Pediatrics Ortho

Question 1

You see a pt w/ deformity from scoliosis confirmed w/ x-ray, discrepancy in leg lengths, and Adam’s test. What should you consider?

Answer 1

level of curvature (Cobb angle)
age of pt/skeletal maturity (Risser score) 
age of menarche
duration
family hx

Question 2

what should be done for pts w/ scoliosis and Cobb angle of 0-20 degrees?

Answer 2

look at age, re-xray pt in 6 months

Question 3

what should be done for pts w/ scoliosis and Cobb angle of 20-30 degrees?

Answer 3

Thoracal Lumbar Sacral Orthosis brace (TLSO) 18-20 hrs/day and ortho referral

Question 4

what should be done for pts w/ scoliosis and Cobb angle of 40+ degrees?

Answer 4

ortho referral

Question 5

if you see a left sided curve in scoliosis, what should you do?

Answer 5

refer pt

left sided curves have high association w/ interspinal anomalies even if no pain

Question 6

what is postural roundback?

Answer 6

flexible deformity not associated w/ vertebral wedging

Question 7

what is Pre-Scheuermann’s Kyphosis?

Answer 7

initially flexible roundback loses its flexibility and pt develops hamstring tightness (occurs in ages 9-12 yrs.).x-ray shows kyphosis w/out wedging

Question 8

what is Scheuermann’s Kyphosis?

Answer 8

associated w/ wedged thoracic vertebra

Question 9

What is the tx for postural roundback?

Answer 9

postural and PT early

Question 10

what is the tx for pre-scheuermann and scheuermann’s kyphosis?

Answer 10

refer for eval and bracing

Question 11

what is a common cause of low back pain in young people?

Answer 11

spondylolysis/listhesis

Question 12

how is spondylolithesis graded?

Answer 12

by how much slide
grade 1: <25% diameter
grade 2: 25-50%
gade 3: 50-75%
grade 4: 75-100%

Question 13

what is spondylolithesis?

Answer 13

A lumbar spinal disorder in which a bone (vertebra) slips forward onto the bone below it

Question 14

what causes spondylolithesis?

Answer 14

repeated stress in hyperflexion and/or rotation

more common in gymnasts, athletes, divers, dancers

Question 15

pt presents with restricted motion, hamstring tightness, decreased walking tolerance (one leg bearing more weight and other leg is hyperextending) and LOW BACK PAIN W/ ROTATION. You notice the pt tends to rotate towards the affected side. what do you suspect?

Answer 15

spondylolysis/lithesis

Question 16

What is Spondylolysis?

Answer 16

Spondylolysis is a stress fracture through the pars interarticularis of the lumbar vertebrae

Question 17

What should be physically examined in spondylolithesis?

Answer 17

lumbar spine exam, distal dermatomes and myotomes

one leg weight bearing w/ rotation

Question 18

What imaging should be ordered in Spondylolithesis?

Answer 18

lumbar spine x-rays (scotty dog film + flexion/extension laterals)
CT, MRI and bone scans can be ordered if dx still questionable

Question 19

what is the treatment for Spondylolithesis?

Answer 19

activity modification
analgesics (avoid opiates)
bracing and PT
surgery in severe cases

Question 20

what is discitis?

Answer 20

bacterial infection of vertebral disc seen w/ vertebral osteomyelitis

Question 21

2-9 yr old pt presents w/ sudden onset of severe back pain, refusal to walk, and irritability. pt is febrile w/ limited back motion. Upon PE, there is localized tenderness over the area along w/ paraspinal muscle spasm. What do you suspect?

Answer 21

discitis

Question 22

what will be seen in the workup for discitis?

Answer 22

ESR (80-100), elevated WBC and CRP, + blood culture

Question 23

what imaging is preferred for discitis?

Answer 23

CT is good, but MRI is better (x-ray not helpful)

Question 24

what is the tx for discitis?

Answer 24

referral to pediatric ID specialist

broad spectrum abx if no organism isolated (IV route for 6-8 wks)

Question 25

what is Legg-Calve-Perthes disease?

Answer 25

avascular necrosis of the femoral head

Question 26

5-10 yr old Caucasian boy is limping and has pain in/slightly above the knee. Upon PE, there is decreased external hip ROM. what do you suspect?

Answer 26

Legg-Calve-Perthes disease

Question 27

what is the tx for Legg-Calve-Perthes disease?

Answer 27

refer to ortho

Question 28

what is slipped capital epiphysis?

Answer 28

common orthopedic condition in 12-17 yr old boys w/ obesity caused by weakening of physis leading to a slip (femoral head falls off femoral neck)

Question 29

overweight teenage boy w/ knee pain walking w/ the limb externally rotated. Upon PE, there is almost no external rotation of the hip. what do you suspect?

Answer 29

slipped capital epiphysis

Question 30

what should be examined in slipped capital epiphysis?

