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Flashcards in Peds: Ortho Disorders Deck (62):

What is Developmental Dysplasia of the Hip

Neonatal hip is unstable secondary to undeveloped muscle, soft cartilaginous surfaces which are easily deformed, and lax ligaments


Why does DDH or CDH occur?

one common is reason is the exaggerated position of the hip in utero causing excess stretching


are the hip problems serious with DDH?

Spectrum of serious hip problems ranging from mild positional instability to frank dislocation of the femoral head from the acetabulum


how do you diagnose DDH?

Diagnosis is made on physical exam and confirmed by ultrasound (because their bones won't show up on X-ray for several months) and radiographic studies


What are the four factors associated with DDH?

1. mechanical
2. hormonal
3. genetic
4. environmental


What are the mechanical reasons for DDH?

they relate to in utero causes..
1. breech position
2. oligohydraminos
3. first born (moms tummy doesn't stretch as much)


What are the hormonal reasons for DDH?

they are maternal hormones
1) estrogens
2) relaxins


What are the genetic reasons for DDH?

9:1 female : male
20% have fam history


What are the environmental reasons for DDH?

infant swaddling


What test should be performed on PE to help diagnose DDH?

1. Asymetric Skin Folds
---->Galeazzi Sign
2. Passive Hip Abduction
3. Barlow test
4. Ortolani test


What does asymmetric skin folds tell you about DDH?

a dislocated hip displaces proximally, causing one leg to be shorter than the other. This leads to wrinkling of the leg on the shorter side. The most significant fold is between the gentials and the gluteus maximus region.


What does passive hip abduction tell you about DDH?

Flexed hips are gently abducted as far as possible. If hip is dislocated, there will be limited abduction. Flexion should be ≥70 degrees. Abduction should be ≥30 degrees. If the hip is lax, but not dislocated, the test will be normal


What is the barlow test?

Provocative test that picks up an unstable but located hip. Contraindicated in a child with a dislocated hip. Flexed calf and knee gently grasped in the hand. Hip is adducted slightly and pushed posteriorly and laterally
Sensation of the femoral head subluxating over the posterior rim of the acetabulum is positive test


What is the ortolani test?

Test to confirm dislocation. Reduction of a dislocated hip by detecting the sensation of a “clunk” when the hips are abducted with the hips and knees in flexion. Thighs should be able to abduct until they are flat against the table
“Clunk” represents the passive reduction of the femoral head back into the acetabulum


What imaging studies should be used until 4-6 months of life?

after this time, radiographs are more helpful.


What is the treatment for DDH?


0-1 Month
Double or triple diapers may be sufficient

0-6 Months
Pavlik harness is used
--->Maintains but does not rigidly fix the hips in a flexed/abducted position. If reduction can not be maintained, closed reduction and spica casting (6 weeks)

6-18 Months (before walking) OR failed Pavlik
Closed reduction under anesthesia and spica casting

18 months to 2 years +
If reduction/casting has failed, open reduction with pelvic and/or femoral osteotomy and post-operative casting is required, followed by prolonged bracing to resolve the residual dysplasia


What is "clubfoot"?

50% are bilateral
-severe fixed deformity of the foot caused by
1. Ankle plantar flexion (equinus)
2. Medial angulation of the hindfoot (varus)
3. Adduction/supination of the forefoot (metatarsus adductus)


what will PE of a clubfoot tell you?

1. rigid deformity, cannot be passively corrected.
2. associated with decreased calf circumference
3. can be a sign of neurogenic deformity so pay attention to other neuro signs.


how is clubfoot often found?

picked up on pre-natal U/S


What is the conservative treatment?

Should begin at birth, always required
1. Initially, passive manipulation and serial casting/taping at 1 week intervals for 1 month, then at 1-2 week intervals
2. Heel cord (Achilles) lengthening often must be performed. Usually limited to 12 weeks


what is the surgical treatment?

All residual deformities corrected in one stage
4-6 months
Post-operative casting
Physical therapy once healed


What is a Calcaneovalgus Foot?

Deformity readily apparent at birth, characterized by the dorsal surface of the foot positioned against the anterior surface of the tibia

-due to interuterine molding

-Initial appearance can be disturbing, but deformity is flexible and responds to time and stretching exercises (2-3 months)


What is metatarsus adducts?

Most common, results from intrauterine molding
Forefoot deviated toward midline, causing the lateral border of the foot to curve (kidney bean shape)
Hindfoot is NORMAL and no equinus at the ankle


how do you treat metatarsus adductus?

