Ortho

Question 1

growth in pediatrics

Answer 1

require 110 calories/kg (only 40 in adult) from birth, height will increase 350% and weight will increase 20- fold

Question 2

growth plates

Answer 2

not uniform- diff bones grow at diff rates (ossification) cartilage eventually replaced by bone

Question 3

subluxated radial head**

Answer 3

radial head slips under annular ligament- usually someone picked them up by arms not abuse annular ligament strengthens as the kid grows so condition less common after about age 5

Question 4

to fix subluxated radial head

Answer 4

reduction- after history and exam reduction is performed by manually supinating the forearm and flexing the elbow past 90 degrees of flexion - while holding the arm supinated the elbow is then maximally flexed during this maneuver as the practitioners thumb applies pressure over the radial head and a palpable click is often heard or felt with reduction of the radial head (watched the video)

Question 5

osteomyelitis

Answer 5

most common organism- staph aureus, in neonates group B may be difficult to localize, treated inpatient

Question 6

dx osteo

Answer 6

radiograpahs may be normal or nonspecific for 10- 14 days, may need bone scan, CT, or MRI blood culture positive in 50- 60% of cases bone aspiration or biopsy tx is 3- 6 weeks IV abx inpatient or home infusions via PICC

Question 7

septic arthritis

Answer 7

usually hematogenous seeding, extension of osteo or direct inoculation into joint from penetrating trauma

Question 8

etiology of septic arthritis

Answer 8

staph aureus, h. flu (historically), kingella kingae in neonates- e. coli, candida, GBS in teens- n gonorrhea

Question 9

presentation of septic arthritis

Answer 9

kids often very ill appearing- fever/ miserable. acute joint inflammation, swelling, redness and pain, “pseudoparalysis”- joint is held in a position to maximize intra- articular space and minimize pressure and pain, ex- hip- flexion, abduction, external rotation knee- partial flexion shoulder- adduction and internal rotation elbow- midflexion

Question 10

“pseudoparalysis”- joint is held in a position to maximize intra- articular space and minimize pressure and pain, ex- hip- flexion, abduction, external rotation

this is a pic of this- septic arthritis of hip

Answer 10

Question 11

dx of septic arthritis

Answer 11

blood culture + in 30- 40% of cases

elevated CPR, ESR

arthrocentesis

imaging- widening of joint space, soft tissue swelling, US useful for hip effusion

Question 12

tx of septic arthritis

Answer 12

abx

I&D

prompt surgical drainage of hip ( and often shoulder) needed to reduce intra- articular pressure and avoid necrosis of the femoral head

Question 13

consideration of spetic arthritis

Answer 13

transient synovitis of hip or “tixic synovitis” often simiar to septic arthritis

history is critical- **follows viral URI, viral pathogen settled inthe joint.

non- infectious, will have mild fever, limp, fussiness, minimal ROM, ESR, CRP, WBC usually normal

managed w/ rest and NSAIDS (motrin), close f/u

Question 14

other considerations if thinking septic arthritis

Answer 14

overlying cellulitis vs septic arthritis

other causes of acute arthritis include HSP, serum sickness, JRA, lupus, tic borne illness

Question 15

Avascular necrosis AVN

Answer 15

devastating factors- unstable slip, reduction of stable slip, superolateral pin placement, fem neck osteotomy

rare in stable slips

Question 16

Legg Calve perthes

Answer 16

due to avascular necrosis- leads to flattening of the femoral head and may leave a deformity which results in osteoarthritis of hip in adult life

Question 17

Legg Calve perthes LCP presentation

Answer 17

subjective- limp d/t pain, LLD, abnormal ROM, pain at groin, thigh, knee- synovitis

objective- decreased ROM: IR, ext, abduction. muscle atrophy- weakness, Trendelenburg sign, LLD

Question 18

LCP treatment

Answer 18

short term goal is to reduce pain and stiffness, longterm goals are to improve function and minimize femoral head deformity

Question 19

Osgood Schlatter Disease*

Answer 19

*most common reason for knee pain in kids: activity- related pain that occurs a few inches below the knee cap or patella on the front of the knee

