Pediatric Ortho

Question 1

Pediatric Orthopedic Conditions

Answer 1

Torticollis
Scoliosis
Nursemaid’s elbow
Transient Synovitis
Little league elbow
Club Foot
Rotational/Angular deformities of the legs
Legg-Calves-Perthes Disease
SCFE
Developmental dysplasia of hip
Osgood Schlatter’s Disease
Sever’s disease
Osteogenesis Imperfecta

Question 2

Torticollis

Answer 2

contraction or contracture of the muscles of the neck that occurs and causes the head to be tilted to one side
Rotation of the chin to the opposite side of the contraction
>80% are congenital in nature the rest is trauma/disease

Question 3

Congenital Torticollis

Answer 3

More common following breech deliveries
Can be associated w/ hip dysplasia and clubfoot
Unilateral contracture of SCM muscle
Fibrosis of SCM occurs w/ a resultant palpable “mass” in the SCM muscle
Mass resolves w/in a few weeks after birth, but it results in a shortened and contracted SCM
If untreated, facial asymmetry/skull deformity (plagiocephally) can occur as well as changes in the cervical vertebrae

Question 4

Diagnosis for Congenital Torticollis

Answer 4

Clinical diagnosis based on physical examination and palpable “mass” of SCM muscle
X-ray of cervical spine recommended

Question 5

Treatment for Congenital Torticollis

Answer 5

Conservative: stretching exercises several times/day to regain full ROM
May need Doc-band to help improve secondary plagiocephaly
Surgery: for patients who fail conservative treatment or those who are diagnosed late
Release of SCM muscle traction/casting and exercises

Question 6

Plagiocephaly

Answer 6

Skull deformity that occurs secondary to external forces on the skull either in utero or during infancy

Question 7

Scoliosis

Answer 7

Lateral curvature of the spine in the upright position
Usually accompanied by rotation as well as an increase in the normal kyphosis (thoracic) or lordosis (lumbar) of the spine
-occurs in 1-3% of population

Question 8

Structural Classification of Scoliosis

Answer 8

Fixed, nonflexible, does not correct w/ side bending
Etiology:
Idiopathic (mechanism unknown, appears hereditary)- 80%
Congenital abnormalities
Neuromuscular (ex. Cerebral palsy, muscular dystrophy)
Dysmorphic syndromes (Neurofibromatosis, Marfan’s, osteogenesis imperfecta)

Question 9

Non Structural Classification of Scoliosis

Answer 9

Flexible and corrects w/ side bending
Etiology:
Compensation d/t leg length discrepencies, local inflammation, muscle spasms

Question 10

Idiopathic Scoliosis

Answer 10

4-5 times more common in girls
Serious curvatures are more frequent in fm
Progresses during rapid skeletal growth
Curve must be greater than 10 degrees
Right thoracic curvature is most common
Left thoracic curvature likely indicates a spinal disorder

Question 11

Complications of Idiopathic Scoliosis

Answer 11

Cardiopulmonary dysfunction (most serious)
Progressive deformity
Pain with aging
Disability

Question 12

Classification by age of idiopathic scoliosis

Answer 12

Infantile
Occurs by age 3
M>Fm
Usually resolves spontaneously
Juvenile
Occurs b/w ages 4-10 years
Adolescent- MOST COMMON
Occurs b/w age 10 until skeletal maturity
Most significant and prevalent form
Fm>M (girls age 10-12y and boys 14-16y)

Question 13

Signs and Symptoms of Idiopathic Scoliosis

Answer 13

Usually asymptomatic

Pain is rare and if present is a red flag (look for secondary cause)

Question 14

Diagnosis of Idiopathic Scoliosis

Answer 14

Confirmed with a standing (AP and lateral) X-ray of entire spine
Determine Cobb angle
Angle of spinal curvature
Identify the upper and lower end vertebrae of curve
Draw a line parallel to the end plate of each vertebrae
The angle at which they intersect is the Cobb angle
Risser Sign (skeletal maturity)
Sensitive indicator of skeletal maturity
Ossification progresses from lateral to medial (SI joint)

