Peds Flashcards
(91 cards)
1
Q
Checklist of how to think
A
Toxins Tumors Trauma Infection Inflammation / immunologic Metabolic Endocrinologic Hematologic Vascular Neurologic Congenital Psychologic
2
Q
Congenital clubfoot
A
Clinical/pathologic anatomy Cavus Adductus Varus Equinus
3
Q
Talipes Equinovarus - in general
A
Congential deformity of hindfoot equinus, forefoot adduciton and varus
4
Q
Talipes Equinovarus - e/e
A
Unknown High correlation to genetics & environment Commonly associated with other defects - spina bifida - arthrogryposis - myelodysplasia Male x2 50% bilateral
5
Q
Talipes Equinovarus - PE
A
R/o hip dysplasia & torticollis
Degree & flexibility of deformity
6
Q
Talipes Equinovarus - imaging
A
X-ray
Parallelism between talus & calcaneous
7
Q
Talipes Equinovarus
A
Progressive casting
Sx
Bracing
8
Q
Torticollis - in general
A
Congenital muscular d/o Most common Contracture of SCM Right side - 75% Palpable mass
9
Q
Torticollis - imaging
A
X-ray
R/o vertebral anomalies
10
Q
Torticollis - PE
A
Check hips with exam and US (20%)
11
Q
Torticollis - tx
A
Therapy 90% effective
Sx if refractive after 1 year
12
Q
Galeazzi
A
Bend legs at knee and place feet on solid surface
Measure knee heights
13
Q
Developmental Hip Dysplasia - in general
A
Continuum of d/o ranging Shallowness of acetabulum Instability / sublux of femoral head Frank dislocation May not be present at birth
14
Q
Developmental Hip Dysplasia - Classification
A
Teratologic Typical - Sublxed - Dislocatable - Dislocated
15
Q
Developmental Hip Dysplasia - Hx & PE
A
Positive FHx Breech presentation - increase 20% Girls (4:1) Left side Foot & knee deformities Torticollis Asymmetry in thigh folds (Ant/post) ROM - decreased abduction Galeazzi sign Ortolani & Barlow
16
Q
Developmental Hip Dysplasia - dx
A
US - Less than 6 months - Use in high risk or equivocal exam - Use to follow rx with pavilik bracing Xray
17
Q
Developmental Hip Dysplasia - tx
A
REFER
Pavlik bracing
- 90-95% effective
- less than 6 months
18
Q
Pavlik bracing resolution
A
Subluxated hips - 99% resolution
Dislocated hip - 50% resolution
19
Q
Developmental Hip Dysplasia - bilateral cases
A
Excessive lordorsis
20
Q
Normal Gait
A
Stance - 60% - Heel strike - Tibial Translation - Heel rise Swing (40%) - Toe off - Midswing - Terminal swing
21
Q
DDX in a toddler (1-3 yo)
A
Trauma Transient synovitis Septic arthritis Diskitis Toddler's fx CP DDH Muscular distrophy Coxa Vara Pauciarticular JRA Leukemia Osteoid osteoma
22
Q
DDx - Child (4-10 yo)
A
Transient synovitis Septic Arthritis Legg-Calve-Perthes dz Discoid meniscus Limb length discrpancy
23
Q
DDX - adolescent (11-15yo)
A
SCFE Hip dysplasia Trauma Overuse syndromes Osteochondritis dissecans
24
Q
DDX of the limping child - in general
A
Inflammatory & infectious
Trauma / fx
Anatomic
Neoplasms
25
DDX of the limping child - inflammatory & infectious
```
Osteomyelitis
Diskitis
Transient synovities
JRA
Psoas abscess
Pyogenic sacroiliits
Lyme arthritis
```
26
DDX of the limping child - anatomic
```
DDH
Coxa vara
Perthes dz
SCFE
Chondrolysis
OCD
LLD
```
27
DDX of the limping child - Neoplasms
Leukemia
| Osteoid osteoma
28
Septic hip - Kocher criteria
Fever (>38.5°C)
Non-weight-bearing
EST (greater than 40 mm/hr)
WBC count > 12,000
29
Kocher criteria probability of septic hip
```
0 predictors - 0.2%
1 predictors - 3%
2 predictors - 40%
3 predictors - 93%
4 predictors - 99%
```
30
Septic Arthritis - in general
Requires urgent management b/c of potential for joint destruction
31
Septic Arthritis - s/s
```
Acute onset of pain, limp/refusal of weight bearing
Hx of mild trauma or concurrent illness
Progresses to febrile systemic illness
Immobile joint
Swelling
Erythema
Tenderness possible
```
32
Septic Arthritis - labs
```
Elevated
WBC
CRP
ESR
Blood culture 30%
```
33
