OrthoBullets (Eprep) OLD > Peds > Flashcards

Peds Flashcards

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1
Q

Obstetrical Clavicle Fracture - Risk factors

A

• Large birth weight (>4kg) • Shoulder dystocia • Prolonged gestation • Forceps delivery

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2
Q

Medial Epicondyle Fracture – Surgical Indications

A

• Absolute o Entrapment of medial epicondyle • Relative o > 5mm displacement (usually goes distal and lateral) o Associated with elbow dislocation o Dominant arm in throwing athlete o Weight-bearing extremity in athlete who weight bears through arm (gymnast)

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3
Q

Infantile Scoliosis - Risk of progression

A

• RVAD > 20 degrees • Phase 2 rib • Cobb angle > 30 degrees

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4
Q

Describe the Kocher Criteria

A

Septic hip? • Temp > 38.5 • CRP • ESR • Refusal to WB • WBC count

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5
Q

Septic Arthritis Poor prognostic factors

A

• Age < 6 months • Delay to treatment > 4 days • Hip • Joint effusion with underlying osteomyelitis

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6
Q

Neonatal Infections: Risk factors in NICU

A

• Phlebotomy sites • Indwelling catheters • Invasive monitoring • Peripheral alimentation • IV drug administration

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7
Q

Lyme Disease Features

A

NIVEA • Neuropathies • Intermittent reactive arthritis • Cardiac arrhythmias (“V-Tach”) • Erythema migrans (“bulls eye” rash) • Acute arthritis

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8
Q

ACL “Rules” to avoid physeal arrest

A
  • Avoid over-tensioning
  • Tunnels filled with soft tissue graft only (less likely to form physeal bars)
  • Avoid bone blocks and hardware at level of physis
  • Tunnels small (6-7mm) - <5% of physis (8mm tunnel in 12yr old = 3-4%)
  • Tunnels perpendicular to physis (not oblique)
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9
Q

NF dystrophic scoliosis features

A
  • short (4-6 levels), sharp curves, <6 yrs
  • Xray findings
    • scalloping end plate (posterior)
    • foraminal enlargement
    • pencilling of ribs
    • vertebral wedging
    • dysplastic pedicles
    • dural ectasia (*MRI pre-op)
    • dumbbell lesion (canal neurofibroma)
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10
Q

Proteus Syndrome - 3 characteristic findings

A
  • hemihypertrophy
  • macrodactyly
  • partial gigantism of hands/feet/both
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11
Q

Hemihypertrophy - associated with (4)

A
  • Klippel-Trenaunay-Weber syndrome
  • Proteus
  • NF-1
  • Beckwith-Wiedemann syndrome
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12
Q

Syndactyly - associated with (4)

A

PACU

  • Poland syndrome
  • Apert syndrome
  • Congentical constriction band syndrome
  • Ulnar longitudinal deficiency
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13
Q

Order of frequency of syndactyly webbing

A
  • 3rd webspace
  • 4th webspace
  • 2nd webspace
  • 1st webspace
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14
Q

Poland Syndrome

A
  • subclavian artery hypoplasia
  • absence of sternocostal head of pec major
  • associated with
    • limb hypoplasia (synbrachydactyly - short digits)
    • carpal coalition
    • RU synostosis
    • sprengel’s deformity
    • scoliosis
    • dextrocardia
    • nail agenesis
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15
Q

Apert Syndrome

A
  • FGFR2***
  • Associated with (TAMP)
    • tarsal coalition
    • acrosyndactyly (spadelike hand)
    • mental retardation
    • premature fusion of cranial sutures
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16
Q

Trigger thumb

A
  • constriction of FPL at A1 pulley
  • 60% bilateral
  • 30% spontaneous resolution if <1 yr
  • <10% spontaneous resolution if >1 yr
  • Surgery –> at 2 years if not resolved
    • A1 pulley release
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17
Q

Clinodactyly

A
  • radioulnar deformity of 5th digit
  • autosomal dominant
  • Associated with:
    • Down syndrome (80%)
    • Russel-Silver syndrome
    • Feingold syndrome
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18
Q