Question 15

MRI for Idiopathic Scoliosis

Answer 15

Indicated if a secondary cause is suspected:
Significant pain
Abnormal neurological symptoms
Left thoracic curve (associated w/ spinal disorder)
Rapid progression

Question 16

Progressive Facts for idiopathic scoliosis

Answer 16

Curves >20 degrees tend to progress in the young
Curves < 30 degrees at maturity have minimal progression as adults
Respiratory symptoms rarely develop in curves < 60 degrees
The greater the curve and the younger the patient, the more likely the curve will progress
Progression is more common in young children who are beginning their growth spurt
Curves in adolescent females are more likely to progress

Question 17

Treatment for idiopathic scoliosis

Answer 17

Early detection is key to prevent progression
Referral to a specialist is mandatory for all patients
Depends on the age of the patient and the angle of the curve
Non-surgical treatment methods will not fully correct the curve (it may improve the curve in some cases), but will prevent progression of the curve and maintain flexibility
Surgical treatment will correct the curve, but it also reduces flexibility

Question 18

Immature and Older children idiopathic scoliosis treatment

Answer 18

Immature patients:
Observation every 6-12 months till the curve reaches 20 degrees
Curves >20-25 degrees will require treatment
Older child (growth has slowed)
Observation if a small curve is present b/c it is less likely to progress

Question 19

Non surgical treatment for idiopathic scoliosis

Answer 19

Spinal Bracing
Indicated in curves <20 degrees if they are progressing
Indicated in curves between 20-40 degrees, particularly in a skeletally immature patient
Ex. Milwaukee Brace and Thoracolumbosacral orthotic (TLSO)
23 hours/day for 2 years or longer
Exercises while in the brace to improve appearance and decrease the curve

Question 20

Surgical Treatment for idiopathic scoliosis

Answer 20

Indicated for curves >45 degrees
2 components:
Deformity correction with intraoperative instrumentation
Spinal fusion
Success rates are high
Results in decreased spine motion which can be quite limiting

Question 21

Nursemaids/ pulled elbow

Answer 21

Head of the radius subluxes distally through the annular ligament

Question 22

Etiology of Nursemaids/ pulled elbow

Answer 22

Children age 1-3 are most affected, rare after age 6
Etiology
Toddler being pulled or swung by an extended arm (longitudinal traction w/ elbow extended and forearm pronated)
Trauma

Question 23

Clinical Signs and Symptoms of Nursemaid elbow

Answer 23

May hear a snap when the radial head subluxes
Immediate elbow pain that increase w/ movement
Arm is held with the elbow flexed and the forearm pronated
Tenderness to radial head

Question 24

Diagnosis and imaging for nursemaid elbow

Answer 24

Clinical diagnosis based on history and PE
Imaging
Typically not indicated unless the history suggests trauma or an unusual mechanism
Usually appear normal
Presumably d/t spontaneous reduction before or during the X-ray with radiographic positioning

Question 25

Treatment for Nursemaids elbow

Answer 25

Reduction Start w/ the elbow extended and the forearm pronated Supinate the forearm and flex the elbow simultaneously while applying manual pressure over the radial head A palpable click can be palpated when reduction occurs Pain resolves immediately and the toddler will start using the arm Immobilization is not recommended following the injury except for recurrent subluxations

Question 26

Little League Elbow

Answer 26

A traction injury to the medial epicondylar physis related to repetitive throwing Pathophysiology Repetitive valgus stress results in shearing, inflammation, traction and abnormal bone development

