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Pediatrics > Pediatric Orthopedics > Flashcards

Pediatric Orthopedics Flashcards

1
Q

What are S and S of osteomyelitis?

A
  1. High fever chills, pain over affected bone
  2. Swelling and tenderness over site of infection
  3. Possible differential DX for hip pain
  4. May refuse to bear weight or walk
    - REFER IMMEDIATELY
    - caused by staph, strep, or salmonella, E coli
    - treated with IV antibiotics
    - immobilize affected joint
    - most common in distal femur and prox tibia
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2
Q

What are S and S of septic arthritis?

A
  1. Irritability
  2. Fever to 104
  3. Refusal to move affected limb
  4. Warm swollen joint held in flexion
    - joint may be destroyed w/in 48 hrs of onset
    - PT involved after antibiotic RX is over
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3
Q

Avascular necrosis of the femoral head secondary to loss of blood supply

A

Legg-calve-perthes disease

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4
Q

What are S and S of legg-calve-perthes disease?

A
  1. Pain in groin, medial thigh or knee
  2. Pain referred from hip
  3. Decreased ROM, especially hip abduction and IR
    • Trendelenburg
  5. Disuse atrophy
  6. Limb length discrepancy
  7. Greatest majority is in boys between 5-7
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5
Q

What are the most common causes of limping in children 0-5 years?

A
  1. Osteomyelitis
  2. Septic Arthritis
  3. Transient Synovitis
  4. Fracture
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6
Q

What are the stages of recovery for legg-calve-perthes disease?

A

takes 1-3 years to complete

  1. Initial
  2. Fragmentation
  3. Reossification
  4. Healed (with some degree of deformity)- Femoral head is revascularized
    - risk for DJD later in life
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7
Q

What are the goals for clinical intervention of legg-calve-perthes disease?

A
  1. Containment of femoral head
  2. Prevention of deformity
  3. Protection of growth plates
  4. Prevention of DJD
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8
Q

What are the clinical interventions of legg-calve-perthes disease?

A
  • Conservative:
    1. Observation and monitoring
    2. Limitation of contact sports
    3. Swimming
    4. Strengthening
  • Vigorous
    1. Splinting
    2. Stretching
    3. Surgery (pelvic or femoral derotational osteotomy)
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9
Q

What are the common apophysitis at the knee?

A
  1. Osgood-Schlatter’s - insertion of the patellar tendon at the tibial tubercle
  2. Sinding Larsen Johansson - inferior pole of the patella
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10
Q

What are the S and S of apophysitis?

A
  1. Will demonstrate tenderness to palpation at the apophysis
  2. MMT of the involved MM will re-produce pain
  3. Self-limiting
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11
Q

What are the treatments of apophysitis?

A
  1. Modalities for pain and inflammation
  2. Bracing
  3. Stretching: Quads and Hamstrings
  4. Strengthening: Quadriceps, Hip ABDuctors, External Rotators
  5. Limit motions that provoke pain
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12
Q

Apophysitis at the insertion of the Achilles’ tendon at the calcaneus

A

sever’s disease

- less common than plantar fasciitis and achilles tendinitis

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13
Q

What signs during evaluation would you see for someone that has severs disease?

A
  1. Length restrictions in the triceps surae
  2. Excessive pronation of the foot
  3. Possible swelling
  4. Antalgic gait with possible compensatory strategies - decr. heel strike, ER compensation, shorter steps, decr time in terminal stance
    - S and S: Bilateral presentation, Sharp or dull pain along the calcaneal apophysis, Reproduction of pain with squeezing the lateral borders of the calcaneus
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14
Q

What are the most common causes of limping in children 5-10 years?

A
  1. Legg-Calve-Perthes Disease
  2. Discoid lateral meniscus
  3. Sever disease (Calcaneal apophysitis)
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15
Q

What are the most common causes of limping in children 10-15 years?

A
  1. Slipped Capital Femoral Epiphysis
  2. Osgood-Schlatter
  3. Patellofemoral Pain
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16
Q

What are the types of forces placed on growing bones?

A
  1. Compression (Tension) - load bone longitudinally, || to direction of growth
  2. Shear - runs || to epiphyseal plate; can lead to torsional or twisting changes in bones
  3. Asymmetric (Pathologic)
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17
Q

What forces stimulates bone growth?

