins
Dx
– Ultrasonography to rule out malignancy if <10 years
– Serial US to measure size every 6-12 months
Tx
– No intervention if asymptomatic
– Refer to urologist if grade 2 or 3, painful, right-sided, or if testicular growth retarded
95
Child fussy; abdomen distended; scrotal/labial swelling (Px, Dx, Tx)
Incarcerated Inguinal Hernia
Px
• Inguinal herniation including abdominal contents
• Incomplete closure of processus vaginalis
• Obese males/weight lifters with history of undescended testicles have increased risk
Dx
– radiograph, US
Tx
Reduce if possible, if not EMERGENT SURGERY
96
Positive history for previous UTI, abnormal voiding
pattern/dysfunction, unexplained febrile illness, chronic
constipation, UTI symptoms (Px, Dx, Tx)
```
Vesicoureteral Reflux (VUR)
Px: Regurgitation of urine from bladder into ureters and potentially to kidneys
Dx
• Ultrasonography – may be normal
• VCUG – presence of reflux
• DMSA – to look for renal scarring
Tx
– Prevent infection --> scarring
> Prophylactic antibiotics?
> Resolve obstructive processes
> Interval UCs
> Repeat VCUG/refer to urologist if not resolved in
12-18 months
```
97
Cryptorchidism Management
Often resolves spontaneously (majority < 3 mo.)
Patient/family reassurance
Referral < 6 mo.
98
```
Absence of one or both testicles
Microphallus sometimes with hypospadias
Cliteromegaly
Labial fusion, masses within the fused labia
Px, Dx, Tx
```
Disorder of Sexual Differentiation or Ambiguous Genitalia
EMERGENT karyotype & lab eval of serum electrolytes, 17-OH progesterone, T, LH, & FSH levels required to rule out/emergently treat congenital adrenal hyperplasia (CAH)
99
```
Hematuria
Edema
Hypertension
(RBC casts in the urine)
(Px)
```
Acute Glomerulonephritis
Px
-"Post-infectious"
-Generally post-streptococcal, recent pharyngitis/impetigo supports Dx
100
Nausea AND
Uncontrollable ipsilateral pain,
UTI, oliguria, OR
Inability to tolerate oral intake
Nephrolithiasis
| EMERGENT urologic assessment needed
101
Renal and bladder ultrasounds demonstrate fluid masses in/around bilateral kidneys, a solitary kidney, or thickened bladder wall (Name & Tx)
Antenatal hydronephrosis
| EMERGENT inpatient assessment/treatment needed
102
Parental AG: toilet training readiness
```
2 hour dryness, dry after naps
Regular, predictable BMs
Follows simple instructions
Can help undress
Wants clean diapers
Asks to go
Asks for underwear
```
103
Peanut allergy prevention
Early introduction of peanut at 4 to 6 months of age in children with severe eczema and/or egg allergy after being evaluated by sIgE or SPT to peanut
104
1. Pruritic hives & angioedema
| Atopic dermatitis
Food allergy presentations typical of Children > Adults
| 1. "Acute Urticaria" & angioedema
105
Pruritus and mild swelling of the lips, tongue, palate, and throat
Food allergy presentation typical of Adults > Children
| "Pollen food syndrome"
106
Anaphylaxis
Celiac Disease
1. EoE
2. EoG
Food allergy presentations typical of any age
1. Infants & young children: usually feeding disorders & FTT; older children: food impaction vomiting, abdominal pain, dysphagia
2. Mimics pyloric stenosis in infants; irritable bowel
syndrome in adolescents and adults
107
1. Profuse, repetitive vomiting and diarrhea, leading to dehydration and lethargy
2. Passage of bloodtinged stools and mucus without anal fissure
3. Recurrent pneumonia with pulmonary infiltrates, hemosiderosis, iron deficiency anemia
Food allergy presentations typical of infants
1. "Food protein-induced enterocolitis syndrome"
2. "Food protein-induced proct-/proctocolitis;" as early as 2 weeks old
3. "Pulmonary hemosiderosis" also FTT
108
Persistant pain to ipsilateral knee; spontaneous, or closely following injury or infection
Osgood-Schlatter Disease
109
Osgood-Schlatter Disease (Px, Dx, Tx)
Osteochondrosis (necrosis of ossification center, and subsequent secondary bone growth/replacement) of the tibial tubercle
Typically seen at ages 11-13
Idiopathic lesions usually develop during periods of rapid growth of the epiphyses
Diagnostically apparent on x-ray
Treatment for most cases is supportive
110
Persistent pain
limp or limitation of motion
Periarticular swelling
Legg-Calve-Perthes Disease (Avascular Necrosis of the Proximal Femur)
111
Legg-Calve-Perthes Disease (Avascular Necrosis of the Proximal Femur) (Px, Dx, Tx)
Between 4 and 8 years of age; vascular supply to the proximal femur is interrupted
Necrosis visible on x-ray, but joint effusion is the early radiographic finding
Minimize impact. Casting/surgical approaches to contain femoral head w/in acetabulum, abduct hip
112
1. Plantar flexion of the foot at the ankle joint
2. Inversion deformity of the heel
3. Medial deviation of the forefoot
Talipes Equinovarus (Clubfoot)
1. equinus
2. varus
3. adductus
113
Talipes Equinovarus (Clubfoot) (Px, Dx, Tx)
Idiopathic, neurogenic, or syndromic (arthrogryposis, Larsen syndrome)
Diagnosed by 3 principle deformities (equinus, varus, adductus)
Manipulation to stretch contracted medial and posterior tissues, cast to hold correction
114
Inward deviation of the forefoot
Metatarsus Adductus
115
Metatarsus Adductus (Px, Dx, Tx)
Flexible: intrauterine positioning (flexible), resolve spontaneously; frequently concurrent with hip dysplaisa, close assessment required
Inflexible (past midline): idiopathic; serial casting to correct, 1- to 2-week intervals
116
Outward directionality of femoral insertion which:
Persists after 2 yo
Increases in angle
Occurs in only one leg
Abnormal Genu Varum (Bow Legs)
117
Abnormal Genu Varum (Bow Legs) (Px, Dx, Tx)
Normal: infancy-3 yo
Secondary to tibial rotation
The patient should be referred to an orthopedist: bracing may be appropriate, an osteotomy may be necessary for severe problems
118
Medially oriented knees:
| in association with short stature
Genu Valgus (Knock Knees)
119
Genu Valgus (Knock Knees) (Px, Dx, Tx)
Normal: 3 yo-8 yo.
