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Flashcards in pediatric musculoskeletal Deck (63):
1

developmental dysplasia of the hip: previously known as...

congenital dislocation of the hip

2

developmental dysplasia of the hip

abnormal development of the hip
- maternal hormones can lead to transient lax hips

- FYI 80% female, 50% first born

3

developmental dysplasia of the hip: contributing factors

- frank breech
- maternal hormones
- parent, sibling with DDH: 5X likelihood

4

frank breech

buttocks presenting part with hips acutely flexed and knees extended

5

degrees of DDH (list)*

preluxation
subluxation
dislocation

6

preluxation*

MILD degree of ddh

femoral head remains in acetabulum (is in contact with it) but is displaced

7

subluxation

degree of ddh; incomplete dislocation

largest %

8

dislocation

most severe form of ddh

femoral head loses contact with acetabulum

9

ddh: diagnosis when

ideally made in neonatal period (tx w/in 2 mo = highest success rate)

10

ddh assessment techniques for diagnosis (list)

- ortolani test
- barlow test
- galeazzi sign
- trendelenburg sign

11

ortolani test

diagnostic tool for ddh

apply forward pressure form behind trochanter during full abduction (careful, can do damage)

12

barlow test

diagnostic tool for ddh

apply pressure from front during adduction

13

galeazzi sign

diagnostic tool for ddh

shortened limb on affected side

14

trendelenburg sign

diagnostic tool for ddh

as patient bears weight on affected hip, pelvis tilts downward on the normal side instead of upward

15

ddh: classic signs (list)

- asymmetric gluteal folds
- limited hip abduction
- unequal knee height
- lordosis/waddling gait

16

ortolani and barlow disappear after...

2-3 months (most reliable within this time period)

ddh

17

most sensitive test after ortolani/barlow disappear

after 3 months, limited hip abduction

18

ddh: therapeutic management goal

obtain and maintain safe, congruent position of the hip joint to promote normal development

begin ASAP! early intervention = favorable outcome

19

pavlik harness

therapeutic management of ddh; hip in controlled flexion and abduction: use pavlik harness

- 0-6 months of age
- worn continuously for ~5mo
- dynamic splinting (adjust for growth)
- not rigid
- 95% effective

20

spica cast

therapeutic management of ddh; used when hip unable to be reduced/remain aligned properly and when pavlik ineffective

21

ddh: therapeutic management - 0 to 6 mo

pavlik harness or spica cast

22

ddh: therapeutic management - 6 to 18 mo

- traction in prep for surgery
- surgery for closed/open reduction
- then spica cast 2-4 mo

23

ddh: therapeutic management - older child

hip correction much more difficult, surgery much more involved

after 4 years: very difficult
after 6 years: poor outcome

24

club foot

deformity of ankle and foot
- talipes equinovarus (tev) most common, 95%
- males affected 2x more than females
- bilateral 50% cases
- family tendency

25

talipes equinovarus

most common form of club foot: 95%
- talipes: involves ankle, foot
- equino: heel is elevated like horse (plantar flexion)
- varus: fixed inversion (turned in)

26

club foot: diagnosis

readily apparent at birth
increased chance of ddh with tev!!!!

27

club foot: therapeutic management (list)

serial casting
surgical correction (if casting is ineffective)

28

serial casting

therapeutic management of club foot
- tx begins in newborn period
- allows for gradual stretching
- cast changed q few days 1-2 weeks, then q 1-2 weeks
- usually casted for 8-12 weeks

29

pmss

p ulse
m obility
s ensation
s kin

cast considerations

30

kyphosis

abnormal increase in convex curve of thoracic spine

31

lordosis

accentuation of lumbar curve

32

scoliosis

lateral curvature + spinal rotation + thoracic hypokyphosis
- most common spinal deformity
- adolescent females 7:1
- genetic component but not fully understood

33

idiopathic scoliosis

no apparent cause

34

congenital scoliosis

associated with neuromuscular disorders

35

scoliosis: clinical manifestations

most noticeable during preadolescent growth spurt

36

scoliosis: diagnosis*

screening assessment (view at hip height)
- adam's position, WEARING ONLY UNDERGARMENTS*, view from behind
- see: asymmetric shoulder height, hip height, abnormal scapular shape
- suspected? definitive tests required; even mild refer to ortho