*swelling in the area and tender to touch

Question 20

Osgood Schlatter Disease- who gets it

Answer 20

occurs most commonly in kids 9- 16yrs, boys and girls equally vulnerable, common in very active kids- kids who play sports that require a lot of jumping, running, kneeling, and squating, happens in a growth spurt many times

Question 21

hereditary/ developmental/ “packaging” disorders

Answer 21

torticollis/ plagiocephaly

developmental dislocation of the hip

rotational deformities

genu valgum/varum

scoliosis

Question 22

torticollis

Answer 22

twisting of the neck- can occur congenitally or be aquired (d/t prolonged positioning of the infant’s head to 1 side)

• one muscle gets longer, other stays short
• parents need to do passive ROM, put them on opposite side- educate parents*

Question 23

plagiocephaly

Answer 23

shape of the skull is asymmetrical, there may be a flattened area at the back of the skull as well as a forward protrusion on one side of the forehead, very often seen in kids w/ torticollis

can use helmets but controversial

Question 24

tx goals for plagio

Answer 24

prevent contractures, stretch tight muscles, prevent delay of normal activities, facilitate normal righting reactions.

Question 25

DDH- HIP developmental hip dysplasia

Answer 25

any hip can be provoked to subluxate (partial contact between femoral head and acetabulum) or dislocate (no contact between femoral head and acetabulum), or any subluxated or dislocated hip that can be reduced

Question 26

incidence of DDH

Answer 26

1.5/ 1000 births 70% females left \> right, 20% bilat lower incidence in native americans, african americans and asians instability at birth- 1/1000 newborns (loose hips but don't come out of the socket)

Question 27

risk factors for DDH

Answer 27

1st born breech delivery or presentation torticollis fam hx culture- swaddling weird genetics

Question 28

etiology of DDH

Answer 28

mechanical theory- perinatal "packaging disorders" primary acetabular dysplasia- predisposes dislocation ligamentous laxity- increased incidence in neonatal DDh patients and 1st degree relatives, effects of prenatal hormones on the infant are similar to mom, fetal/infant girls estrogen

Question 29

screening for DDH

Answer 29

assess with Barlow/ Ortolani, look at creases/ gluteal folds should be symmetrical. US not recommended for all newborns only if + Barlow/ Ortolani sign- should also be referred to ortho - hips should be examined at every well visit (2-4 days for newborns discharged in less than 48 hours after delivery, by 1 month, 2 months, 4 months, 6 months, 9 months, 12 months)

Question 30

management of DDH

Answer 30

early reduction of hip beneficial for remodeling, could use Pavlik harness for 6-8 wks, or closed/ open recution and spica cast- should be following up through skeletal maturity

Question 31

goals of tx for DDH

Answer 31

same regardless of age of presentation- obtain reduction, maintain stability- AVOID AVN- need to keep good blood flow

Question 32

Slipped capital femoral epiphysis SCFE

Answer 32

older kid presents w/ hip pain, 8- 15 years, male\> female, common in obese kids, could be knee and/ or hip pain, could be acute or chronic, minimal trauma, pain could be anywhere in affected limb, will limp

Question 33

tx SCFE

Answer 33

urgent ortho referral especially if they can't bear any weight- will need pinning to reconnect. Goal is to prevent further slipping of joint out of socket and AVN

Question 34

SCFE exam

Answer 34

may reveal decreased external hip rotation, vague pain to knee groin or thigh, one leg may be shorter than other, limp, loss of or pain with IR- remember to always examine other hip (25% bilat involvement) need AP/ frog lateral xrays

Question 35

rotational deformities

Answer 35

children are often referred to ortho for intoeing- 1 in 10 children intoes between ages 2 and 5, parents notice that the child trips/ falls and appears to to have feet that turn in, sometimes called pigeon- toed

Question 36

metatarsus adductus

Answer 36

caused by intrauterine positioning; hereditary tendencies. incidence- occurs bilat in 50%, boys = girls, more common in first born (because moms hips havent stretched yet)

