Ortho Lecture Flashcards by Cassidy Ruocco

Wide ranging spectrum of hip abnormalities:

generalized hip laxity
complete hip dislocation
acetabular abnormality

Developmental dysplasia of the hip (DDH)

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Usually present at birth
May present at 8-24 months
Affects left hip 3:1

Risks:
first child
girls>boys
breech presentation
family hx

Developmental dysplasia of hip

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Initially asymptomatic
First noticed with walking (decreased leg length, limp)
Asymmetry of skin folds if unilateral
Loss of motion (abduction)

Developmental dysplasia of the hip (DDH)

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PE:
Perform until walking age
Barlow’s test (dislocation test)
Ortolani test (relocation test)

Xrays:
AP view of pelvis

Developmental dysplasia of the hip (DDH)

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Barlow’s test tests for….

dislocation

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Ortolani’s test tests for…

Relocation

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If the baby is female and was breech, perform ultrasound at..

6 weeks

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Pavlik (brace/harness) for tx

best used under 6 months of age
brace until stable, usually 8-12 weeks
90-95% successful

Developmental dysplasia of the hip (DDH)

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Tx for Developmental dysplasia of the hip (DDH) if kid is over 6 months old?

Casting!

spica cast for 8-12 weeks

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Tx for Developmental dysplasia of the hip (DDH) if kid is over 2 years old?

Surgical reduction

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Idiopathic osteonecrosis of femoral head

Legg-Calve-Perthes disease

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Progression:

Loss of blood supply
Bone dies (osteonecrosis)
Loss of structural rigidity
Femoral head collapses

Legg-Calve-Perthes dz

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Onset: age 2-12 yo, ususally 4-8 yo

Boys>girls 4:1
90% unilateral

Typical child:
Small stature, thin, physically active

(rare in Black children)

Legg-Calve-Perthes dz

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Pain and limping
worse with activity
pain radiates to groin/proximal thigh

Decreased AROM and PROM
abduction (20-30 degrees)
internal rotation

Legg-Calve-Perthes dz

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Dx made with:

X rays..AP and frog lateral
initial increased density at femoral head
crescent sign
shear fx in subchondral bone

Legg-Calve-Perthes dz

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Tx:

Femoral head re-vascularizes
Usually regenerative in 12-18 months
Restrict vigorous activity
NSAIDs
Crutches if needed

Legg-Calve-Perthes dz

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Slippage of femoral head epiphysis (usually posteriorly)

MC adolescent hip disorder
Girls 8-15 yo, boys 9-16 yo (MC in boys)

Bilateral in 30-40%

Slipped Capital Femoral Epiphysis (SCFE)

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“Red flags”=

older child
male
obesity (over 50% are in the 95th percentile for weight)
limp
pain in hip, groin, thigh or knee

Slipped Capital Femoral Epiphysis (SCFE)

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Onset may be sudden or progressive
Pain with activity
Pain in hip, groin, thigh, knee
Limp
Decreased hip motion (internal rotation)
Possible limb shortneing

Slipped Capital Femoral Epiphysis (SCFE)

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Dx made with Xray:

AP and frog lateral
“fuzzy” irregularities on physis
appears that the epiphysis has slipped/rotated

Slipped Capital Femoral Epiphysis (SCFE)

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What is the tx for Slipped Capital Femoral Epiphysis (SCFE)

Surgical fixation:

single cannulated screw into epiphysis
non weight bearing for ~6 weeks

(if left untreated, SLIPPAGE WILL PROGRESS)

Sterile effusion of the hip

ages 2-5 most common
2-3x more common in boys

Transient Synovitis of the Hip (Toxic Synovitis)

Acute onset (usually)
Worse in AM
Limp is initial presentation
Pain in groin/thigh
Decreased abduction
AFEBRILE!

Transient Synovitis of the Hip (Toxic Synovitis)

Rest
Monitor temp
Reassurance!
Full resolution in 3-14 days

Transient Synovitis of the Hip (Toxic Synovitis)

Intrauterine constraint (ie: small uterus, twins, uterine fibroids) can cause...