Question 27

Symptoms of Little League Elbow

Answer 27

``` Acute or gradual Acute suggests avulsion injury Pain to medial epicondyle Swelling Stiffness Decrease in performance Weakness ```

Question 28

Signs of Little League Elbow

Answer 28

Tenderness to medial epicondyle Pain worsened by valgus stress May have decreased range of motion (ROM) Wrist flexion and forearm pronation may bring on pain

Question 29

Diagnosis of Little League Elbow

Answer 29

Imaging is not required but an X-raymay show widening of the apophysis

Question 30

Treatment of Little League Elbow

Answer 30

Complete rest from throwing activities Stretching and strengthening (PT) is helpful Prevention is key (proper throwing mechanics, proper conditioning, limiting # of pitches and 3-4 days of rest b/w games pitched)

Question 31

Dysplasia

Answer 31

abnormal growth or development

Question 32

Dislocated Hip

Answer 32

Femoral head is not in contact with the acetabulum

Question 33

Subluxation of hip

Answer 33

Femoral head is w/in the acetabulum but can partially come out of the socket w/ a provocative maneuver

Question 34

Development of dysplasia of the hip

Answer 34

Term used to describe a spectrum of hip disorders in young children Congenital hip dysplasia is the most common Others include conditions associated with neuromuscular abnormalities 98% of the cases are reversible 2% are severe and irreversible

Question 35

Epidemiology for dysplasia of the hip

Answer 35

Incidence: 1-2 cases per 1,000 live births in the US Frequently bilateral Females > Males Left hip > Right hip

Question 36

RF for dysplasia of the hip

Answer 36

``` First born child Female born in breech position musculoskeletal abnormalities (metatarsus adductus, clubfoot and torticollis) Certain syndromes (Trisomy 21) FH of DDH ```

Question 37

congenital dysplasia of the hip

Answer 37

Hip is fully formed by 11th weeks of gestation Proper growth of the acetabulum requires a round femoral head In congenital dysplasia, the hip forms normally but dislocates around the time of birth Once the normal articulation is disrupted, the acetabulum and femoral head grow abnormally and this will progress if not treated early Acetabulum shallower, saucerlike Femoral head flattened and anteverted Joint capsule loose/lax

Question 38

prognosis for dysplasia of the hip

Answer 38

If untreated, leads to deformity, disability and painful arthritis in adults Early diagnosis and early intervention is KEY

Question 39

Signs/symptoms for dysplasia of the hip

Answer 39

Very subtle and can be easily missed In infants, you can’t see any abnormality, you can only feel it In children 3-12 months (not walking) Restricted hip abduction is the hallmark sign Shortening of thigh compared to contralateral side Abnormal skin folds

Question 40

Unilateral Signs/symptoms of dysplasia of the hip in an older child

Answer 40

Unilateral Painless limp and a lurch to the affected side Leg length discrepency Positive Trendelenburg sign (weakness of gluteus medius)

Question 41

Bilateral Signs/symptoms of dysplasia of the hip in an older child

Answer 41

Loss of hip abduction Waddling gait Flexion contracture of the hips with secondary hyperlordosis of lumbar spine

Question 42

Infant hip exam with 2 special tests

Answer 42

Examine one hip at a time Examine supine on exam table Examine the patient when they are calm and comfortable 2 tests should be performed: Barlow Maneuver- hip is purposefully dislocated and then reduced by doing the Ortolani Maneuver Ortolani Maneuver- Gentle reduction of the dislocated hip

Question 43

Barlow Maneuver

Answer 43

Loosen the diaper but do not remove completely Stabilize the pelvis by grasping the pubic symphysis and sacrum firmly w/ one hand Place your examining hand on the baby’s bare thigh w/ your thumb along the medial thigh, your fingers along the lateral thigh and your first web space or index finger over the anterior knee Flex the hip to 90 degrees and slight adduction, create an axial load along the femur using the first web space or index finger Trying to push the femoral head posteriorly out of the acetabulum over the posterior rim You would be able to feel the dislocation w/ the tip of your index finger/ring finger

Question 44

Ortolani Maneuver

Answer 44

Hands are in the same position as in the Barlow Maneuver Widely abduct the hip Palpate the greater trochanter as you abduct the hip and reduce the hip into the socket A palpable clunk of the femoral head as it reduces back into the acetabulum is a positive Ortolani sign