Passive stretching (?+/-), 75% will correct
Corrective shoes or serial casting for more severe cases
Small percentage require surgical treatment (after 18 months of age)


what is congenital vertical talus?

Rare, characterized by talus positioned in marked plantarflexion and talonavicular joint dislocation
Rigid, “rockerbottom” deformity with equinus of the hindfoot and dorsiflexion/abduction of the forefoot
Neurologic in origin (spina bifida)


what is the only true treatment for CVT?

surgery performed before walking age


Describe congenital torticollis?

Unilateral contracture of the sternocleidomastoid causing the head to tilt toward the affected side with the chin pointed away
(sometimes a smooth mass can be palpated)


what is the treatment for congenital torticollis?

passive stretching, then surgery is that doesn't work


how do you know what side if affected in congenital tortiocllis?

head tilt is toward affected side
chin points towards unaffected side


there is a high correlation between congenital torticollis and ____



what can result if congenital torticollis is not treated?

facial asymmetry


define intoeing:

the turning of feet toward the midline during walking
(normal angle is 10 degrees inward to 25 degrees outward)


what are the main etiologies of in-toeing?

1. internal tibial torsion
2. femoral anteversion
3. metatarsus adductus


what is the most common cause of intoeing under the age of two?

internal tibial torsion


what is internal tibial torsion?

excessive inward twisting of the tibofibular unit
- inturned thigh foot axis on exam
- usually a result of in-utero position


how do you correct internal tibial torsion?

corrects spontaneously!

most resolve by age 2, otherwise refer to ortho!!


what is the most common cause of intoeing after the age of two?

femoral anteversion


what is femoral anteversion?

increased ante version of the femoral neck relative to the knee---> causing child to sit in "w" position. generally corrects by age 10. excessive IR of the hip. More common in females.


What are the three causes of out toeing?

1. outward rotation contracture of the hip
2. torsional variations in femoral and tibial development
3. flexible flat feet


what do you need to do about out toeing?

most will resolve, just reassure parents.


What is genu varum?



is genu varum normal? what do you need to rule out?

yes, normal. resolves by 2.
rule out:
1. rickets
2. blount disease
3. skeletal dysplasia


when do you need to refer for genum varum?

1. bowing is excessive
2. asymetric
3. findings atypical
4. >3 years


what is genu valgum?

knock knees


when is genu valgum normal?

between ages 3-4
corrects by 5-8


what do you measure for genu varum? what do you measure for genu valgus?

inter-condylar distance (distance between medial femoral condyles when medial malleoli are touching)

inter-malleolar distance: distance between medial malleoli when medial femoral condyles are touching


what is pes planus?

flat feet
- loss of the longitudinal arch of the foot
- most are flexible and associated with generalized ligamentous laxity


wwhat must you distinguish pes planus from?

other neuro disorders, trauma, tumors


what is often present with pes planus?

hindfoot valgus (heel eversion)


What is a nursemaids elbow?
what is the mechanism of injury?

common injury seen in toddler age group
radial head subluxation--annular ligament subluxes around the radial head.

MOI: hyperextension and supination of the forearm


how will a child present with nursemaids elbow?

will not use affected arm


how do you reduce nursemaids elbow?

move hand into supinated psotiion while applying pressure to the radial head. an audible click may be heard.


what is scoliosis?

an asymmetry of the spine that causes both lateral deformity (curvature in the frontal plane) and rotational deformity (rib cage asymmetry in forward bending).


Is scoliosis a diagnoiss? where does it occur most commonly?

no! it is a physical finding.
most common place along the spine is thoracolumbar


What is the most common "type" of scoliosis?

idiopathic--more common in females
can be secondary to neuromuscular d/o or congenital problems


how do you screen for scoliosis?

1. check level of pelivs
2. adams test --> bend forward slowly and check spine

presence of hump is hallmark for rotational malalignment.


what are you looking for X-ray with scoliosis?

cobb angle measure on AP view


how do we classify scoliosis according to age?

infantile: birth - 3
juvenile : 4- 10
adolescent: >11


What is treatment based on for scoliosis?

treatment based on skeletal maturity and whether it is progressive.

no treatment necessary for non-progressive deformities.

progressive deformities:
1. 50 degrees = will likely progress regardless of skeletal maturity. surgical intervention need. REFER!


What is congenital scoliosis?

caused by failure of formation or segmentation of vertebrae during embryonic development.
often associated with other abnormalities with heart, kidney and spinal cord.


what is the best way to assess leg length in infants? in children?

infants = supine
children = standing


what is the difference based on leg length discrepancy in cm?

2 cm -= tolerated
2-5 = allow shorter limb to catch up
>5 = prosethetic.