Skeletal dysplasia or rickets
If short stature, refer to orthopediatry
120
In-toeing beyond age 2
| More internal rotation of the hip than external rotation
Femoral Anteversion
121
Femoral Anteversion (Px, Dx, Tx)
Apparent malformation
X-ray to confirm
Resolves spontaneously; may require osteotomy if hip/joint pain manifests
122
1. Post-injurious, sudden...
2. Protracted, gradual onset of...
Ipsi-/bilateral hip/thigh/medial knee pain, limitation of internal rotation of the hip, limp on which the patient...
3. can
4. cannot
Bear weight
Slipped Capital Femoral Epiphysis
1. acute (symptoms resolve in < 3w)
2. chronic
3. stable
4. unstable
123
Slipped Capital Femoral Epiphysis (Px, Dx, Tx)
Displacement of the proximal femoral epiphysis due to disruption of the growth plate; secondary to stress increase across proximal femoral physis or reduced resistance to shear; endocrine or renal disorders, obesity, coxa profunda, femoral/acetabular retroversion
AP, lateral pelvic X-Ray
Crutches and immediate referral to an orthopedic surgeon for internal fixation of femoral head to the neck
124
Elbow fully pronated and painful
Elbow will not bend
Point tenderness over the radial head
Nursemaid’s Elbow
125
Nursemaid’s Elbow (Px, Dx, Tx)
Physio x-ray
Reduce: from fully supinated/extended slowly to fully flexed; or elbow at 90, slowly hyperpronate wrist; click felt over radial head
Sling for a day or longer if pain persists
Sign of abuse, especially if recurrent
126
Typically non-painful, lateral curvature of the spine
Scoliosis
127
Scoliosis (Px, Dx, Tx)
Idiopathic, congenital, neuromuscular, syndromic
Lumbar or thoracic
PA, lateral x-rays to confirm
<20 degrees w/o progression: no treatment required
20-40: bracing (if skeletally immature)
40-60: surgery (instrumentation, fusion)
128
Limping and hip pain
Limitation of motion, particularly internal rotation
Swelling apparent around joint
Temp < 38.4C
Toxic Synovitis
129
Toxic Synovitis (Px, Dx, Tx)
Acute inflammatory reaction following upper respiratory/gastrointestinal infection
ESR, white blood cell count WDL (vs. septic arthritis)
Clear, yellowish fluid on aspiration (vs. purulent w/ SA)
Radiographic changes: nonspecific, DCE-MRI: definitive
Generally self-limited; rest and NSAIDs (vs. operative drainage followed by antibiotic treatment for SA)
130
Internal rotation of the leg b/t knee and ankle
In-toeing
131
In-toeing (Px, Tx)
20 deg is physio at birth, neutral by 16 months
Accentuated by laxity
Often resolves spontaneously, may require osteotomy if persists/becomes symptomatic (painful)
132
Points of assessment/diagnostics for trauma, sprains, and strains
```
Directed physical examination for swelling, tenderness, deformity, and instability
Radiographic examination (rule out physeal fracture)
```
133
Treatment for most fractures, sprains, and strains
Rest, Ice, Compression, & Elevation (RICE) and NSAIDs for sprains
Early protected motion for sprains and stable strains (possibly after brief splinting)
Surgical repair for unstable strains
Closed reduction and immobilization for most fractures
134
Epiphyseal fractures
Radiograph every dislocation to rule this out
Elbow epiphyseal fractures often require open reduction and fixation; closed reduction is typically sufficient for others, but if they fail, open reduction should be performed; all under anesthesia
Bony bridges may form that will cause premature cessation of growth even with adequate reduction
135
Torus vs. Greenstick
Crushing compression of bone cortex
3w immobilization is typically all that is necessary: soft bandage/casting
vs.
Realignment, snugly fitting hard cast
136
Clavicular Fracture
Sling for comfort; typically resolves in less than a year
137
Supracondylar Fracture
Closed reduction and percutaneous pinning performed under general anesthesia