A

compression (tension) forces

- intermittent compression stimulates more growth than tension (i.e., walking)

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18
Q

What forces result in torsion of bones?

A

Shear

- occurs as a result of typical m forces on bone

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19
Q

What forces cause uneven growth of a bone?

A

asymmetric (pathologic)

  • results in malalignment
  • genu varus or valgus
  • scoliosis
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20
Q

What is the typical skeletal structure in a newborn?

A
  1. Rigid, kyphotic spine
  2. Shallow acetabulae
  3. Coxa valga: An increased angle between the neck of the femur and the shaft of the femur
  4. Antetorsion within the femoral shaft
  5. Femoral lateral bowing
  6. Hip flexion and ER contracture
  7. Physiologic genu varum of the knee
  8. Excessive dorsiflexion and frontal-plane mobility in the talo-crural joint
  9. Hindfoot and Forefoot varus
  10. MTP flexion contracture
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21
Q

What are the CNS built-in demands to achieve upright “normal” posture?

A
  1. Tireless weight lifting as the body achieves antigravity control and strength in a cephalocaudal direction
  2. Muscle elongation through reciprocal innervation
  3. Joint capsule and ligament mobility within the spine and lower extremities
  4. Automatic postural reactions
22
Q

What are the variances from typical resolution of newborn biomechanics alignment?

A
  1. in the typical child- i.e. Metatarsus Adductus in W-sitter
  2. in the child with atypical development or CNS injury- i.e. Child with Cerebral Palsy
23
Q

How is torsion measured?

A

Ryder’s test a.k.a. Craig’s test or Trochanteric prominence angle test (TPAT)
- Angle of the intersection of the transcondylar axis distally with the femoral neck proximally

24
Q

Medial twist of the shaft of the bone, distal on proximal, when the transcondylar axis (TCA) is aligned on the frontal plane, the femoral head and neck are directed anteriorly

A

Femoral antetorsion

  • in newborn = 40 degrees
  • in adults = 5-15 degrees
25
Q

What forces create problems with femoral torsion?

A
  1. Habitual sleeping and sitting postures - increased ante torsion in W sitters
  2. Pathologic CNS conditions (Hemiplegic CP)
  3. Muscle action upon the femur
26
Q

What is the gold standard for femoral torsion?

A

CT scan
- only utilized with surgical correction via femoral osteotomy (usually only occurs with comorbid condition like CP)
- clinical measures:
~foot progression angle can be used, but not specific enough
~Ryder’s test (Craig’s test, TPAT) used only if greater trochanter is formed

27
Q

_________ demonstrates high correlation with Femoral Neck Antetorsion

A

Hip rotation ROM

  • newborn = 2 x as much ER as IR
  • 0-2 yr = 120 total rotation
  • > 2 yr = 95-110 total rotation
  • after 4-5 yrs, if IR> 60 or < ER, they have ante torsion! Maybe compensated with tip/fib lateral torsion
  • mild antetorsion: IR = 70-80
  • Mod antetorsion: IR = 80-90
  • severe antetorsion: IR > 90
28
Q

What difference between IR and ER indicates femoral ante torsion?

A

Femoral torsion deformity exists when IR exceeds ER by >30 degrees

29
Q

What are the normal values for FNA in newborns, 5 yrs, 9 yrs, and 16 yrs?

A
  • newborn = 31 degrees
  • 5 yrs = 26 degrees
  • 9 yrs = 21 degrees
  • 16 yrs = 15 degrees
30
Q

What is the significance of femoral torsion on the body structure and function level?

A

Places the hip abductor muscles at a biomechanical disadvantage during gait by decreasing the functional lever arm relative to the hip joint center

  • Inefficient Gait
  • Impaired balance or safety with ambulation
31
Q

What is femoral ante torsion angle significant for in terms of orthopedic injury/ pathology?

A
  1. Decreased FNA is associated with SCFE
  2. Increased or decreased FNA is associated with DJD of the hip
  3. Diminished FNA is associated with torn acetabular labrum of the hip
32
Q

What are the adaptive equipment and orthotics to correct femoral torsion?

A
  1. Braces
  2. Twister cables or straps
  3. Custom-made shoes
    - this is not just directed at femur and will affect the rest of the leg as well
33
Q

What are positioning interventions to correct femoral torsion?

A

Avoid W-sitting;
Encourage tailor sitting
- after 7 yrs, femoral derotational osteotomy is only effective treatment for antetorsion

34
Q

How does the tibia compensate for femoral ante torsion?