Risk factors for brachial plexus birth palsy

A
  • macrosomia
  • multiparous pregnancy
  • prolonged labour
  • difficult delivery
  • shoulder dystocia
  • difficult arm/head extraction in breech
  • previous BPBP
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19
Q

Brachial plexus birth palsy

A
  • 80-90% spontaneous recovery
  • antigravity biceps by 2 mths = full recovery anticipated
  • biceps recovery at/after 5 mths= incomplete recovery anticipated
  • poor prognostic signs
    • horner syndrome
    • phrenic nerve palsy
    • total plexopathy (flail extremity)
  • most common problem = IR contracture of arm = glenoid dysplasia (posterior subluxation, humeral head flattening, increased glenoid retroversion)
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20
Q

Brachial plexus birth palsy - signs of preganglionic lesion (4)

A
  • horner syndrome
  • elevated hemidiaphragm
  • winged scapula
  • absence of rhomboid/rotator cuff/lat dorsi function
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21
Q

Brachial plexus birth palsy - Indications for microsurgery

A
  • no biceps function at 3-6 mths
  • flail extremity + horners at 3 mths
  • others say - flail or horners @ 1 mth
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22
Q

Erb’s Palsy treatment

A
  • “waiter’s tip” - arm adducted, IR, pronated, extended at elbow
  • can trial splinting (sup, ER)
  • sx options
    • pec major release
    • subscap release
    • anterior capsule release
    • lat dorsi & teres major transfer (in young patients to try and prevent progression of dysplasia)
    • external rotation osteotomy of humerus (in significant dysplasia)
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23
Q

What is Sprengel’s deformity

A
  • small, undescended scapula
  • associated with
    • scapular winging
    • hypoplasia
    • omovertebral connections (bony or fibrous connection from scapula to vertebral column)
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24
Q

