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Peds > Ortho > Flashcards

Ortho Flashcards

1
Q

What Rotational Changes occur? (6)

A

Foot progression angle, Hip rotation, Thigh/Foot Axis, Metatarsus adductus, Calcaneouvalgus, Knee Alignment

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2
Q

Torsional Conditions: Evaluation - history? (2) Exam? (5)

A

History
Progression of torsion
Preferred sleep and play positions

Examination

  • Foot progression angle
  • Hip rotation: Anteversion/Retroversion
  • Thigh/Foot Axis: Tibial Torsion
  • Metatarsus adductus
  • Calcaneouvalgus
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3
Q

Foot Progression Angle is? Includes? (4)

A
  • Angle of where foot is facing in relation to straight line
  • Includes all torsional segments
  • Version of the hip
  • Tibial torsion
  • Forefoot position
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4
Q

Angle between long axis of foot and progression of body degrees for in-toeing? Out? Normal? Mean?

A

In-toeing (-)
Out-toeing (+)
Normal: -3 to +20
Mean: +10

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5
Q

Typical Progression: Foot Progression Angle?

A

Out-toeing which decreases over time

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6
Q

How do you measure? Hip Rotation: Anteversion/Retroversion? What is version?

A
  • Measure in prone with neutral hip extension

- “Version” is the relationship between femoral neck and shaft

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7
Q

What is anteversion? (3) Retroversion? (3)

A
  • Anteversion: Head of the femur is directed anteriorly
    Internal rotation
    In-toeing
  • Retroversion: Head of the femur is directed posteriorly
    External rotation
    Out-toeing
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8
Q

Typical Progression: Hip Rotation - infants? The second resolve by? And? Total hip rotation = ? (3)

A
  • Infants: Anteversion + ER contractures (appears to be out-toeing)
  • ER contractures resolve by 5-6 years and anteversion becomes more apparent
  • Total Hip Rotation (ER + IR)
    Up to age 2: 120
    Thereafter: 95-110
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9
Q

Can’t in-toe 2/2? Version has to?

A
  • ER contractures

- Version has to do with femoral neck alignment in relation to head

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10
Q

How do you measure thigh foot axis? +/- = ?

A
  • Measure of tibial torsion and angle of foot
  • Long axis of foot vs. long axis of thigh
  • Internal (-)
  • External (+)
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11
Q

Thigh Foot Axis - tx required if? What are they? (3)

A
  • Treatment required if natural resolution does not happen
  • Friedman Counter Strap
  • Derotation Strap
  • Dennis Browne Bar
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12
Q

Thigh foot axis - if left untreated? (3)

A

Osteoarthritis of knee
Patellofemoral instability
Osgood Schlatters

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13
Q

What is the trans malleolar axis?

A

Line along femur that bisects the malleoli

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14
Q

Typical Progression: Thigh Foot Axis - infants? What happens with growth?

A
  • Infants: Internal (-30 to +20)

- Spontaneous de-rotation with growth and onset of walking

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15
Q

Metatarsus (forefoot) Adductus is how common? Position - forefoot? Hindfoot? DF ROM?

A
  • Most common positional deformity in infants
  • Forefoot: Curved medially
  • Hindfoot: Slight valgus as is typical for infants
  • Full dorsiflexion ROM
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16
Q

Metatarsus (forefoot) Adductus tx for mild? Mod? Severe? Based on? If left untreated?

A
  • Mild: resolves naturally
  • Moderate: corrective shoes
  • Severe: Joint manipulation and serial casting
  • Based on flexibility
  • If left un-treated: Increased risk of stress fractures
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17
Q

Calcaneovalgus position? (2) Tx? Differential? It’s not just curvature, it’s an? Impacts?

A
  • Forefoot: curved laterally
  • Full or excessive dorsiflexion ROM
  • Treatment: none, resolves naturally
  • Differential: Vertical talus
  • not just curvature, it’s an alteration of position of talus
  • impacts DF ROM
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18
Q

Typical Progression: Knee Alignment - newborn? 1-2 yrs? 2-4? 4-16?

A

Newborn: Peak Varum
1-2 Years: Straight
2-4 Years: Peak Valgum
4-16 years: Approaching sex-specific norm

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19
Q

Rotational Profile - what do you look at for hip, tibia (2), foot? in-toeing - foot, tibia, hip?