Question 45

Imaging for Dysplasia of the hip

Answer 45

Not reliable in children < 6 weeks of age 6 weeks to 4 months: Ultrasound is the imaging test of choice >6 months: X-ray is the imaging test of choice

Question 46

Treatment for Dysplasia of the hip

Answer 46

Short window of opportunity for conservative treatment; therefore early diagnosis is key The sooner the hip can be reduced and maintained, the better the outcome Birth to 6 weeks is the most opportune time Birth to 6 months: Pavlik harness- gold standard Maintains hip flexion of 100 degrees and prevents adduction Safe and effective in 80-90% of cases Worn several weeks until the hip is stable

Question 47

Treatment Surgery for Dysplasia of the hip

Answer 47

Failure to obtain or maintain a stable reduction Dislocated hips that are missed Closed or open reduction and casting +/- osteotomy Delays in treatment make reduction more difficult and complicated

Question 48

Legg Calve Perthes Disease (LCPD)

Answer 48

Disruption of blood supply to the femoral head resulting in avascular necrosis of the proximal femoral head Avascular necrosis- necrosis of bone followed by replacement of new bone

Question 49

Epidemiology of LCPD

Answer 49

Highest incidence b/w the ages of 4-10 M>Fm (4:1) Bilateral in 15% of cases

Question 50

Early/Initial Stage for LCPD

Answer 50

Synovitis of hip joint w/ effusion and early ischemic changes in the ossific nucleus of the femoral head X-ray shows joint swelling and possible lateral displacement of the femoral head d/t swelling Femoral head appears denser Mean duration- 6 months

Question 51

Regenerative/Fragmentation Stage LCPD

Answer 51

Necrotic area begins to be replaced by new bone X-ray shows fragmentation and compression of the femoral head w/ widening of the femoral neck Duration- 1 to 2 years

Question 52

Reossification Stage LCPD

Answer 52

Femoral head starts healing (shape may be normal or irregular and flat (coxa plana))

Question 53

Complications for LCPD

Answer 53

Osteoarthritis if untreated | Permanent femoral head deformity (affects motion and gait)

Question 54

Symptoms for LCPD

Answer 54

``` Onset is gradual Mild hip pain Referred knee/thigh pain Limp Limited ROM Pain is relieved by rest and aggravated by weightbearing ```

Question 55

Signs of LCPD

Answer 55

Decreased abduction and IR Tenderness over the anterior hip joint +/- Leg length discrepency +/- Thigh and calf muscle atrophy

Question 56

Imaging used for LCPD

Answer 56

X-ray: Gold standard AP and lateral frog view of both hips MRI: Can assess the extent of the necrosis

Question 57

Treatment Goals for LCPD

Answer 57

Ultimate Goal: to prevent deformity of the femoral head while healing which decreases risk of DJD Initial Goal: relieve pain and maintain ROM Rest

Question 58

Treatment based on age for LCPD

Answer 58

6 years/older child: Abduction brace to keep the femoral head w/in the acetabulum (helps mold the femoral head and prevent deformity) Worn continuously for up to 2 years Surgery in select cases

Question 59

Prognosis depends on what for LCPD

Answer 59

Age of onset Degree of involvement Adequacy of treatment

Question 60

Slipped Capital Femoral Epiphysis (SCFE)

Answer 60

Displacement of the proximal femoral epiphysis due to disruption of the grown plate Results in upward and anterior displacement of the femoral neck Bilateral in 25% of cases (up to 1-2 years after the initial episode) Can occur acutely in the setting of trauma (Salter I fracture) Primarily gradual onset

Question 61

Epidemiology of SCFE

Answer 61

Uncommon Most common in boys 10-17 years old (during rapid growth spurt) Occurs earlier in females d/t advanced skeletal maturity More common in African Americans Occurs more commonly in 2 body types: Overweight/obese adolescents Tall and thin

Question 62

Etiology of SCFE

Answer 62

Trauma (acute slippage) Suspected to be hormonal (gradual slippage) Has been associated with hypothyroidism

Question 63

Complications for SCFE

Answer 63