Septic Arthritis - Radiographs
Negative at onset of symptoms (soft-tissue swelling)
Changes due to bone infection after 7-10 days
- Protracted, active process
- Erosion and joint narrowing with cartilage destruction
34
Septic Arthritis - Bone scan
Only necessary if localization not possible
| Positive after 24-48h
35
Septic Arthritis - Aspiration
```
WBC - 80-200
>75% PMN
Gram stain not sensitive
Cultures
- Staph aureus
- Kingella Kingae
- Less H. flu
```
36
Osteomyelitis - in general
Generally secondary to hematogenous spread
| S. aureus most common
37
Osteomyelitis - clinical presentation
```
Local swelling
Pain
Possible pseudoparalysis
Sudden onset of fever
Systemic illness in children
Slower onset in adolscents
```
38
Osteomyelitis - imaging
Bone destruction on radiograph (metaphyseal) late finding (several days)
39
Transient synovitis - in general
Most common cause of lower extremity pain
| 3-8yo
40
Transient synovitis - presentation
Rapid onset of hip pain
Limited ROM
Limping or inability to bear weight
Frequent receding viral illness
41
Transient synovitis - ddx
Septic arthritis
42
Transient synovitis - labs
Normal
CBC
ESR
CRP
43
Transient synovitis - eval
US - effusion
Aspiration
- WBC 5-15K
>25% PMN
44
Transient synovitis - tx
Goal - expedite spontaneous resolution
Brief bed-rest / NWB - light traction may alleviate pain
NSAIDs
Routine aspiration - no demonstrable therapeutic benefit
Crutches until limp resolves
Average duration of s/s - 10d
45
Muscular Dystrophy - in general
```
Boys 2-5 yo
Delayed ambulation
Stumbling
Falling
Stair difficulty
Proximal weakness
Gower's sign
Toe walking
Pseudohypertrophy of the calf
Elevated serum creatinine phosphokinase
```
46
Duchenne
Caused by an error in an x-linked recessive gene, meaning it mainly affects boys
47
Trigger thumb - in general
Nodular enlargement of flexor tendon that becomes locked at A1 pulley
Presents 4-24m of age
30% bil
Flexed, locked thumb
48
Trigger thumb - tx
Less than 1 yo - observation
| Sx
49
Brachial Plexus Injury - RF
```
Shoulder/fetal dystocia
Obesity
Prolonged labor
Breech presentation
Multiparous PG
Traction injury
```
50
Erb's Palsy
```
Most common
C5-C6
Position - Waiter tip
- Shoulder Adducted / IR
- Elbow extended
- Forearm pronated
- Wrist/fingers flexed
```
51
Klumpke's Palsy
C8-T1
Hand paralysis
Should/elbow maintained
52
Brachial Plexus Injury - tx / recovery
Recovery dependent of severity
- 90% spontaneously resolve in 1 yr
- Most improvement 1st 3 months
53
Brachial Plexus Injury - Management
ROM
Microscopic repair of plexus
Muscle procedures
Rotational humeral osteotomy
54
Nursemaid's elbow - in general
Radial head subluxation under annular ligament
| Secondary to forceful traction on arm
55
Nursemaid's elbow - presentation
<4yo
Arm held in pronation with slight flexion
Pain at radial head
56
Nursemaid's elbow - imaging
x-ray
| r/o fx
57
Nursemaid's elbow - tx
```
Reduction
- posterior pressure on radial head whil flexing & supinating arm or hyperpronation
- immediate click and relief of pain
No immobilization if 1st time
Recurrent may need casting
```
58
Most common complication caused by tx in ED/UC
Pressure sore
59
Pediatric Fx system of naming
Salter-Harris
60
Distal Femoral Physeal fx - in general
Direct blow mechanism
Salter I or II common
Check NV status
- Less common than with tibial injury
61
Distal Femoral Physeal fx - complications
```
High rate of premature growth arrest
- rare <2yo
- 80% 2-11yo
- 50% >11yo
Angular deformity
Leg length discrpancy
```
62
Distal Femoral Physeal fx - f/u
6m x-ray of other side
| At regular intervals until maturity
63
SCFE
Slipped Capital femoral epiphysis
64
SCFE - s/s
Referred knee pain
65
SCFE - complications
Obligate external rotation
AVN
THR
66
SCFE - tx
w/c or crutches until sx
67
Patellar Sleeve fx