A

Hip - version and total rotational profile
Tibia - trans malleolar axis
Thigh foot axis - incorporates position of foot
Foot - heel bisect or and what toes it’s bisecting

Foot: Metatarsus adductus
Tibia: Internal tibial torsion
Hip: Femoral anteversion

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20
Q

Rotational Profile - out-toeing - foot, tibia, hip?

A

Foot: Calcaneovaltus
Tibia: External tibial torsion
Hip: Contracture of external rotators

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21
Q

Developmental Dysplasia of the Hip is? Wide range of severity? (5)

A
  • General “looseness” or “instability” of the hip joint
  • Wide range of severity
    Normal
    Subluxable - in joint but can move a bit
    Dislocatable - can be totally popped out
    Subluxed - is kind of out of joint
    Dislocated - completely out of joint
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22
Q

Developmental Dysplasia of the Hip: Risk Factors - mechanical? (3) Physiologic? (2)

A

Mechanical
Small intrauterine space
Breech position
Hips on mothers sacrum

Physiologic
Estrogen and relaxin effecting the female fetus
6:1 female risk factor

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23
Q

Developmental Dysplasia of the Hip: Risk Factors - environmental? (3)

A

Swaddling
Positioning
Carrying

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24
Q

Developmental Dysplasia of the Hip: Evaluation (4) Imaging used?

A
  • Hip ROM: Limited abduction
  • Asymmetry of thigh folds
  • Apparent shortening of femur/uneven knees (“Galeazzi Sign”)
  • Hip “clicks” are usually insignificant
  • Imaging (ultrasound) bc of radiation; bones are made out of cartilage, don’t show up on xray
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25
Q

Developmental Dysplasia of the Hip: Evaluation techniques? (2) Describe each. These signs disappear when?

A
  • Barlow: Dislocates over the posterior rim; IR and pressure
  • Ortolani: reduces dislocation: ER and flexion
  • These signs disappear by 2 months, limited abduction is the only sign after that
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26
Q

Developmental Dysplasia of the Hip: Intervention goal? Infants (12 mos? Without intervention? (4)

A
  • Goal: Relocate and preserve joint shape
    Infants (12 months: Surgical intervention
  • Without Intervention
    Hip replacement
    AVN
    Femoral nerve palsy
    Erosion of the acetabular rim
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27
Q

Legg Calve Perthes Disease (LCPD) is? Caused by? (2) Most common presentation? Resolves how? What kids do best? Most common presentation?

A
  • AVN of the ossific nucleus of the femoral head – medial circumflex artery
  • Unknown cause
  • 2nd hand smoke??
    Small, active children
    5-10 years old
    Learning disabilities
    More common in males
  • Spontaneous resolution over 1-3 years
  • Children
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28
Q

LCPD exam findings? (5) Tx? (3)

A 
Limp
Trandelenburg gait
Limited abduction, internal rotation
X-Ray: Subchondral fracture, femoral head collapse, coxa magnum (head doesn't grow in the confines of the acetabulum)
Pain: Groin, medial thigh, medial knee

Treatment: WIDE RANGE – observation, casting, derotational osteotomy

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29
Q

Slipped Capital Femoral Ephiphysis (SCFE) types? (3) Risk factors? (3)

A

Types
Acute: Significant trauma
Acute on Chronic: Chronic slip, trauma makes it worse
Chronic: Most common type

  • Risk factors:
    Obesity
    African american
    Males
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30
Q

SCFE exam? (4) Intervention? (2) Primary responsibility is? Should monitor?

A 
Examination
Pain: Groin, medial thigh, medial knee
Hip held in ER
Hip moves passively into ER with hip flexion
50% of cases are bilateral

Intervention:
Pinning surgery ( head to neck approximation)
Non weight bearing

  • should monitor other side
  • NWB crutch walking
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31
Q

Blount’s disease aka? What is it? Differential from? (3)

A
  • Infantile Tibial Vara
  • Compression at the medial knee causes suppression of growth that gets worse, not better, over time
  • Differential from typical genu varum, rickets, Vitamin D deficiency
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32
Q

Blount’s Disease: Infantile Tibial Vara: Evaluation? (4) Intervention? (2)