Question 37

metatarsus adductus

Answer 37

clinical manifestations- forefoot adducted and occasionally supinated; the lateral border of the foot is convex; can range in severity from very flexible to extremely rigid

Question 38

metatarsus adductus physical exam

Answer 38

examine the forefoot alignment: classification can be determined by line bisecting the hindfoot and the flexibility of the forefoot. - normal- line bisecting the hindfoot passes through the 2nd toe or between the 2nd and 3rd toes - mild (or type 1)- line bisects 3rd toe - moderate (or type 2)- line bisects 3rd and 4th toe - severe (or type 2)- line bisects the 4th and 5th toes fexibility: actively flexible- when foot is tickled it corrects passively flexible- able to correct w/ gentle pressure on 1st metatarsal head rigid- does not correct with stretching

Question 39

tx for metatarsus adductus

Answer 39

don't routinely need radiographs tx- for actively flexible feet- no tx needed for passively flexible feet- stretching exercises by the parents (5x per foot each diaper change, hloding for 10sec at a time) for rigid feet- serial casting or the Wheaton brace

Question 40

internal tibial torsion

Answer 40

-caused by intrauterine positioning, genetic, positioning during activities. \*Is most common cause of intoeing in children \<2 years, may be associated w/ metatarsus adductus (33%) - parent may say kid sits on their feet more than other positions

Question 41

physical exam for internal tibial torsion

Answer 41

foot- thigh angle- pt in prone position, let feet fall free to their placement so it is not affected by examiner's movement - inward rotation- internal tibial torsion - external rotation- external tibial torsion

Question 42

tx for internal tibial torsion

Answer 42

no xrays needed. many diff treatments have been tried, night splints, shoe wedges, orthotics, attempts to control sleeping/ sitting/ walking patterns of kids -studies have shown it resolves spontaneouosly about 24 months w/o non- operative treatments listed above, therefore tx not necessary

Question 43

femoral anteversion

Answer 43

cause is controversial, congenital vs abnormal sitting habits \*most commmon cause of intoeing in \>2 years old associated w/ ligamentous laxity parents often say the kid "W sits"

Question 44

femoral anteversion physical exam

Answer 44

patient lies in the prone position w/ knees flexed at 90 degrees. let the legs fall into medial and lateral rotation by gravity normal- at birth anteversion is 30- 40 degrees and decreases progressively; adults range from 8- 14 degrees - if there is any asymmetry in hip rotation, suspect hip disorder and get xrays

Question 45

clubfoot

Answer 45

1/1000 births foot is turned to the side and it may even appear that the top of the foot is where the bottom should be Important: must distinguish b/w metatarsus adductus and clubfoot - metatarsus adductus- forefoot adduction - clubfoot- hindfoot equinus, hindfoot varus, midfoot cavus, and forefoot adduction

Question 46

genu valgum\*

Answer 46

peaks in late childhood, +anterior/ medial knee pain, circumduction/ out toe gait, typically symmetric differentials- metabolic bone dx= rickets, post traumatic valgus, skeletal dysplasia (to remember- L is for love- the knees love each other, they are pointing towards each other, making the toes point out)

Question 47

genu varum\*

Answer 47

-intrauterine positioning, normal and will straighten out on own differentials- Blount's, metabolic bone dx- rickets, trauma

Question 48

for test know diff between genu valgum/ varum

Answer 48

Question 49

Rickets

Answer 49

failure of calcium to be depositied in bone matrix and epiphysis. Vit D and PTH play important role at maintaining homeostasis classified by cause- Vit D def, chronic renal insuff, or renal tubular insuff

Question 50

prevention of rickets

Answer 50

adequate ultraviolet light of 10mcg/ 400IU PO daily of a vitamin D preparation and an adequate dietary supply of calcium and phosphorus to prevent rickets - 20 min/ do of ultraviolet light to face of a light- skinned baby is sufficient, longer in pigment.