``` Traumatic cases have a worse prognosis Avascular necrosis severe arthritis Gradual cases Does not commonly cause avascular necrosis Slight leg shortening Mild external rotation deformity Osteoarthritis if delayed treatment ```

Question 64

Symptoms of SCFE

Answer 64

``` Hip/groin pain Referred medial knee pain Limp Usually gradual onset of symptoms over weeks/months Sudden if d/t trauma ```

Question 65

Signs of SCFE

Answer 65

Antalgic gait Tenderness over hip External rotation deformity (toing out) Limited ROM (IR, abduction, flexion)

Question 66

Imaging for SCFE

Answer 66

X-ray imaging (AP and lateral views- both hips) Preslippage: Widening of the epiphyseal plate and joint swelling Slippage: Displacement of the femoral head Best seen on lateral view Klein’s line (X-ray finding) Think of it as an ice cream scoop slipping off a cone

Question 67

Treatment for SCFE

Answer 67

Refer to orthopedic surgeon immediately Non-weightbearing with crutches Surgery: May have traction prior to surgery to reduce the slip Internal fixation of the head of the femur to the neck of the femur (pinning) Non-weightbearing for several months till the epiphyseal place closes

Question 68

Prognosis and Prophylaxis for SCFE

Answer 68

``` Good particularly in a gradual slip Poor if d/t an acute, traumatic slip Prophylaxis Pinning of contralateral hip (controversial) Not recommended ```

Question 69

Transient Synovitis of Hip

Answer 69

Self-limited, nonspecific synovial inflammation of the hip joint resulting in a joint effusion Most common cause of hip pain in children Fm Cause is unknown (viral infection suspected-URI/GI in prior 4 weeks) Diagnosis of exclusion

Question 70

Symptoms of Transient Synovitis of Hip

Answer 70

Acute onset Hip/groin pain Referred knee pain Limp or refusal to WB

Question 71

Signs of Transient Synovitis of Hip

Answer 71

Temp of 37.3-38.2C may be present Hip held in slight flexion, abduction and ER Decreased ROM

Question 72

Diagnosis of Transient Synovitis of Hip

Answer 72

Rule out other hip pathology such as septic hip, SCFE, LCPD, developmental conditions, trauma, osteomyelitis Observation alone if child is well-appearing, afebrile, mobile, symptoms <48hrs and a reliable caretaker F/U in 48 hours: if improving or symptoms resolve w/in 1 week, diagnosis is confirmed

Question 73

Clinical Intervention for Transient Synovitis of Hip

Answer 73

child is ill appearing, immobile, febrile, or the pain is rapidly progressing, then w/u required: Clinical Intervention Labs (CBC, ESR, CRP, aspiration of joint fluid w/ cx) Imaging X-ray to r/o Fracture, SCFE, LCPD, osteomyelitis U/S to detect effusion and for guidance during arthrocentesis Does not differentiate transient synovitis from septic arthritis

Question 74

Treatment and Follow up for Transient Synovitis of the Hip

Answer 74

``` Treatment Conservative treatment Rest NSAIDS (ibuprofen) Non-weightbearing till symptoms improve ``` Follow Up Within 48 hours and 1 week to confirm symptom improvement Repeat X-ray at 6 weeks to assess for LCPD or sooner if persistent limp/pain

Question 75

Angular/Rotational Deformities of Legs

Answer 75

``` Genu Varum Blount’s Disease Genu Valgum In-Toeing: MOST COMMON Internal Tibial Torsion Metatarsus Adductus Femoral Anteversion Out-Toeing Femoral Retroversion (external femoral torsion) External Tibial Torsion Flat Feet ```

Question 76

Genu Varum

Answer 76

Bowleg” Normal till age 3 Usually secondary to tibial rotation Refer if persists past age 2, worsens rather than improves, occurs in only 1 leg