A

Thickening of medial tibial cortex
Breaking of medial metaphysis
Lateral thrust of knee in stance
Overweight, early walkers

Intervention
HKAFO 23 hours per day
Surgery

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33
Q

Leg Length Discrepancies - what’s considered normal? Causes? (3) Impairments? (3)

A

-

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34
Q

Leg Length Discrepancies: Evaluation & quantification? (5)

A
  • Level pelvis with blocks under foot, measure blocks
  • Tape measure
  • ASIS to: medial malleolus, lateral mallelous, heel pad
  • Umbilicus to heel pad
  • Radiologic measurements - scannogram
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35
Q

Leg length intervention? (4)

A

Conservative: Shoe lift
Surgical: Mosely graph predicts growth, can help time
Stop growth in the longer leg by damaging the growth plate
Lengthen the shorter leg

36
Q

Lengthening the Shorter Leg- Factors to consider? (2)

A

Soft tissue mobility

Stability of joints above and below

37
Q

Physeal Distraction – the Illizarov Method (4) Stop what?

A
  • Can also correct rotational deformities
  • 1mm per day, ¼ mm 4 times per day
  • Active participation in PT while device is in place
  • Pain can be significant, extended
  • Stopping Growth in the Longer Leg
38
Q

“Club Foot” Talipes Equinovarus: Examination - what kind of muscles? Position of ankle? Forefoot? Hindfoot? Calcaneous? Talar head? Cause? (3)

A 
- Hypoplastic muscles
Position
- Ankle: Plantarflexion
- Forefoot: Adduction + Pronation (Medially curved)
- Hindfoot: Varus
- Calcaneous: Small
- Talar Head: Small and flattened
- Cause – largely unclear
- Positional
- Associated with other disorders
39
Q

“Club Foot” Talipes Equinovarus: Intervention? (4) Goal? (3)

A
  • Ponseti Method:
  • Serial Casting in 70 degrees abd forefoot
  • Talonavicular joint reduction
  • Percutaneous Achilles tendon lengthening
  • Goal: Restore alignment, allow for weight bearing and ambulation
40
Q

Congenital Limb Deficiencies - % of the two categories? Most are? How common? Typically? Most common type?

A
  • 40% acquired
  • 60% congenital
  • Most are spontaneous mutations
  • 30% of children are effected in more than one limb
  • Typically unilateral
  • Left elbow in females
41
Q

Spranger’s Classifications? (4)

A

malformation
disruption
deformation
dysplasia

42
Q

What is a malformation? (3)

A
  • incomplete in development
  • Longitudinal deficiencies
  • Cleft palate, atrial septal defect
43
Q

What is disruption? (3)

A
  • cessation of development due to outside force
  • Transverse deficiencies
  • Amniotic band syndrome
44
Q

What is deformation? (3)

A
  • developed in full, but the wrong shape
  • Can be corrected with bracing, taping, splinting, casting
  • Rotational changes, LCPD, SCFE
45
Q

What is dysplasia? (3)

A
  • developed in full, but atypical differentiation throughout
  • Effects a whole system
  • Osteogenesis imperfecta, arthrogryposis
46
Q

Skeletal deficiencies? (2)

A
  • Transverse: Typical development to a particular point, then stops
  • Longitudinal: Elements missing along the long axis
47
Q

Congenital Limb Deficiencies most are from? 20-30% of kids effected have? Most transverse deficiencies are? Most common?

A
  • Most are from sporadic mutations
  • 20-30% of children effected have more than 1 limb involved
  • Most transverse deficiencies are unilateral
  • Most common: Left, transverse below elbow, females
48
Q

Proximal Femoral Focal Deficiency (PFFD) is a? What may be involved? (5) Severity graded how? (5)

A
  • Congenital absence or hypoplasia of the proximal femur.
  • Acetabulum, femoral head, patella, tibia and fibula may be involved.
  • Severity graded A – D
  • Femoral head presence, shape
  • Acetabulum presence, shape
  • Femur length
  • Joint presence, articulation
49
Q

Acquired Amputations majority to? Minority due to? (3)

A

70-85% due to trauma
15-30% due to disease
Ewing’s Sarcoma
Osteosarcoma

50
Q

Acquired Amputations: Surgical Interventions? (4)