37

scoliosis: therapeutic management (list)

- observation
- bracing + exercise
- spinal fusion

38

bracing

therapeutic management of scoliosis; can halt/slow progression until skeletal maturity (non-curative)
- worn 16-23 hours a day initially
- adherence is an issue
- exercise used in conjunction (increase muscle strength of spine, abdomen)

39

spinal fusion

therapeutic management of scoliosis; correction of severe curve that doesn't respond to bracing
- significant pain, possible respiratory compromise (atelectasis)

40

scoliosis spinal fusion: mobility considerations

day of surgery: log roll q2' (no twisting/bending!!)
pod 1: elevate HOB, sit at side of bed
pod 2: sit in chair for 1' x2
pod 3: ambulate 3x
- turn q2

41

osteomyelitis

acute or chronic bone infection usually caused by bacteria, can lead to bone destruction, abscess formation, and dead bone

boys > girls

42

osteomyelitis: etiology

- exogenous source (puncture wound, open fracture, surgical contamination)
- hematogenous source (bloodborne bacterium)

43

osteomyelitis: clinical manifestations

- severe pain
- limited movement
- fever
- restlessness, irritability

44

osteomyelitis: diagnostic eval

- hx sx
- leukocytosis
- increased esr
+ blood culture, joint aspirate culture
- x-ray: changes evident only after 2-3 weks

45

leukocytosis

increased wbc

46

osteomyelitis: therapeutic management

- IV abx for at least 4 weeks
- followed by oral antibiotics

47

septic arthritis

bacterial infection of the joint, usually hematogenous spread
- staph aureus most common causative agent
- most common joints affected: knees, hips, ankles, elbows

48

septic arthritis: most common causative agent

staph aureus

49

septic arthritis: most common joints affected

hips, knees, ankles, elbows

50

septic arthritis: clinical manifestations

severe joint pain
swelling, tissue warmth, erythema
systemic illness may be present (fever, malaise, ha, n/v, irritability)

51

septic arthritis: diagnosis

- joint aspiration!
- early xray only reveals soft tissue involvement (but important for baseline)

52

septic arthritis: treatment

- IV abx based on gram stain 3-4 wks
- adequate, timely drainage of infected synovial fluid
- immobilization of joint (pain control)
- pain management

after 5 days tx, begin PT. extensive PT allows maximum functioning

53

muscular dystrophy

genetic, gradual, progressive degeneration of muscle fibers
- progressive weakness, wasting of skeletal muscles
- variable: age of onset, rate of progression, muscle groups affected

54

duchenne muscular dystrophy

most severe, most common, most aggressive type of md
- x linked inheritance
- death usually by 30

55

duchenne muscular dystrophy: clinical manifestations

- onset between 3 to 5 years
- usually lose ambulation ability by 12
- cause of death usually respiratory tract infection or cardiac failure (all muscles affected!)

56

duchenne muscular dystrophy: diagnostic eval

- elevated serum cpk enzymes
- muscle biopsy
- gower sign

57

gower sign

classic presentation of dmd; difficulty rising from sittin

58

cpk enzyme

creatine phosphokinase: enzyme found mainly in the heart, brain, and skeletal muscle.

elevated serum levels in dmd

59

duchenne muscular dystrophy: therapeutic management

NO CURATIVE TREATMENT
- genetic counseling (think of pregnancy spacing, sons)

60

osteogenesis imperfecta*

characterized by bone fragility, fractures, deformity, blue sclera*, hearing loss, discolored teeth; autosomal dominant

most common osteoporosis syndrome in children; usually normal lifespan!

61

blue sclera: think...

osteogenesis imperfecta!

62

osteogenesis imperfecta: therapeutic management

primarily supportive!!
- strengthen muscles = prevent contractures
- light resistance exercise
- handle carefully (fracture prevention)
- limited benefit from pharm
- family support!

63

osteogenesis imperfecta: therapeutic management

primarily suppotive!!
- strengthen muscles = prevent contractures
- light resistance exercise
- handle carefully (fracture prevention)
- limited benefit from pharm
- family support!