Disease associated with Sprengel’s

A
  • Congenital scoliosis
  • Klippel-Feil
  • Torticollis
  • Poland Syndrome
  • Facial asymmetry
  • UE abnormalities
  • Diastematomyelia
  • Pulmnary or renal dx
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25
Components of Madelung's Deformity
VARA * Vicker's ligament (lunate to radius\*) * increased radial inclination * volar subluxation of the carpus * apparent dorsal subluxation of the ulna
26
Teratologic DDH associations
* arthrogryposis * myelomeningocele * SMA * CMT * CP * Larsen's * Ehlers-Danlos * Down Syndrome * Mucopolysaccharoidosis (later in life)
27
DDH associated with packaging problems
* prematurity * oligohydramnios * multiparous birth * congenital knee dislocation * congenital torticollis (20%) * metatarsus adductus (10%)
28
Indications for screening US in DDH
* positive family hx (parent or sibling) * breech position in utero * congenital muscular torticollis * congenital knee dislocation * positive physical exam * equivocal exam in patient at risk
29
DDH Ultrasound Parameters
* Alpha angle = bony acetabular roof + ileum * Normal \> 60 * Beta angle = cartilaginous acetabular roof + ileum * Normal \< 55 * \*BIG BETA BAD
30
DDH Radiographic Parameters
* Hilgenreiner's line - horizontal across superior aspect of both triradiate cartilage * Perkin's line - perpendicular to H at lateral edge of acetabulum * \*ossific nucleus in infero-medial quadrant * \*if no ossificationuse medial aspect of femoral neck * Shenton's line * Acetabular Index (AI) * \>30 abnormal in infant (1 yr) * \>20 abnormal \>2 yrs * Center-edge angle of Wiberg * \<20 abnormal
31
DDH Blocks to Reduction
\*OUTSIDE --\> IN * iliopsoas and adductor longus contracture * hip capsule * inverted labrum * inverted limbus (hypertrophied labrum) * TAL * pulvinar (fatty tissue filling space) * ligamentum teres
32
Pavlik Harness - Position & Complications
* 90 degrees flexion (anterior strap) * Risk: Femoral nerve palsy * \<60 degrees abduction (posterior strap) * Risk: AVN (impingement of posterosuperior branch of MFCA) * \*Length of Pavlik tx = age + 3 mths (1/2 full time, 1/2 part time)
33
DDH Closed Reduction Principles
* traction, flexion, abduction * confirm with medial dye pool \< 5-7mm * "safe zone" of Ramsey * maximum passive ABD to ADD where hip is stable * adductor tenotomy - as required to increase safe zone * spica cast - "in 90-100 degrees flexion within the safe zone avoiding \> 60 degrees abduction and neutral rotation" * post-op CT or MRI * cast x 3-4 mths, change at 6 weeks
34
DDH Indications for Open Reduction
* failed closed treatment * non-concentric reduction (likely block present) * reduction requiring extreme, dangerous positioning * gross instability
35
Spica Position after Open Reduction/Pelvic Osteotomy
* 30 degrees flexion * 30 degrees abduction * minor IR * \*cast x 6 weeks, abduction brace x 6 weeks * \*if medial approach = spica x 3 months
36
Bony Changes in DDH (femur & acetabulum)
* Femur * small head * short anteverted neck * valgus * posterior GT * tight isthmus (esp M/L) * Acetabulum * shallow, hypoplastic * anteverted * anterolateral & superior deficiency
37
DDH Anterior Approach - Advantages & Disadvantages
* Advantages * Capsulorrhaphy possible\* * Lower risk of osteonecrosis (MFCA)\* * Direct access to acetabulum/blocks to reduction * Able to do pelvic osteotomy through same incision * Shorter duration of spica (6 wks) * Familiar surgical approach * For high-riding dislocations, older patients (\>1 yr) * Disadvantages * Post-op stiffness * Potential blood loss * Risk to LFCN
38
DDH Medial Approach - Advantages & Disadvantages
* Advantages * Direct access to medial structures (lig teres) * Avoid damage to abductors, splitting iliac crest apophysis * Less stiffness * Less invasive, minimal dissection, quicker * Less blood loss\* * Better scar * Disadvantages * Capsulorrhaphy not possible\* * Pelvic osteotomy not possible (ie use in \<18 mths) * Poor visualization of acetabulum * Labrum not accessible * Higher risk osteonecrosis\* * Longer duration of cast (3 mths)\* * dont have capsulorrhaphy to help maintain reduction as in anterior approach
39