A
  • Further amputation to revise residual limb
  • Limb replantation
  • Upper more successful than lower extremity
  • Children achieve better functional outcomes than adults
51
Q

Phantom Sensations? (2)

A

Increasing prevalence with age

Not always pain

52
Q

Scoliosis: Evaluation? Screening? (4)

A

Deviation of spinal axis

Shoulder and pelvic asymmetries
Forward bend test
Scoliometer
Radiography

53
Q

Risser Sign? (3)

A

Skeletal Maturity
Graded 0-5
Based on ossification of iliac crest

54
Q

Cobb Angle? (4)

A
  • Severity of Curvature
  • End vertebrae are cephalic and caudal with most tilt
  • Intersection of lines perpendicular to end vertebrae
  • > 10 is diagnostic
55
Q

Scoliosis Descriptors? (3)

A

Direction of curve: Convex side
Magnitude: with Cobb Angle
Flexibility

56
Q

Scioliotic flexibility? (2) Non-structural? (2)

A
  • Structural
    » Cannot be corrected
    » Vertebrae rotate towards the convex side -> Rib hump
  • Non-Structural
    » Corrects with sidebend towards the convex side
    » Usually non-progressive
57
Q

Most curves are? If L is identified…? Non-structural corrects with? Non-struc is usually?

A
  • 90% of thoracic curves are R. If Left curve is identified, more extensive evaluation is needed
  • Non-structural corrects with side bend towards apex – the “direction of the curve” side.
  • Non- structural is usually non-progressive
58
Q

Types of Scoliosis? (3)

A

Congenital
Neuromuscular
Idiopathic

59
Q

Congenital Scoliosis caused by? (3) May have? Many become?

A

Go back

- Caused by anomalous vertebral development
>> Error in segmentation
>> Error in formation
- May have a rotational component
>> Kyphoscoliosis
>> Lordoscoliosis
- Many become stable and do not progress
60
Q

Neuromuscular Scoliosis - types? (2) Develop when? Tend to be? Most associated with? Tx? (3)

A
  • Long, C type curves, may become S curves with compensation
  • Develop at a young age
  • Tend to be progressive
  • Most associated with SCI in young children, SMA or MD

Treatment
Botox
Custom seating
Surgery

61
Q

Idiopathic Scoliosis - type? Cause? How common? Types? (3)

A
  • Lateral curvature of unknown cause
  • Most common form in children
  • Infantile, Juvenile or Adolescent
62
Q

Adolescent Idiopathic Scoliosis (AIS) - most cases are? Who gets them more? Most curves are? Performance levels? (2)

A
  • 80% of all idiopathic scoliosis cases
  • 3.6:1 Female:Male ratio
  • 5:1 with curves > 20o
  • 1.4:1 with curves
63
Q

Adolescent Idiopathic Scoliosis - progression is defined as? Increased risk for? (5)

A
  • Progression is defined as a change of > 5o on two consecutive exams
  • Increased risk for progression
  • Younger age/lower Risser sign at dx
  • Double curve patterns
  • Inc Curvature
  • Females
64
Q

Females are…?

A

Females are 10 times more likely to progress than males with the same magnitude

65
Q

Adolescent Idiopathic Scoliosis: Intervention, Non-Surgical candidates? (2) Exam how often? Tx?

A
  • Idiopathic curves
66
Q

One technique for tx?

A

Shroth technique - kids learn to understand movement of their spine and how to pelvic tilt

67
Q

Adolescent Idiopathic Scoliosis: Intervention, Exercise - used as? Exercise goals? (4) Exercise alone has?

A
  • Used as first line of intervention for curves >20o
  • Exercise goals
    > Maintain or improve trunk and pelvic strength
    > Improve lateral flexion and trunk shift ROM
    > Stretching: Pectorals and lower extremities
    > Increase lung capacity and volume
  • Exercise alone has not been shown to prevent progression, even with high patient compliance
68
Q

Adolescent Idiopathic Scoliosis: Intervention, Orthotic Management - indications? (2) Impact of orthotic mgmt?