Answer 30

``` X-ray (hip film) if >6 months old hip ROM (little/no external rotation of the hip will be present) ```

Question 31

what is the tx for slipped capital epiphysis?

Answer 31

refer to ortho (surgery)

Question 32

how is congenital hip dysplasia identified?

Answer 32

Ortolani and Barlow maneuver (palpable clunk when hip is reduced in and out of acetabulum)

Question 33

what is the best imaging choice for congenital hip dysplasia?

Answer 33

ultrasound

Question 34

child has palpable clunk with the ortalani maneuver; however, imaging is normal. What should you do?

Answer 34

tx w/ Pavlik harness | have ortho f/u

Question 35

pt has knee pain w/ bending, squatting and kneeling. Upon palpation of the patella, there is tenderness and pain w/ quad flexion. what do you suspect?

Answer 35

chondromalacia

Question 36

what should you do if you suspect chondromalacia?

Answer 36

knee exam, x-ray w/ sunrise view | tx w/ NSAIDs, quad strengthening, PFO brace, occasionally patellar realignment

Question 37

adolescent presents w/ anterior knee pain and has a bump located over the tibial tuberosity. what do you suspect?

Answer 37

osgood schlatters disease

Question 38

what are causes of osteomyelitis?

Answer 38

S. Aureus (most common) Newborns can acquire Neisseria gonorrhoeae from infected birth canal Gonoccocal arthritis in sexually active teens, or younger children w/ sexual abuse

Question 39

infant presents w/ fever, focal swelling, redness and is guarding the affected body part. they are unable to support weight and asymmetric movement of the extremities is noted. what do you suspect?

Answer 39

osteomyelitis

Question 40

what should be ordered if you suspect osteomyelitis?

Answer 40

labs: CBC-WBC (elevated in 50%), ESR and sed rate elevated, CRP X-ray bone scan MRI (best option)

Question 41

child looks ill, is febrile, and refuses to walk/move affected joint. there is effusion and erythema in the joint. the child is holding the joint in a position of least pain. what do you suspect?

Answer 41

septic joint disease

Question 42

what should be ordered if you suspect septic joint disease?

Answer 42

labs: CBC, sed rate, CRP, blood cx, joint aspiration w/ gram stain and cell count x-ray

Question 43

what is the tx for septic joint?

Answer 43

immediate referral (delay can result in irreversible damage), joint wash-out, adequate antibiotic coverage for sufficient period of time

Question 44

what is the most common cause of heel pain in children?

Answer 44

calcaneal apophysitis (inflammation of posterior calcaneal growth plate)

Question 45

child who just started an organized sport complains of heel tenderness. what do you suspect?

Answer 45

calcaneal apophysitis

Question 46

how do you treat calcaneal apophysitis?

Answer 46

NSAIDs, gel heel cup, limit extensive activity (will resolve on its own)

Question 47

child complains of medial foot/calf pain w/ prolonged weight bearing. The child relies on arms to sit up and you note inversion. what do you suspect?

Answer 47

pes planus

Question 48

how do you check for pes planus?

Answer 48

Gower's sign to rule out neuromuscular condition subtalar ROM to rule out tarsal coalition heel cord tightness

Question 49

what is the tx for pes planus?

Answer 49

supportive shoes, orthotics in severe cases and lots of reassurance

Question 50

what is calcaneovalgus?

Answer 50

dorsiflexed and everted foot (EXTERNALLY rotated) due to "packaging defect"

Question 51

what is metatarsus adductus?

Answer 51

kidney shaped foot deviates MEDIALLY with vagus heel d/t "packaging defect" foot sits on ground while holding baby up, sole is pointed in the right direction

Question 52

what is club foot?

Answer 52

congenital condition where pt is unable to dorsiflex foot is kidney shaped w/ heel varus food is adducted and sole is INVERTED almost upward usually accompanied by other abnormalities

Question 53

how is calcaneovalgus treated?

Answer 53

spontaneously resolves on its own

Question 54

how is metatarsus adductus treated?

Answer 54

correct to neutral manually

Question 55

how is clubfoot treated?

Answer 55

needs intervention, can't be corrected manually

Question 56

child complains of pain in the wrist/proximal forearm. they are holding their forearm and won't supinate the hand. you feel a "winding up" sensation when you supinate the hand. what do you suspect?

Answer 56

nursemaids elbow

Question 57

how should a nursemaids elbow be treated?

Answer 57

reduction, arm held straight, lower arm-traction applied, arm is supinated and flexed to 90 degrees. you will feel a pop over the radial head.

Question 58

what are factors associated w/ brachial plexus injuries?

Answer 58

large birth weight, breech delivery (born bottom first), shoulder dystocia, gestational DM

Question 59

baby is born w/ arm internally rotated and pronated w/ no movement at the shoulder or elbow w/ hand/wrist flexion. what do you suspect?

Answer 59

brachial plexus injury

Question 60

what is the tx for brachial plexus injury?

Answer 60

most will resolve over several weeks | may protect joints if appropriate

Question 61

what is ewing sarcoma?

Answer 61

bony tumor

Question 62

pt presents with pain and has a palpable mass close to the bone. you notice Codman's triangle on x-ray. what do you suspect?

Answer 62

ewing sarcoma

Question 63

what is the tx for ewing sarcoma?

Answer 63

surgical- immediate referral!

Question 64

what should be examined if you suspect ewing sarcoma?

Answer 64

- careful inspection of painful sites w/ palpation - *comprehensive neurologic examination* to evaluate asymmetric weakness, numbness, or pain (tumors can push on nerve) - lungs (asymmetric breath sounds, pleural signs, rales) - skin- petechiae, purpura - fever and wt loss indicates metastatic disease

Question 65

what is osteochondroma?

Answer 65

benign and asymptomatic cartilaginous tumor of bone most frequently see in the hand (no tx necessary)

Question 66

what are fibromas?

Answer 66

Fibrous cortical defect that can occur anywhere in the body. § On x-ray, it will have a regular, sclerotic border. § Main problem is pathological fractures.