Perthes - Poor Prognostic Factors
* onset of symptoms \> age 8\* * female * premature physeal closure * lateral hip subluxation * reduced hip ROM (abd) * \>50% femoral head involvement/collapse\* * aspherical head, incongruent joint (Stulberg) * Herring B or C * Catterall III or IV * Salter-Thompson B * 2+ Catterall at risk signs * \*\*\*head involvement (shape, congruency) + age at onset of disease most important risk factors\*\*\*
40
Perthes - Catterall Radiographic Head-At-Risk Signs
* Need 2 or more * Gage sign ("V" in lateral epiphysis) * Calcification lateral to epiphysis * Lateral subluxation of femoral head * Horizontal physis * Metaphyseal cysts \*G-MLCH
41
Perthes - Waldenstrom's Radiographic Stages
1. Initial (xrays normal 3-6 mths) 2. Fragmentation (lasts 1 yr) - use all classifications during this stage\* 3. Re-ossification (3-5 yrs) 4. Remodeling
42
Perthes - Catterall Classification
* Group I = anterior head involvement only * Group II = anterolateral/central head * Group III = 75% head involvement * Group IV = total head involvement \*fragmentation stage
43
Perthes - Stulberg Classification
* \*At maturity - correlates shape of head and development of radiographic OA * Type 1 = normal hip joint * Type 2 = spherical head * Type 3 = non-spherical head (60% develop OA within 40 yrs) * Type 4 = flat head * Type 5 = flat head with incongruent hip joint
44
Perthes - Herring Classification
* Group A = no involvement of lateral pillar * Group B = \>50% lateral pillar maintained * Group C = \<50% latearl pillar maintained * Group B/C\* * lateral pillar = lateral 15-30% of epiphysis * use during fragmentation stage * BEST PREDICTOR OF LONG TERM OUTCOME\*
45
Perthes - Salter-Thompson Classification
* Group A = subchondral fracture/crescent affected \<50% of femoral head * Group B = \>50%
46
Salter Pelvic Osteotomy - Amount of Coverage Achieved
up to 15 deg lateral coverage and 25 deg anterior coverage
47
Risk Factors for SCFE
* african descent/pacific islanders * male gender * renal failure * endocrine abnormalities * radiation/chemo * obesity * down syndrome
48
Indications for Endocrinology workup in SCFE
* Age \< 10 * Weight \< 50th percentile Labs: TSH, GH, BUN/Cr (renal osteodystrophy)
49
Conditions that weaken physis (associated with SCFE)
* hypothyroidism * panhypopituitarism * GH abnormalities * hypogonadism * hyper- or hypoPTH * renal osteodystrophy * previous radiation/chemo
50
Physeal zone affected in SCFE
HYPERTROPHIC | (think fat kid)
51
Deformity of distal fragment in SCFE
* Varus in coronal plane * Extension in sagital plane * External rotation in axial plane * (VAR-EX-EX)
52
SCFE - Imaging Findings
* Retroversion deformity * Metaphyseal blanch sign of Steel (double density) * Klein's line (AP) * Trothowan's sign (asymmetry in Klein's line) * Sham's sign * Southwick angle (AP&frog) - normal 12
53
SCFE Classification Systems
* Temporal (acute \<3 weeks, chronic \>3 weeks, acute on chronic) * Percent slippage (mild 0-33%, mod 33-66%, severe \>66%) * Loder Classification (stable vs unstable) * Southwick angle difference (mild \<30 deg, mod 30-60, severe \>60)
54
Indications for prophylactic fixation of opposite hip in SCFE
* Age \<10 * Associated condition (endocrinopathy) * Mental delay * Poor compliance/follow-up * Symptoms on other side\*\*\* * Posterior sloping angle \>12
55
SCFE In Situ Fixation - Key Points
* Fracture table, gentle\* traction * Guide pin starts anterolateral (screw heads posterior) * Avoid start point at/distal to LT * Keep start point lateral to intertrochanteric line (impingement) * 7.3 mm cannulated screw, 4-5 threads minimum crossing * Approach-withdraw method to confirm no screw penetration * Single vs multiple screws (unstable SCFE) * Stable = PWB, unstable = NWB
56
SCFE - Late Treatment Osteotomy
* Left with retroversion deformity + anterior FAI * Flexion intertrochanteric osteotomy = Imhauser osteotomy * lateral approach to femur * osteotomy just proximal to LT * FLEXION primary goal (anterior wedge of bone removed from osteotomy) * IR distal shaft (anteverts head) * mild valgus * ttwb x 3 mths
57
Coxa Vara - Types
* Developmental (genetics - AD) * Congenital (eg with PFFD) * Dysplastic (skeletal dysplasias, OI, rickets) * Acquired/traumatic