Question 51

genetically linked musculoskeletal disorders

Answer 51

DMD, scoliosis

Question 52

muscular dystrophy

Answer 52

progressive skeleta neuromuscular disease characterized by persistet deterioration for striated muscle tissue. Distinguished from other neuromuscular diseases by 4 criteria: 1. primary myopathy 2. genetic base 3. pregressive nature 4. degeneration of muscle fibers

Question 53

when muscle cells degenerate in muscular dystrophy, the muscle tissue is replaced with what

Answer 53

fat and fibrous tissue

Question 54

physical characterisctics of muscular dystrophy

Answer 54

muscle weakness, fatigue, respiratory/ heart complications

Question 55

more characterstics of muscular dystrophy

Answer 55

progression through stages of functional ability: - low strength/ endurance; normal ambulation w/ posible overwork weakness; slight deficiency in function - reduction in activity; tendency to fatigue easily; reduced strength/ endurance; habitual activity, mild contractures and possible overwork weakness; ambulation with assistance - poor stregth/ endurance; overwork weakness; contractures; limited ambulation and decrease in physical activity and standing - ambulation significantly decreased; functional use of wheelchair; severe contractures and muscular weakness; pulmonary difficulties and cardiomyopathy

Question 56

implementing a physical activity program in muscular dystrophy

Answer 56

components of an exercise program should include strength, endurance, and aerobic power that is essential for standing, walking, and funtional tasks. Goals to provide short term/ realistic goals, reduce rate of deterioration, prevent contractures, focus on submaximal exercises and reduce to intensity to avoid fatigue

Question 57

Scoliosis

Answer 57

many varieties, etiology unknown, unpredictable, treatment disputed

Question 58

Scoliosis

Answer 58

lateral curvature of spine with a minimum Cobb angle of \>10 degrees (found by radiologist). can use a scoliometer to screen- normal is less than 7.

Question 59

Scoliosis grouped into

Answer 59

1. idiopathic- w/o associated dx/ anomalies 2. congenital- underlying anomaly 3. neuromuscular

Question 60

osteogenic sarcoma

Answer 60

85% of malignant bone tumors in kids clinical manifestations- pain localized at affected site, may be severe or dull, often relieved by position of flexion

Question 61

osteogenic sarcoma frequently brought to attention when

Answer 61

child limps, curtails own physical activity, or is unable to hold heavy objects

Question 62

osteosarcoma

Answer 62

most common bone cancer in kids\* peak incidence- 10- 25 yrs associated w/ growth spurts of adolesence most frequently affects the distal portion of the femur; also humerus, tibia, pelvis, jaw and phalanges localized pain in affected site- often relieved by flexing extremity progressive, insidious or intermittent pain at tumor site limping, limited ROM, palpable mass, eventually pathological fracture frequently metastasizes to lungs

Question 63

dx of osteosarcoma

Answer 63

xrays following traumatic injry may be first indication of dx, need CT or MRI to detect areas of metastasis - amputation common

Question 64

therapeutic management of osteosarcoma

Answer 64

goals: remove tumor so doesn't spread, tx may include resection or amputation depending on location and/ or surgeon, chemo before and after surgery, thoracotomy if mets to lungs, cure rate 75% w/o mets

Question 65

Ewing Sarcoma

Answer 65

second most common bone tumor in kids - arises in marrow spaces of bone rather than the oxxeous tissue - tumor originates in shaft of long bones, trunk bones, or skull - most commonly affects femus, ribs, vertebrae, pelvic bones

Question 66

Ewing Sarcoma who gets it

Answer 66

occurs most exclusively in pts under 30, majority between 4 and 25, peak incidence between 10-20\*

Question 67

s/s Ewing Sarcoma

Answer 67

pain, soft tissue swelling, fever, if vertebral tumor- neuro s/s, if rib- respiratory s/s

Question 68

dx of Ewing Sarcoma

Answer 68

same as osteogenic sarcoma (xray, CT or MRI to see if mets)

Question 69

therapeutic management of Ewing Sarcoma

Answer 69

intensive radiation of involved bone, combined with chemo chemo- reduces tumor bulk to maybe do surgery resection to salvage limb cure rate approx 70% w/ small extremity tumors and no mets