A

tibia twists laterally

  • birth = - 15
  • 3 yrs = + 5
  • cold to adult hood = avg +10 (range -5 to +30)
35
Q

Angle between a straight-line through the knee axis and the axis through the medial and lateral malleoli

A

transmalleolar axis

  • Birth: 0 degrees
  • Increasing to 20 degrees by middle childhood
36
Q

If internal tibial torsion persists, what is there increased risk for?

A

Knee OA

- benefit in sprinting

37
Q

If external tibial torsion persists, what is there increased risk for?

A
  1. Greater patellofemoral instability
  2. Predisposing factor in onset of Osgood-Schlatter syndrome (especially on dominant jumping and sprinting side)
    - tibial torsion naturally improves to 18 mos, then use flexible straps or Denis Browne bar
    - orthopedists believe no tx, and if no resolution derotational osteotomy is indicated
38
Q

What does metatarsus adductus increase risk for?

A

4th and 5th met head stress fractures

39
Q

What is the treatment intervention for metatarsus adductus?

A

Moderate (grade 2): taping, shoes, bracing
Severe (grade 3): serial casting, surgery with shoes/braces
- Questionable outcomes

40
Q

Adduction of the forefoot; Varus position of the hindfoot; Equinus of the ankle; Boys 2x more

A

Talipes Equinovarus: Clubfoot
- Causes: Myelomenigocele or Arthrogryposis (due to lack of innervation), Genetic predisposition, Positional related to the size of the infant vs. uterus, Idiopathic

41
Q

What are the interventions for clubfoot?

A
  1. Manipulation
  2. Taping and Stretching
  3. Bracing/Serial Casting
  4. Surgery (3 mo to 1 year) - Posterior medial release
  5. Physical Therapy -Stretching and splinting/taping, Monitoring Casts, Appropriate developmental activities; kids often delayed due to bracing
42
Q

What are the angles at the knee at newborn, 20 months, 3 yrs, and 7-13 yrs?

A

Newborn: 16 degrees varus
20 months: 0 degrees
3 y/o: 10 degrees valgus
7-13 y/o: 0-5 degrees valgus

43
Q

How does genu vacuum resolve?

A
  • Variable compression on the medial and lateral condyles of femur and tibia in standing and walking
  • By 12 months the calcaneus everts, peaks at 2-3 years (just before peak of knee valgus)
44
Q

What are the interventions for genu varum and valgum?

A

Varum:
- If persists after 2 y/o without correcting or worsens then KAFO’s or HKAFO’s
- Staple lateral femoral growth plate called epiphysiodesis
Valgum:
Staple medial femoral growth plate called epiphysiodesis

45
Q

What would you need to deferentially diagnose with genu varum?

A
  1. Vitamin-D-resistant rickets
  2. Achondroplasia
  3. Renal osteodystrophy
  4. Osteogenesis Imperfecta
  5. Blount’s disease - idiopathic and progressive; medial metaphysics peaking, obese, lateral thrust during gait
46
Q

What would you need to deferentially diagnose with genu valgum?

A

Obesity
- Conditions associated with genu valgum:
Knee extensor mechanism injuries, IT band syndrome, stress fractures, plantar fasciitis
- feet are fatter and flatter, possible long term implications

47
Q

Most children will have flexible, painless flat foot that requires no treatment.
But we should evaluate for differential diagnoses of?

A
  1. congenital vertical talus
  2. tarsal coalition
  3. skew-foot: Hindfoot valgus, metatarsus adductus
48
Q

What foot deformities are present with metatarsus adductus?

A
  1. dorsiflexion
  2. forefoot shape from bottom is deviated medially
  3. heel position in valgus
49
Q

What foot deformities are present with clubfoot?

A
  1. forefoot shape from bottom is deviated medially

2. heel position in varus

50
Q

What foot deformities are present with calcaneovalgus?

A
  1. dorsiflexion
  2. forefoot shape from bottom is deviated laterally
  3. heel position in valgus
51
Q

Children with flexible, painless flat feet usually require no treatment. What needs to be differentially diagnosed for possible surgical intervention?

A
  1. congenital vertical talus
  2. tarsal coalition
  3. skew-foot: Hindfoot valgus, metatarsus adductus

Pediatrics (19 decks)

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