Question 77

Blount’s Disease

Answer 77

Pathologic, developmental bowing secondary to disrupted growth of the upper medial tibial epiphysis Etiology unknown More common in obese early walkers and African Americans and positive FH May be unilateral or bilateral 2 forms: Infantile- begins before age 3 Adolescent- begins after age 8 Progressively worsens unlike physiological bowing Tx: Bracing if started early (<3yr) and Surgery

Question 78

Genu Valgum

Answer 78

“Knock-knee” Occurs from age 3-8 years of age May be caused by skeletal dysplasia and rickets Refer if persists past age 8, worsens rather than improves, occurs in only 1 leg, or if associated with short stature Usually resolves, though bracing and/or osteotomy may be necessary

Question 79

Toeing in

Answer 79

Most common rotational deformity Etiology: Metatarsus adductus/varus of foot in infants Internal tibial torsion in toddler Increased femoral torsion in child >10 yrs old Most are benign and self-limited Tx: reassurance and education of parents

Question 80

Toeing In: Internal Tibial Torsion

Answer 80

Toeing in” Rotation of the lower leg b/w the knee and ankle Normal at birth (20 degrees) but returns to neutral by 16 months Can be increased by laxity of knee ligaments Present if toeing in and patella faces straight forward (deformity is distal to knee) Self-limiting and resolves by itself w/ increased growth Stretching and corrective shoes show no benefit

Question 81

Toeing In: Metatarsus Varus

Answer 81

Lateral border of foot is convex and medial border is concave Vertical crease in medial aspect of arch if rigid 10-15% of cases have associated hip dysplasia Treatment depends on if the deformity is fixed If flexible- stretching exercises and wearing a straight/reverse shoe is helpful If fixed (unable to passively correct)- corrective casts if caught early, otherwise surgery

Question 82

Toeing In: Femoral Anteversion

Answer 82

“Toeing in” beyond age 2-3 years old More internal rotation of the hip than external rotation Present if toeing in and the patella faces medially (deformity proximal to knee) Improves with growth External rotation exercises are encouraged (bike riding, skating)

Question 83

Out Toeing and Treatment

Answer 83

Often associated w/ genu valgum May be aggravated by sleeping in prone position and using wide diapers Treatment Observation and reassurance Avoid wide diapers and wide canvas slings stretching

Question 84

Osgood-Schlatter’s Disease

Answer 84

Disturbance of the patella tendon attachment to the tibial tubercle apophysis Early adolescent males are most commonly affected 20% occur bilaterally Common cause of knee pain in adolescents Most common in athletic adolescents (running sports, jumping sports, etc)

Question 85

Osgood-Schlatter’s Disease Etiology

Answer 85

Unknown, suspect partial avulsion Contributing factors: Repetitive micro-avulsion (overuse) of tibial tubercle Traction-type injury on apophysis where patella tendon attaches (tendon growth can’t keep up with bone growth)

Question 86

Osgood-Schlatter’s Disease Background

Answer 86

Proximal tibial epiphysis fuses to the shaft of the femur by age 20. B/w the ages of 7-14 year, an extension of the epiphysis is visible on X-ray and forms the anterior tibial tuberosity Anterior tibial tuberosity is where the patella tendon attaches

Question 87

Osgood-Schlatter’s Disease Pathophys

Answer 87

Localized traction tendonitis as a result of constant traction of the patella tendon at it’s insertion avulsion of small amounts of cartilage and bone Recurrent irritation of the growth plate by the patella tendon from repetitive injury chronic inflammation

Question 88

Osgood-Schlatter’s Disease Complications

Answer 88

Osteoarthritis (OA) Painful ossicle in the distal patella tendon Painful kneeling Displaced avulsion fracture of tibial tubercle Permanent bump (“Knobby knees”) at tibial tubercle

Question 89

Osgood-Schlatter’s Disease Signs/ Symptoms

Answer 89

Anterior knee pain (point over tibial tubercle) Swelling over tibial tubercle Pain worsened by kneeling, squatting and going up/down stairs Point tenderness over tibial tubercle Often with a noticable lump Often bilateral