58
Coxa Vara - Op vs Non-Op
* Non-Op * Asymptomatic, HE angle \< 45 * Asymptomatic, HE angle 45-60 (follow with serial radiographs) * Operative * Symptomatic, HE angle 45-60 * HE angle \>60 likely to progress * Progressive decrease NSA \<100 * GOAL = HE \< 38
59
Hemihypertrophy - important association\*\*\*
Get renal/abdominal US to rule out visceral malignancy Beckwith-Wiedemann = Wilm's tumor
60
LLD - Prediction Methods
* Arithmetic method * Anderson & Green tables * Moseley straight line graph * Paley multiplier method\* (most accurate)
61
Limb growth / year
Leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr) * proximal femur - 3 mm / yr (1/8 in) * distal femur - 9 mm / yr (3/8 in) * proximal tibia - 6 mm / yr (1/4 in) * distal tibia - 5 mm / yr (3/16 in)
62
Physeal Bar Excision - Indications
\<50% of the physis At least 2 yrs growth remaining
63
LLD General Treatment Principles (based on length)
* 0-2 cm = shoe lift * 2-5cm = contralateral epiphysiodesis, shortening (if after skeletal maturity) * 5-20cm = lengthening * 15-20cm = lengthening + epiphysiodesis/shortening, amputation
64
Max Shortening Parameters
* 10-20% of length * Femur 5cm * Tibia 3cm * Humerus 4cm
65
Hueter Volkmann Law
* theory suggest that mechanical forces influence longitudinal growth * growth accelerated by tension * compressive forces inhibit growth * implicated in scoliosis\* * also idea behind 8-plates
66
Limb Lengthening Important Points
* lengthen at metaphyseal level * delay lengthening after corticotomy by 5-7 days * lengthen at rate of 1 mm/day (0.25mm 4x/day) * limit lengthening to \<20% bone length * femur 8cm * tibia 5cm
67
Lower Limb Alignment Milestones Through Growth
* Birth: 10-15 varus * 6 mths: 20 varus (max) * 18 mths: neutral * 3 yrs: 12 valgus (up to 20) * 6 yrs: standard 7 valgus \*Salenius and Vankka graph
68
Angular Measurements for Tibia Vara
* Metaphyseal-diaphyseal angle * MD \< 10 physiologic * MD \> 16 Blounts * Tibiofemoral angle: \>15 abnormal * Epiphyseal-metaphyseal angle: \>20-30 abnormal * Ratio of femoral MDA and tibial MDA * \>1 = physiologic * \<1 = more likely Blounts (more angle from tibia than femur)
69
Blounts Classification
Langenskiold Classification (Infantile Blounts) * I = beak * II = saucer * III = step * IV = bent * V = double epiphysis * VI = bony bar = increasing medial metaphyseal sloping with bony bridge @ V/VI
70
Infantile Blounts - Indications for Surgery
* Age 3-4 * Langenskiold stage III or above * MD angle \> 16 * Progressive deformity \*risk of recurrence slighly less if performed before age 4
71
Infantile Blounts - Surgical Principles
Proximal tibial valgus & rotational osteotomy * Multiplanar\* * valgus, lateral translation, ER * correct increased posterior slope * Lateral & anterior compartment fasciotomy * Fibular osteotomy (resect 1 cm) * Osteotomy below tibial tubercle, at CORA * Dome osteotomy, convex proximal * Over-correct into 10-15 valgus * May need bony bar resection, medial tibial plateau elevation if any joint depression (V, VI)
72
Skeletal Dysplasias causing Genu Valgum
PEMMS * Pseudoachondroplasia * Ellis-Van Creveld (EVC) * MED * Morquio * SED
73
Genu Valgum - Indications for Surgery
* TF angle \> 15 * Intermalleolar distance \> 10cm * Mechanical axis at lateral plateau in children age \> 10
74
Causes of Intoeing by Age
* Infant = metatarsus adductus * Toddler = internal tibial torsion * \>3 yrs = femoral anteversion
75
Lower Extremity Rotational Profile - Normals
* Femoral anteversion: 15 degrees * Hip IR: 30-60 * Hip ER: 30-60 * Thigh-foot angle: 10 ER (-5 to +20) * Transmalleolar axis: 20 ER * Heel-bissector line: 2nd webspace \*GT prominence test - IR until GT most prominent = femoral anteversion
76
Indications for Derotation Osteotomy in Femoral Anteversion
* age \> 8 with pain, \<10 ER * anteversion \> 50 and IR \> 80 \*amount of rotation needed to correct excessive anteversion = prone IR-ER/2 \*WAIT UNTIL AGE 8 to do any surgery
77
Tibial Bowing
* Anterolateral = NF * pseudarthrosis * bracing to prevent # * if get # - IM nail & bone graft * amp option = symes * Posteromedial = physiologic, calcaneovalgus * spontaneous improvement * LLD - avg 4cm, deal with later (epiphysiodesis) * Anteromedial = fibular hemimelia * osteotomy with lengthening vs. amp
