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1

What are associated anomalies with this deformity?

Klipell Fiel

congential scoliosis

UE abnormalities

diastomeomyelia

renal disease

 

2

What is the classification of spregnel?

3

What are the procedures for spregnel

Done for stage 3/4 to improve cosmesis and abduction

Between ages 3-8, >8 is not a good candidate

Woodward with clavicular osteotomy is the preferred procedure

Procedure is done prone, tunnel subfacia anterior to do the clavicle

4

What are risk factors for brachial plexus palsy

large babies
difficult presentation
shoulder dystocia
forceps delivery
breech position
prolonged labor

5

What are prognostic factors for brachial plexus palsy?

90% will recover without intervention - can occur for up to 2 years

70% of those affected will develop glenoid retroversion

Good - biecps twitch by two months

Bad 

lack of biceps function
preganglionic injuries; Horner's syndrome, loss of rhomboid function

avulsion injuries (worst prognosis) 

6

What is Erb's palsy?

Mechanism

results from excessive displacement of head to opposite side and depression of shoulder on same side producing traction on plexus

occurs during difficult delivery in infants or fall onto shoulder in adults

Physical exam

clinically, arm will be adducted, internally rotated, at shoulder; pronated, extended at elbow (“waiter’s tip”)
C5 deficiency

axilllary nerve  - weakness in deltoid, teres minor
suprascapular nerve - weakness in supraspinatus, infraspinatus
musculocutaneous nerve  - weakness to biceps 

C6 deficiency

radial nerve - weakness in brachioradialis, supinator

Prognosis  - best prognosis

7

What is klumpke's palsy?

Mechanism

rare in obstetric palsy
usually avulsion injuries caused by excessive abduction (person falling from height clutching on object to save himself)
other causes may include cervical rib, or lung mets in lower deep cervical lymph nodes

Physical exam

deficit of all of the small muscles of the hand (ulnar and median nerves)
clinically, presents as “claw hand”

wrist  held in extreme extension because of the unopposed wrist extensors
hyperextension of MCP due to loss of hand intrinsics
 flexion of IP joints due to loss of hand intrinsics

Prognosis

poorer
frequently associated with a preganglion injury and Horner's Syndrome

Ptosis, myosis, anhydrosis

8

Draw the brachial plexus

9

What are indications for microsurgery associated with bracial plexus palsy

complete flail arm or horner's at one month

10

Diagnosis?  Incidence?  Options for treament (general)

Brachial Plexus Palsy - No IR

  • At time of birth
    • PT for ROM and monitor
    • 90% will improve
  • Early micro surgery (graft or repair)
    • fail arm at one month
    • horner's syndrome at one month
    • root avulsion (only grafting)
  • contracture release (any age)
    • pec, subscap z-lengthening, arthroscopic subscapular release 
  • L'Episcopo lat dorsi/teres major transfer with pec major contracture release
    • requires a congruent joint
    • usually children < 4yo
  • Proximal humerus rotational osteotomy
    • incongruent joint
    • >5yo

 

11

Deformity associated with madelung's

Volar carpal subluxation

proximal radial synostosis

increased radial inclination

volar tilt

volar-ulnar tethering of vickers ligament

12

What is vickers ligament

thickening of radiolunate ligament - madelungs

13

What is leri-wiell

rare genetic disorder caused by mutation in the SHOX gene 
SHOX stands for short-statute homeobox-containing gene
anatomically at the tip of the sex chromosome - pseudo-sex linked disorder
causes mesomelic dwarfism (short stature)
Normal intellegene
associated Madelung's defomity of the forearm

14

What is the treatment for this deformity

watch if they are young, deformity is small; assess with serial XR

Consider OR for pain or functional deformity

Physiolysis or Vickers release - open physis with progression

Radial ostotomy, vickers release, +/- ulnar ostoetomy, +/- ulnar epiphyseodesis

15

What is the evidence for screening DDH

No evidence to screen

Imaging prior to 6 months in infants with clinical evidance, fam hx, breech, 

16

What factors are associated with increased incidence of LCP?

positive family history
low birth weight
abnormal birth presentation
children exposed to second hand smoke
Asian, Eskimo and Central European decent

17

What are the risk factors of LCP?

family history of disease in 1.6-20% of cases
has been found to be associated with ADHD in 33% of cases
bone age is delayed in 89% of patients

 

18

What factors are associated with poor prognosis in this patient?

bone > 6 years
female sex
decreased hip range of motion

Lateral pillar, head sphericity

Most patients will do ok until 6th decade

 

19

What are the caterall risk factors associated with LCP?

Gage sign - V-shaped radiolucency in the lateral portion of the epiphysis and/or adjacent metaphysis
 

calcification lateral to the epiphysis
lateral subluxation of the femoral head
horizontal proximal femoral physis
metaphyseal cyst

20

What are the lateral pillar and stulberg classfications

Lateral pillar (fragmentation phase)

A- none

B - >50% no height loss

B/C - >50% height loss

C - < 50% lateral pillar

21

What are treatment options for LCP?

Goal : low stulberg classficiation

< 8 = nothing, casting is controversial

> 8, lateral pillar B and B/C in fragmentation phase = femoral osteotomy or pelvic ostetomy containment procedure

C - later treatment

22

Outcomes you should know for LCP

no positive effect has been found for containment surgery performed after initial or early fragmentation stage


children with lateral pillar A and those with B under 8 years did well regardless of treatment


large recent studies show improved outcomes with surgery for lateral pillar B and B/C in children > 8 years (bone age >6 years)  


poor outcome for lateral pillar C regardless of treatment

23

Risk factors for developing this pathology

males (male to female ratio is 3:2)
African Americans
Pacific islanders
obese children - single greatest risk factor

during period of rapid growth
bilateral in 20% (20-40% May go on to develop bilateral)

24

When would you consider endocrine WU for SCFE and what are you looking for?

child is < 10 years old
weight is < 50th percentile

 

hypothyroidism (labs show elevated TSH)
renal osteodystrophy (abnormal BUN and creatinine)
growth hormone treatment

25

What is the risk of AVN associated with the loder classification?

stable  - AVN = 10%

able to bear weight with or without crutches

unstable - AVN = 47%

unable to ambulate (not even with crutches)

26

Chondrolysis after SCFE is associated with

unrecognized implant penetration of the articular surface
spica cast immobilization
Advanced SCFE
Intertrochanteric osteotomy

27

AVN following SCFE is associated with

 unstable slip (47%)
hardware placement in posteriosuperior femoral neck 
Increased number of pins
Cuneiform osteotomy

28

What are options for late deformity in SCFE

arthroscopic vs mini anterior for osteochondroplasty

surgical dislocation for more severe deformity

Southwick osteotomy

29

Differential?  Indications for surgery?

  • Differential for aquired coxa vara
    • AVN: (DDH or Perthes)
    • Fibrous Dysplasia
    • SCFE
    • Rickets
    • Osteomyelitis of Hip and Septic Arthritis
    • traumatic
    • Paget's Disease
  • Imaging/Indications for valgus osteotomy
    • Hilgenreiners angle < 45 - nonop
    • Hilgenreiners angle > 60 
    • neck shaft angle < 110 
  • Considerations with osteotomy
    • ​might need to tension abductors
    • may have LLD

30

thought to be a cause of sacral agenesis

maternal diabetes