Rotational deformities (in-toeing, out-toeing)

MC cause of "toeing in" Exaggerated with weight-bearing Amount of rotation is non-progressive **no treatment necessary** (spontaneous resolution, may use braces or orthotic shoes)

Internal tibial torsion

MC cause of "toeing in" after age 3 Patella may be shifted medially Usually corrected by age 8 Braces, orthotics not helpful

Femoral Anteversion

Normal in older children/adults Pes planus may be evident No tx

External tibial torsion

Foot progression angle..watching the angle the foot is rotated while walking in-toeing expressed as "-" out-toeing expressed as "+"

A diagnostic to use if kid has a rotational disorder (**normal adults walk 0-30 degrees**)

assesses the amount of tibial rotation patient must be prone with knees at 90º look for rotation of foot compared to femur 20-30º of external tibial rotation is normal

Measurement of thigh-foot angle

patient be prone with knees at 90º swing lower legs toward/away from each other 40-50º in both directions is normal compare bilaterally

Measurement of femoral ante/retroversion

Inflammation at the tibial tubercle apophysis Presents early adolescence Usually around increased growth Caused by: repetitive motion jumping, running

Osgood-Schlatter's

Usually a gradual onset Pain worsens with jumping, running, kneeling Usually have some deformity of tibial tubercle Point tender at tibial tubercle Often bilateral MC in boys

Osgood Schlatter's

Tx of Osgood Schlatter's?

Ice, heat, NSAIDs active rest, knee pads rarely immobilize May take several months for results

Medially rotated forefoot Occurs at **tarsometatarsal** **joints** most likely due to position of fetus in utero Usually spontaneously resolve by 6 mos If not, serial casting at 6 mos (for about 2 mos)

Metatarsus Adductus

Congenital deformity of foot 4 components **plantar flexion (equinus) of ankle** adduction (varus) of heel high arch (pes cavus) of midfoot adduction (varus) of forefoot

Talipes Equinovarus (Club foot)

Tx: Immediate casting (before leaving hospital) serial casts every 1-2 weeks treat for 2-4 months may brace after casting (surgery if no results after 4 months)

Talipes Equinovarus (Club foot)

Lateral curvature of the spine greater than 10º Usually thoracic or lumbar spine May involve rotation, kyphosis and/or lordosis

Scoliosis (majority are idiopathic)

Most sensitive test for scoliosis?

Forward bend (Adam's forward bend test) ## Footnote **Looks for unilateral elevation Measure with inclinometer**

Diagnostics: X-Rays AP and lateral measure the **Cobb angle** measured from beginning and end of curve provides objective method for monitoring curve progression

Scoliosis

young age at diagnosis female initial curve \>11º if mature, \<30º curve seldom progresses \>50º may progress, develop symptoms

Risks for progression of scoliosis

Scoliosis angle of 20-40, what is tx?

Brace

Scoliosis angle greater than 50 degrees, what is the tx?

Surgical intervention | (fusion or rodding)

Unilateral contraction of the sternocleidomastoid (SCM) muscle

Torticolis

First noticed at 4-6 weeks old **“cock robin” position** tilted toward affected side rotated away from affected side Possible palpable “tumor” in muscle belly Decreased cervical motion

Torticolis

Passive stretching exercises Usually resolves within a year Surgical intervention: longer than 18 months release of SCM tx for?

Torticolis

Most common elbow injury in children Caused by increased joint laxity Radial head is wedged in annular ligament Occurs between ages 2-3, rarely over 7

"Nursemaid elbow" subluxation of the radial head

Caused from forceful pronation/extension Pain initially, then minimal Unwillingness to use arm Arm held in extension by side **dx: HISTORY MOST IMPORTANT!**

Subluxation of radial head

Tx of subluxation of radial head?

Manipulation fo radial head: pressure on radial head forcefully flex and supinate forearm

Growth plate (physis) injuries/fractures 15% of pediatric long bone fractures Mechanism is same as other traumatic injuries, sprains or fractures **75% are type II**

Salter-Harris fractures

Genetically transmitted disease Defect in Type I collagen Fragility of skeleton Sx: Short stature Lax ligaments Several bony deformities Blue sclera Decreased hearing Poor dentition

Osteogenesis Imperfecta (**tx symptomatically, tx fractures routinely**)