Orthopedics evaluation and intervention Flashcards
(46 cards)
What is etiology of developmental dysplasia of hip and who gets it?
70% female, usually first born, hereditary, breech birth
Etiology of multiple factors: mechanical-positional, cultural, increased incidence with torticollis
What are classifications of developmental dysplasia of hip?
Normal, Subluxtable, Dislocatable, Subluxed, Dislocated
What are evaluation instability tests for DDH?
Barlow: dislocates a reduced hip, “bad”, adduct and apply posterior pressure, listening for clunk
Ortalani: reduces a hip that is out, one leg at a time “out”, abduct and lift left anteriorly, feel clunk
These tests may be negative even if dyplastic because: irreducible, patient tolerance, difficult after 3-4 months of age
What is appearance of kids with DDH?
LLD, galeazzi, uneven thigh folds
Waddling gait with lordosis
Limited hip abduction: unilateral late diagnosis- difference of 10 deg, bilateral less than 60 deg
What imaging is used to evaluate DDH?
US: 6-8 weeks
Radiographs: > 4 mo, femoral head ossification 4-9 mo, AP, frog leg, Von Rosen view (45 deg abduction, 25 deg IR)
What are the lines drawn on Xrays when evaluating DDH?
Hilgenreiner’s line: horizontal through triradiate cartilages
Shenton’s line: inferior neck and inferior border of superior pubic ramus
Perkin’s line: perpendicular to Hilgenreiner’s, intersect lateral acetabular roof
Acetabular angle: Hilgenreiner’s line at triradiate to acetabular roof, less than 20 deg at 24 months, greater than 40 deg significant at birth
What is treatment for DDH?
Less than 6 months: observation, abduction orthosis
6-12 months: orthotics
What is orthotic for DDH?
Pavlik or Rhino
Pavlik: good for younger immobile kids, watch for brachial plexus and femoral nerve injury, stop if fail to reduce in 3 weeks or palsy signs, 90-95% success in 6 weeks
Factors to succeed are diagnosed under 6 weeks, bilateral, acetabular angle under 35 degrees
Factors for failure: parent education, parent motivation, “off the shelf” (because they fail to fit properly, difficult to don/doff, poor follow up)
Rhino: older, more mobile; ortolani positive
What if braces and orthotics don’t work for DDH?
Closed reduction and spica casts: 6-12 mo of age
Surgical intervention: 12 mo of age and older, muscle release and proximal femur osteotomy, spica until stable
What is PT intervention for DDH?
orthotic management
Range, strength, and gross motor skills: during immobilization, after immobilization, after surgery
What are the types of clubfoot and what is treatment?
Equinus, varus, adductus
If mild and due to fetal positioning: serial cast, weekly progressions
If severe and due to underlying neuromuscular diagnosis: surgical correction at 4-6 mo of age; night splint; PT for PROM, strength, and gross motor concerns
What is metatarsus adductus and calcaneovalgus?
Adductus: forefoot curves medially
Calcaneovalgus: forefoot curves laterally, hindfoot valgus, navicular on the floor; foot appears dorsiflexed; vertical talus or rocker bottom deformity
What is evaluation and treatment for pes planus?
Arch develops age 3-5
Compensatory posture: must determine cause, WB vs. NWB, bilateral vs. unilateral
Treatment: keep eye on it, if there’s no pain they are probably ok
What is cause of congenital muscular torticollis?
Abnormal intrauterine posture: too much baby not enough space, contracture
Injury to SCM during delivery: direct muscle trauma (fibrosis, contracture), compartment syndrome (nerve and muscle damage, swelling, fibrosis)
What is torticollis posture?
Contralateral head rotation coupled with ipsilateral tilt.
Name to side of the tilt.
What is plagiocephaly?
occurs in torticollis or craniosynostosis
Torticollis: flattened occiput, eye will appear larger on one side, ear will be lower and more anterior
Craniosynostosis: cranial sutures are sealed and you will only see a flattened occiput
What is etiology of torticollis?
Right > Left
Mean age of dx= 4 months
Associated conditions: hip dysplasia, plagiocephaly, progressive facial asymmetry, vision deficits
What is part of the exam for torticollis?
History: birth weight/multiples, unplanned events, NICU/ventilator use
Postural deviations: palpation of cervical muscles, cranial asymmetry, extremities and spine, resting and active
Range and strength: active and passive, cervical, extremities
Neuro: gross motor development, tone and posture, vision, language delays
What are torticollis differential diagnosis?
Full AROM and no fibrosis: normal radiograph- BPT, congenital absence of cervical muscle, CNS lesions or tumors, visual involvement
Without full AROM and no fibrosis: abnormal radiograph- congenital structurally absent (hemivertebrae, unsegmented bar vertebrae, scoliosis, subluxation), rule out syndromes and trauma
What is treatment for torticollis?
Begin as soon as possible: with consistent timely therapy 85-90% should resolve within 4-5 mo PROM Strength HEP shaping helmets?
What is refractory torticollis? What are concerns and approach for this?
Plateau in gains after 4-5 months of PT and/or 7-8 months of age.
Concerns: facial asymmetry, plagiocephaly, irreversible contracture
Approach: consider/evaluate other causes for torticollis, modify treatment approach, get physician involved (focused neuro/developmental eval, radiograph)
What is plan for treatment of refractory torticollis based on the radiograph results?
Radiograph normal/physician eval normal: continue program, consider botox injections, consider CT scan if no improvement after botox
Radiograph normal/physician abnormal: neuro findings, developmental delay, MRI scan of c spine brainstem brain, may continue program
Radiograph abnormal/physician normal: refrain from PROM continue AROM, refer to ortho surgery clinic, consider botox injections
What are injection sites for botox?
Rotational deficits: SCM, upper trap
Lateral flexion deficits: scalenes
After all conservative measures have failed what is treatment for torticollis?
Surgical intervention
Age > 18-24 months