8-12 yo
Inferior pole sleeve of cartilage may displace
May have small ossified portion
<2mm displaced, intact extensor mechanism - tx non-operatively
68
Patella fx - in general
Tension band or screw if large enough
Consider excising small marginal fragments
Good PPX
69
Patella fx - complications
Alta
Ext lag
Quad muscle atrophy
70
Proximal tibial physeal fx
Usually Salter II fx
Occasionally Salter I or IV
Post displaced epiphysis or metaphysis can cause vascular injury
HYPEREXTENSION
Exploration or arteriography if ischemic or diminished pulse after fx reduction
71
Principles of distal tibial growth
```
Distal tibia ossific nucleus
- appears: 2-3 yo
- fuses: girls-15; boys-17
Fuses central to medial and then lateral over 18 months
Distal fibula ossific nucleus
- appear: 2 yo
- fused: 20yo
Secondary ossification centers
```
72
SC joint fx / dislocation
SC dislocation posterior can be emergent b/c of trachea
One of the last growth plates to fuse
Most kids fuse w/o tx
May need to be reduced, but pretty stable post-reduction
Sx - Severe shortening; open fx
73
Proximal humerus fx
If >2yr of growth left & <10 yo - no sx
| If <2yr growth left - may need sx
74
Elbow fx
As you grow/age you see growth in a weird pattern - CRITO
Ulna is not linging up with the humerus
Can inject dye before x-ray, but most ERs will say no or MRI
75
Supercondyler humerus fx - in general
Extension > Flexion type
Gartland classification
Recall the anterior interosseous N.
76
Supercondyler humerus fx - Gartland classification
I - Crack; non-displaced
II - crack and angulated backward
III - Hinge is not intact
IV - can move all around
77
Supercondyler humerus fx - tx
I - cast
| II & III - fixation with pins
78
Elbow dislocation
Usually can be reduced in the ER, but find the medial epicondyle
79
Ossification
Capitellum - 6m to 2yr
Medial epicondyle - 5-9yr
Trochlea - 7-13yr
Lateral epicondyle - 8-13yr
80
Septic hip - in general
Most common in first decade
Difficult to dx - if in doubt, admit and observe
Serious sequelae
81
Modified Kocher criteria
```
0 predictors - 17%
1 predictor - 37%
2 predictors - 62%
3 predictors - 83%
4 predictors - 93%
5 predictors - 98%
```
82
Septic hip - etiology
Hematogenous spread
Direct seeding of synovium
Metaphyseal osteomyelitis then enters the joint
83
Septic hip - work-up
```
X-rays
Blood cultures
CRP
ESR
CBC with differential
US
Aspiration
```
84
Septic hip - Aspiration
Definitive Dx
| Cloudy appearance WBC count between 80-200 with >75% polys
85
Septic hip - tx
Standard - I&D
- approach depends on preference
IV abx followed by oral abx
Serial CRPs
86
Compartment syndrome - injury
Can occur at any site here muscle is contained in a closed fascial space
Common areas are lower leg, forearm, foot, hand, gluteal region & thigh
Develops when pressure in the osteofascial compartment cause ischemia and necrosis
Ischemia can be caused by swelling or constricting dressings
End stage is and ischemic Volkmann's contracture
87
Compartment syndrome - assessment
```
High risk
- tibia or forearm fx
Crush injuries
tight dressings or casts
Difficult to assess in the pt with altered mental status
```
88
Compartment syndrome - s/s
```
Pain out of proportion to injury
Pain with passive stretching
Paresthesia
Decreased sensation or functional loss
Tense swelling
Weakness or paralysis and loss of pulses are late sign
```
89
Compartment syndrome - dx
Dx is Clinical
Based on hx of injury & PE
Intracompartmental pressures are helpful
Tissue pressures >35-45mmHg or with 30 mmHg of diastolic pressure are suggestive of compartment syndrome
90
Compartment syndrome - tx & management
Management - loosening tight dressings, splints & casts
| If no improvement, then fasciotomy is requires
91
Compartment syndrome - Three A's
Anxiety
Analgesia
Agitated