78
Optimal age for amputation in limb deficiency
10 mths - 2 yrs * Syme - simple, tapered prosthesis * Boyd - prevents heel pad migration, better end bearing - but longer length
79
PFFD - Classification
* spectrum of problems @ acetabulum, prox femur, knee, lower leg (mild/mod/severe) * Aitken classification - Class A-D based on acetabulum and femoral head severity * Gillespie/Torode Classification - best * Group A = congenital short femur - long enough to allow WB * Group B = PFFD, need prosthesis to WB, however have anterior displacement of tibia * Group C = little to no femur, but without anterior displacement of tibia = easier prosthesis fit
80
Fibular Hemimelia - Associated Abnormalities
* shortening of femur (PFFD) and tibia * hip dysplasia, coxa vara * LLD * genu valgum - lateral femoral condyle hypoplasia * cruciate ligament deficiency, absent menisci * anteriomedial tibial bowing * patella alta * equinovalgus * tarsal coalition (talocalcaneal - complete) * = ball and socket joint * absent lateral ray(s)
81
Fibular Hemimelia - Classification
* Birch Classification * depends on foot function - if preservable or requires amp * Type 1 = foot preservable * % inequality/LLD determines tx * Type 2 = foot nonpreservable * function of upper extremity determines early amp vs salvage
82
Tibial Deficiency - Classification
* Jones Classification * Type 1 = tibia not seen at birth * 1A = no tibia (no functional knee) * 1B = upper tibia late to ossify (functional knee\*) * Type 2 = prox tibia w absent distal tibia * functional knee\* * Type 3 = absent prox tibia w distal tibia * more rare, no knee * Type 4 = diastases of tib/fib * most common * no ankle mortise, foot in rigid equinus
83
Congenital Knee Dislocation - Associated Conditions
* metatarsus adductus * equinovarus foot * CVT * clubfoot * ipsilateral hip dislocation (70-100%)
84
Congenital Knee Dislocation - Classification
* Type 1 * recurvatum, can passively flex to 90 * Type 2 * subluxation, can passively flex to 45 * Type 3 * dislocation
85
Congenital Patellar Dislocation - Associations
DAN LED * Down's * Arthrogryposis * Nail-Patella syndrome * Larsens * Ellis-Van Creveld syndrome * Diastrophic dysplasia
86
Clubfoot Perani Grading System
* posterior crease * empty heel * rigid equinus * medial crease * lateral border * lateral head of talus * 3 or greater = likely to need at least 4 castsw with tenotomy
87
Clubfoot - Associated Conditions
* tibial hemimelia * hand abnormalities * arthrogryposis * diastrophic dysplasia * myelomeningocele * amniotic band syndrome * larsen's
88
Clubfoot - Posteromedial Release General Concepts
* prone, cincinnati incision * if \<18mths - TA tenotomy/lengthening * release ankle capsule * release subtalar joint * FHL lengthening * Tib post lengthening * FDL, abductor hallucis lengthening * \*do not release plantar fascia (planovalgus) * release TN joint * release spring ligament * release CC joint * Realign foot & pin * straight lateral border of foot * 1st MT lateral to talar axis (abducted) * hindfoot valgus * Cast x 3 mths, pins out at 4-6 wks
89
Congenital Vertical Talus - Associated with
* SNAIL * syndromic (trisomy 13/15/18) * neural tube defects (myelomeningocele\*, sacral agenesis, diastematomelia) * arthrogryposis * idiopathic * larsens (think of snail shaped like a vertical talus - AK)
90
CVT - Deformity
* severe flatfoot * fixed hindfoot equinus & valgus * tight achilles/peroneals * midfoot dorsiflexion * dorsolateral dislocation of navicular on talus * forefoot abduction and dorsiflexion * tight dorsolateral muscles (TA/EHL/EDL/PB/PL) * hypoplastic talar neck * hypoplastic, wedge-shaped navicular * talar plantar flexion * calcaneus plantar flexion - can see cuboid d/l * attenuation of spring ligament
91
CVT - Classification
* Coleman classification * Type 1 = no cuboid subluxation/dislocation * Type 2 = cuboid subluxation/dislocation * harder to treat
92
CVT - Radiographic Findings