Question 90

Osgood-Schlatter’s Disease Diagnosis

Answer 90

Clinical based on hx and examination X-rays not indicated unless acute onset of pain or following trauma to r/o an avulsion fracture May be normal or may show fragmentation at tibial tubercle

Question 91

Osgood-Schlatter’s Disease Treatment

Answer 91

Conservative Activity restriction, ice, NSAIDS, protective padding, quad/hamstring stretching and strengthening and time May take several months to resolve Condition heals once the epiphysis closes

Question 92

Prognosis for Osgood Schlatter's Disease

Answer 92

Excellent Bony prominence will persist into adulthood May get minor pain when kneeling

Question 93

Severs Disease

Answer 93

AKA Calcaneal apophysitis Similar in nature to Osgood-Schlatter’s Disease Definition: Low grade inflammation at the insertion of the Achilles tendon to the calcaneal apophysis More common in boys aged 8-14 years old Often bilateral Common in high impact activities/sports

Question 94

Sever's Disease Etiology

Answer 94

Overuse Improper footwear Tightness in calf muscle and achilles tendon

Question 95

Signs/ Symptoms of Sever's Disease

Answer 95

Local pain, tenderness and swelling to the heal over the apophysis Pain is aggravated by activity

Question 96

Imaging and Diagnosis for Sever's Disease

Answer 96

Imaging: X-ray not always indicated but will reveal sclerosis of the apophysis Diagnosis: Clinical based on history and examination

Question 97

Treatment and Prognosis for Sever's Disease

Answer 97

Treatment: NSAIDS, ice, activity restriction, heel cord stretching, calf strengthening Heel cup (insert) may help Brief immobilization with a walking boot or cast for rare, resistant cases followed by PT Prognosis: Excellent Self limiting

Question 98

Club Foot

Answer 98

``` AKA: Talipes Equinovarus Occurs in 1:1000 live births More frequent in males 3 categories: Idiopathic May be hereditary Neurogenic Associated with syndromes (arthrogryposis and Larsen syndrome) ```

Question 99

3 Features used for Clinical Diagnosis for Club Foot

Answer 99

``` 3 features must be present: Plantar flexion of the foot at the ankle joint (equinus) Inversion deformity of the heel (varus) Medial deviation of the forefoot (varus) Other common features: Unable to dorsiflex ankle >90 degrees Foot resists realignment Calf muscle may be shortened and underdeveloped ```

Question 100

Treatment for Club foot depending on age

Answer 100

Newborn to 3 months- serial casting 3-6 months- serial casting and possible surgery 6-9 months- surgical release of soft tissue >18 months- Bone surgery >4 years- tendon transfers if recurrent

Question 101

Treatment for Club Foot

Answer 101

Treatment: The earlier the treatment, the faster the correction Need to have patience!! Stretch the contracted tissues followed by casting to hold the correction Long term treatment: Night braces may be necessary for several years

Question 102

Osteogenesis Imperfecta (OI)

Answer 102

Rare genetic connective tissue disorder characterized by multiple and recurrent fractures Multiple types (I-VII) with varying degrees of illness Type I is most common Some types result in fetal death (Type II) Affected patients are frequently suspected of having suffered child abuse

Question 103

Common PE findings for OI

Answer 103

``` Moderately affected children have numerous fractures and are dwarted due to bony deformities and growth retardation Common PE findings: Blue sclera Thin skin Hyperextensibility of ligaments Otosclerosis w/ hearing loss Hypoplastic and deformed teeth Wormian bones (accessory skull bones that are completely surrounded by cranial sutures) ```

Question 104

Prognosis of OI

Answer 104

Depends on the type Type I: Patients attain normal height with minimal functional limitations Type II: fatal in perinatal period Remainder of types results in decreased height, they can be fully mobile to completely wheelchair bound depending on the type

Question 105

Diagnosis and Treatment of OI

Answer 105

Diagnosis: Genetic testing and X-ray findings Treatment: Bisphosphonates to decrease incidence of fractures Surgery to correct deformities of long bones Preventive measures: intramedullary rod placement to prevent deformity from fracture malunion