What is nursemaid's elbow? What is the mechanism of injury?
Subluxation of the radial head; Upward force on the arm causes the radial head to slip out of the annular ligament which normally keeps it in place
What are the clinical features of Nursemaid's elbow?
- Sudden onset of pain which is difficult to localize
- Elbow is held flexed and no swelling is present; hand function is normal
What is the management for nursemaids elbow? Why is radiograph not needed?
Management: Treatment of the subluxation is to reduce it by simultaneously flexing the elbow and supinating the hand
Diagnosis is on the basis of clinical presenation; if a film is ordered, the technologist may accidentally reduce the subluxation in the process of positioning the arm for the radiograph
What are the clinical features of torticollis?
- Head is tilted toward the affected side with the chin pointed away from the contracture
- Decreased range of motion and stiffness are noted when stretching the head to the opposite side
What is the management for Torticollis?
Treatment includes stretching exercises to relieve the muscle contracture; if head asymmetry is noted, helmet therapy must be initiated by 4-6 months of age to correct head shape as the head grows
What are the clinical features of scoliosis?
Asymmetry of the shoulder height, scapular position and the waistline may be present; Pain is absent
What positional should radiographs be taken to diagnose scoliosis? What is calculated to measure the degree of scoliosis?
Standing posterior-anterior (PA) and lateral radiographs of the spine
Describe the management for the following levels of scoliosis
- 10-20° of scoliosis:
- 20-40° of scoliosis:
- >40° of scoliosis:
- 10-20° of scoliosis: Follow up scoliosis film is obtained 4-6 months later; 5° of progression is considered significant
- 20-40° of scoliosis: Bracing is indicated
- >40° of scoliosis: Surgery is indicated
After growth has concluded, surgery is considered if scoliosis is > __°
What is kyphosis?
Anterior-posterior (AP) curvature of the thoracic spine
What is the most common cause of back pain in children?
Back strain - muscular soreness from overuse or bad body mechanics
What anatomic abnormality leads to developmental dysplasia of the hip?
Occurs when the acetabulum is abnormally flat, leading to the easy dislocation of the head of the femur
Developmental dysplasia of the hip (DDH) is more common in ____ (6:1 ratio)
What are the risk factors for DDH?
Female sex, first born, breech presentation, family history and oligohydramnios
What two maneuvers are positive in physical examination of DDH?
- Positive Barlow maneuver: with the hips at 90° flexion, place thumb on medial side of thigh and middle finger on the greater trochanter and apply gentle pressure posteriorly and laterally - "clunk" is positive
- Positive Ortolani manuever: Abduct the hip, applying gentle pressure upward with the middle finger to slide the head of the femur back into the acetabulm - feeling the hip slipping into the acetabulum is positive
What is the Galeazzi sign in DDH?
Assesses the asymmetry of femur position; place hips in 90° flexion and if the hip is dislocated the affected femur is shifted posteriorly compared with the normal limb
How is DDH diagnosed if the physical exam is equivocal?
Ultrasound is used to assess DDH in young infants because the femoral head does not ossify until 4-6 months of age
AP radiographs of the pelvis may be used to assess for DDH if the infant is older than 6 months
What are the two methods of treating DDH? When is each used?
- Pavlik harness: typically used for 2-3 months if the diagnosis is made by 6 weeks of age
- Surgery may be required if the diagnosis is made beyond 6 weeks of age, the hips are bilaterally dislocated, irreducible on exam or the Pavlik harness fails to stabilize the hip
What are some possible complications of DDH
- Avascular necrosis of the femoral head
- Limb length discrepancy
- Painful abnormal gait
What cause of limping in a child is considered an orthopedic emergency?
Septic arthritis of the hip
What is the differential diagnosis for a painful limp?
Mnemonic: the joint STARTSS HOTT
- Septic arthritis
- Transient synovitis
- Acute rheumatic fever
- Rheumatoid arthritis
- Trauma (fracture, strain, sprain)
- Sickle cell disease
- Slipped capital femoral epiphysis
- Henoch-Schonlein purpura
- Tumor (osteosarcoma, leukemia)
What is transient synovitis?
A common self-limited postinfectious response of the hip joint
What are the clinical features of transient synovitis?
- Low grade fever
- Hip pain (may be acute or insidious in onset)
What is the management for transient synovitis? What happens to WBC count and ESR?
Treatment includes NSAIDs, bed rest, and observation
WBC count and ESR are normal or only slightly elevated
What is Legg-Calve-Perthes disease?
Idiopathic avascular necrosis fo the femoral head
There is an initial ischemic episode of unknown etiology that interrupts vascular circulation to the capital femoral epiphysis. The articular cartilage hypertrophies, and the epiphyseal marrow becomes necrotic. The area revascularizes, and the necrotic bone is replaced by new bone. This process can take 18-24 months. There is a critical point in these dual processes when the subchondral area becomes weak enough that fractures of the epiphysis occurs. At this time the child becomes symptomatic. With fracturing, further reabsorption and replacement by fibrous bone occurs, and the shape of the femoral head is altered. Articulation of the head in the hip joint is interrupted. The bone reossifies with or without treatment, but without treatment the femoral head flattens and enlarges, causing joint deformity. These children need prompt referral to an orthopedist.
What is the age of onset for Legg-Calve-Perthes? Who is the typical patient?
Age of onset is 4-9 years
Patients are typically active, thin boys who are small for their age
Children with Legg-Calve-Perthes havve decreased ________ rotation and ______ of the hip
In Legg-Calve-Perthes, where can the pain be referred?
Pain may be referred to the knee and to the groin
insidious onset of a limp with knee pain, activity related and resolves with rest
- pain less acute and severe than transient synovitis or septic arthritis.
What type of radiographs are used to see Legg-Calve-Perthes disease? What is seen on imaging?
AP and frog-leg lateral radiographs of the pelvis
- follow disease progression and response to treatment.
Increased density in the affected femoral head or a subchondral fracture in the femoral head, termed the "crescent sign"
However, there may be no radiographic findings early in Legg-Calvé-Perthes disease. MRIs and bone scans are helpful in recognizing early disease but are of limited value for following disease progression.
What is the management for Legg-Calve-Perthes disease? When is surgery indicated?
Physical therapy and restriction of vigorous exercise
1- full ROM
2- less than 6 yrs
3- involvement in less than 1/2 of femoral head
Surgery/referal--> is indicated if there is more than 50% damage to the femoral head or if there is movement of the femoral head out of the acetabulum, child older an 6 yrs