* Lateral radiograph * Talar axis metatarsal base angle (TAMBA) * \>35 = pathognomonic for CVT * navicular ossifies at age 3 - 1st MT used as proxy * Forced PF lateral - Eyre Brook view * persistent dorsal dislocation of TN joint * \*oblique talus reduces on this view * Forced DF lateral * persistent plantarflexion of talus and calc * AP * talocalcaneal angle \>40 (N 20-40) * valgus midfoot
93
CVT - Treatment
* serial casting to stretch dorsolateral soft tissues * 5-6 weekly casts * opposite correction to clubfoot - equinus last * bring into equinus, hindfoot varus and forefoot adduction * last cast = maximal PF and inversion * K-wire pinning of TN joint * retrograde from navicular into talus - want TAMBA \<30 - bury pins * small 1 cm open incision over TN joint - do not cut capsule * unless not reduced and need to open subtalar joint with a 2 cm medial incision and transfer for tib ant to dorsal aspect of talar neck to help correct deformity\* * fractional lengthening of dorsolat tendons * if PF limited to \<25 - lengthen EDC/tib ant * if forefoot adduction \<10 - lengthen PB * perc tenotomy of achilles (\*med to lat) * long leg cast, 5-10 DF, pins out at 6 weeks * boots & bars full-time 2 mths, nighttime 2 yrs
94
Cavovarus - muscle imbalance
* peroneus longus \> tib ant (PF) * tib post \> peroneus brevis (inv) * weak instrinsics (DF MTP, flex IP)
95
Cavovarus - treatment options
* Depends on deformity, flexible vs fixed * Toe deformities * Girdlestone-Taylor (flex to ext) * Jones (IP fusion + EHL to 1st MT neck) * Soft tissue procedures * plantar fascia release\* (ALL) * TAL (equinus) * Osteotomies * Forefoot = cotton (1st MT DF osteotomy) * Midfoot = midfoot closing wedge osteotomy * Calcaneus = lateral closing wedge/slide * Tendon transfer * tib post - to lateral cuneiform (for DF) * PL to PB * Arthrodesis - triple = salvage
96
Tarsal Coalition - Important Points
* calcaneonavicular \> talocalcaneal (middle facet\*) * 50% bilateral * associations * fibular hemimelia * Apert syndrome * clubfoot * onset of symptoms * age 8-12 = CN * age 12-15 = TC
97
Accessory Navicular - Types
* Type 1 = sesamoid in tib post tendon * Type 2 = separate ossicle attached via synchondrosis * Type 3 = bony enlargement
98
Hallux Varus - classification (congenital)
* Congenital - classification * Type 1 = normal toe, tight AbdH * Type 2 = polydactyly or longitudinal epiphyseal bracket\* * Delta phalanx\* * associated with tarsal coalitions, apert syndrome * Type 3 = dysplasia (diastrophic)
99
Physis & Associated Conditions
* Reserve zone * Gaucher disease * Diastrophic dysplasia * Pseudoachondroplasia * Proliferative zone (\*ECM) * Achondroplasia * Gigantism * MHE * SED * Hypertrophic zone (Maturation zone, Degeneration zone, Zone of provisional calcification ) * SCFE * Rickets * Mucopolysacharide dx * Fractures (zone of prov calc) * Primary Spongiosa * Scurvy
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Achondroplasia
* most common skeletal dysplasia * autosomal dominant - but 90% new mutations * FGFR-3 * gain in function - inhibits chondrocytes = reduced endochondral ossification, reduced growth * Growth arrest at PROLIFERATIVE zone * Features * Rhizomelic shortening (prox \> distal limb) * Foramen magnum stenosis\* * TL kyphosis, TL stenosis, hyperlordosis * \*narrow interpedicular distance (L1-L5) * NOT cervical instability * Champagne glass pelvis * Genu varum
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Pseudoachondroplasia
* autosomal dominant * COMP mutation - chromosome 19 * epiphysis are delayed/abdnormal * rhizomelic shortening * normal facies * cervical instability\* * lower extremity bowing * joint hyperlaxity, DDH, early OA
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Diatrophic Dysplasia
* autosomal recessive * mutation in sulphate transport protein * rhizomelic shortening * A-A instability, cervical kyphosis * cleft palae, cauliflower ears
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Cleidocranial Dysostosis
* autosomal dominant * proportionate dwarfism * defect in CBFA-1 - transcription factor for osteocalcin * affects IM ossification - skull, clavicle, pelvis * mild short stature * frontal bossing * delayed teeth * absent clavicles * coxa vara