A
  • Skeletally immature (Risser Sign 0-2)
  • Curve from 25-45o
  • Impact of orthotic management decreases as size of curve increases.
69
Q

Types of braces? (3)

A
  • Charleston: Worn only at night, positions in significant sidebend
  • Milwaukee: rarely used
  • Boston: worn during day; causes PPT to increase invertebral space
70
Q

Adolescent Idiopathic Scoliosis continues until? Exercise should be? How long to wean from brace? May progress how? Tx is successful if?

A
  • Continues until curve is no longer controlled or skeletal maturity is reached
  • Exercise should still be performed while wearing the brace
  • 12 months to wean from brace
  • May progress a small amount after brace is discontinued
  • Treatment is “successful” if curve is no more than 5o different from when brace was discontinued
71
Q

Curve is uncontrolled when? 1/4 do what?

A

Curve is “uncontrolled“ when >40 degrees. About ¼ of curves progress even with orthotics

72
Q

Adolescent Idiopathic Scoliosis: Intervention, Surgical for what curves? Goals of surgical intervention? (5) What approach most common? More advanced curves may?

A
  • For curves >40o

Goals of surgical intervention

  • Halt progression
  • Prevent complications
  • Achieve maximal correction
  • Balanced trunk
  • Solid fusion
  • Posterior approach is most common
  • More advanced curves may include both anterior and posterior approach
73
Q

Surgery complications? (2)

A

pain, pulmonary dysfuncition

74
Q

Adolescent Idiopathic Scoliosis: Intervention, Surgical - two other forms?

A
  • Bone graft packed into disk spaces and facet joints

- Metal stabilization “rods”

75
Q

Three types of rods used? Describe each (3), (2)

A 
- Harrington 
> Does not allow sagittal plane correction
> Rarely used
> Flattened lumbar lordosis
- Luque
> Prevents loss of lumbar lordosis
> Risk of neurological damage
- Cotrel-Dubousset
76
Q

Adolescent Idiopathic Scoliosis: Intervention, Post-Op Care (2)

A
  • Orthosis for 9-12 months – until fusion is “solid” on radiographs
  • Average hospital stay: 5-7 days
77
Q

Role of PT? (5)

A
  • Precautions lifted gradually over 1 year by MD
  • No trunk rotation
  • No lifting >5 lbs.
  • Donning/doffing prosthesis – to be done in bed (may be limited in overhead motion)
  • Encourage functional mobility, isometrics
78
Q

Arthrogryposis Multiplex Congenita (AMC) present when? Etiology? Hallmarks? (5) Most kids? Majority are?

A
  • Present at birth, non-progressive
  • Unknown etiology
  • Hallmarks of the disease
    > Joint contractures in 2 or more body areas
    > Lack of muscle development/weakness
    > Featureless, cylindrical extremities
    > Fibrosis
    > Decreased DTRs
  • Most children effected are bright and motivated
  • Majority of cases are not genetically based
79
Q

Arthrogryposis Multiplex Congenita (AMC) - findings?

A

xx

80
Q

xx

A

xx

81
Q

Arthrogryposis Multiplex Congenita (AMC): Intervention? (5)

A
  • Well timed surgical intervention
  • Club foot repair when standing
  • Debate over surgically reducing dislocated hips
  • Knee flexion contracture when ambulating
  • Shoulders are rarely addressed surgically
82
Q

AMC PT? (8)

A 
Positioning
Splinting
Stretching
Normalizing development
Balance Skills
With aging
Pain management
Wheelchair training
83
Q

Osteogenesis Imperfecta - what kind of problem? (2) Manifestations? (3)

A
  • Inherited connective tissue disorder – many different mutations
  • matrix, type I collagen problem

Bowing of long bones
Spinal deformities
Recurrent fractures with minimal trauma

84
Q

Osteogenesis Imperfecta May also exhibit? (6)

A 
Blue sclera
Dental deformities
Hearing loss
Growth deficiency
Easy bruising
Excessive sweating
85
Q

Osteogenesis Imperfecta: Intervention - goal? (5)

A
  • Goal: Prevent deformities
  • Limit immobilization
  • Scoliosis cannot be managed with brace
  • Internal fixation with IM rods and/or spinal fusion
  • Fracture risk decreases by puberty in most patients
86
Q

Osteogenesis Imperfecta: PT Interventions? (4)

A

Strengthening
Environmental adaptation
Caregiver education
Encouraging independence and social integration

Peds (7 decks)

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