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Mucopolysaccharidoses
* lysosomal storage diseases * autosomal recessive * Hunter's = X-linked recessive * urine test - mucopolysaccharide breakdown products * features * short stature * corneal clouding * bullet-shaped phalanges\* * mental retardation (except morquio's\*) * cervical instability\* * DDH * carpal tunnel syndrome
105
Mucopolysaccharidoses Subtypes
* I - Hurler Syndrome (most severe) * alpha-L-iduronidase deficiency * accumulation of dermatan sulfate * treat with bone marrow transplant * death in first year of life * II - Hunter Syndrome * X-linked recessive\* * accumulation of dermatan/heparan sulfate * III - Sanfilippo Syndrome (most common) * accumulation of heparan sulfate * IV - Morquio Syndrome (most common) * Type A (galactosamine-6-sulphatase) * Type B (beta-galactosidase deficiency) * accumulation of keratan sulfate * \*normal intelligence
106
Multiple Epiphyseal Dysplasia
* autosomal dominant * multiple genes (COMP1, COL9A2, COL9A3) * proportionate dwarfism * multiple abnormal epiphyses * shortened metacarpals/metatarsals * valgus knees\* * double layer patella\* * DDH * OA/joint contractures * NO spinal involvement\*
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Spondyloepiphyseal Dysplasia
* proportionate dwarfism * cervical instability\*\*\* * platysondyly * SED congenita * COL2A1 gene * proliferative zone affected * coxa vara, genu valgum * retinal detachment, myopia * SED tarda * X-linked recessive, SEDL gene * milder, later onset
108
Radial Head Dislocation - Associations
SMASHED LUCK NK * Silver's syndrome * Marfan's * Achondroplasia * Steel syndrome * Hereditary multiple exostosis * Ehler's Danlos * Down syndrome * Larsen's syndrome * Ulnar longitudinal deficiency * Cornelia de Lange * Klippel-Feil syndrome * Nail-Patella syndrome * Klinefelter's
109
Marfan's Syndrome
* Autosomal dominant * Fibrillin-1 gene (FBN1) - chromosome 15q21 * MSK - tall, thin etc * 60-70% have scoliosis * narrow pedicles, wide TPs, vertebral scalloping * dural ectasia\* * acetabular protrusio * pes planovalgus * superior lens dislocation * aortic root dilatation * Ghent classification * 1 major criterion from 2 different organ systems + 3rd system
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Dural ectasia associations
* Marfan's * Ehler's Danlos * Achondroplasia * NF MEAN
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Ehlers-Danlos Syndrome
* Classification * Classic (Type 1, gravis) * Autosomal dominant * COL5A1, COL5A2 = type V collagen * Type III - hypermobility * Autosomal dominant * Type VI - kyphoscoliosis * Autosomal recessive * Mutation in lysyl hydroxylase * Severe kyphoscoliosis * Type VII - arthrochalasis * autosomal dominant * COL1A1, COL1A2 * congenital bilateral hip dislocation, hypermobility
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Ca/Phos/Vit D homeostasis
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OI - Classification
* Type 1 (dominant, blue sclera) * AD * Type II (lethal perinatal) * AD * Type III (progressive deforming) * AR * Type IV (dominant, white sclera) * AD
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VACTERL
Vertebral anomalies Anal anomalies Cardiac anomalies Tracheo-esophageal fistula Renal anomalies Limb anomalies (radial deficiency)
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Syndromes associated with cervical instability
Skeletal dysplasias: * Pseudoachondroplasia * MPS - Morquio’s (type IV) * SED * Diatrophic dysplasia Connective tissue: * Down's * Marfans * Larsens * Ehlers-Danlos NOT achondroplasia\*
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Risk factors for DVT in paeds MRSA osteomyelitis
CRP \> 6 Age \> 8 MRSA PVL (Panton-Valentine leukocidin) Surgical treatment CAMPS\*
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Panton-Valentine leukocidin (PVL) associated with
Some strains of CA-MRSA harbor genes encoding for Panton-Valentine leukocidin (PVL) * Complex infections * Multifocal infections * Prolonged fever * Myositis * Pyomyositis * Intra-osseus or subperiosteal abscess * Chronic osteomyelitis * DVT
OrthoBullets (Eprep) OLD
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