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Children's Health: Orthopedics

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40%
The length of the spine accounts for ____% of the length throughout life.
20
Spine is fully ossified by age....
7
Cartilaginous end plates are highly vascular through age _____
20
Annulus of discs are highly vascular up to age ______
Preschool: 1%
Elementary Age: 6%
High School: 18%
Adult*: 20%
What age groups typically experience spinal pain?
Acute trauma
<5 yoa
Limb weakness
Fever
Radiating pain
Weight loss
>4 weeks duration
Night waking
What are the red flags of pediatric spinal pain?
5. Due to fat pad.
Pes planus is normal up to age ....
by 2yoa with walking.
When is a foot arch visible?
6-8 years of age.
When does a child have a normal arch typically?
Conservative Flexible flat foot typically responsive to conservative care. Exercises including - rolling foot on broom handle, picking up marbles with toes, gastroc/soleus stretch if flat foot with toe out.
Medical: Orthotics
How do we treat pes planus?
8-12 years old
Pes cavus typically appears at what age?
Refer for neurological evaluation.

Polio, charcot-marie tooth, spinal cord tumor, muscular dystrophy, and cerebral palsy.
What do we do with a patient who has pes cavus?
Poor shoe size.
MCC of foot pain is caused by...
Drinking straw check. Have child stand on drinking straw and cut it to the length/width of their foot.
How can we assess for poor shoe size?
AVN of the tarsonavicular joint
Age 4-5 is most common
It is caused by overzealoous activity
Treatment is with arch supports or casting
Prognosis is excellent at 1 year.
Tell me about Kohler's "D"s?

(What is it, most common age, etiology, treatment, and prognosis)
Most common postural deformity. It is ankle dorsiflexion with eversion.

We treat it with flexing and inverting 20 times 6-8 times per day. Cast may be necessary in severe cases.
What is Talipes Calcaneovalgus? How do we treat?
Club foot. It is congenital ankle plantarflexion with supination and adduction.

Treatment is serial casting, bracing, and surgery.

Be sure to rule out dip dysplasia, spinal defect, calf atrophy, tib/fib angulation abnormality
What is Talipes Equinovarus? what is the treatment?
1. Cerebral Palsy (most common)
2. Autism
3. Muscular dystrophy
4. Peroneal muscular atrophy/Charcot Marie Tooth
5. Unilateral hip dislocation
6. Spinal cord tumor
We see a child who is walking on their toes. What can cause this?
Hemiplegia, shortening of the affected leg and arm, wasting of affected leg and arm, limited abduction of the hip, exaggerated knee jerk.
What are signs and symptoms of cerebral palsy?
Yes. For a period of time during early walking years they can walk on their toes. It will spontaeously resolve as the child develops.
Is it normal for children to walk on their toes?
Orthopedic bracing, botox injections, and physical therapy.
How do we treat toe walking?
It is almost always self correcting in a toddler.

Could be metatarsus adductus, tibial torsion, and femoral anteversion.
What can cause toeing in?
2
Tibial Torsion typically resolves by age...
9
Femoral anteversion generally corrects by age...
physiological bowing. Tibia is internally rotated when knee is facing forward.
What does tibial torsion look like?
Feet and knees are medially rotated
What does femoral anteversion look like?
W-sitting can exacerbate the probem.
What can make femoral anteversion worse?
Bow Legs
What is genu varum?
Greatly resolved by 2yoa. Gone by 5-6yoa.
What is the prognosis of genu varum?
Progressive angular deformity of prox tibial plateau.

Associated with Precocious walking, african heritage, obesity
What is tibia vara? What is it associated with?
Long term bracing and surgery. Prognosis best with earlier detection and earlier onset.
What is the treatment and prognosis of tibia vara?
Girls
Patellar dislocation is more common in...
Appears mid childhood. It is an increase in synovial fluid production in gastroc/semimembranosis bursa. It is benign and self limiting.

Recurrence rate is high. Can be associated with septic arthritis or juvenile chronic arthritis.
What is a baker's cyst? What can be it associated with?
10-16 yoa. 5:1 male.
Who gets a slipped capital femral epiphysis?
1. Externally rotated leg
2. Limp
3. Groin, knee or thigh pain (5% have knee pain)
4. Short leg
What are the symptoms of a slipped capital femoral epiphysis?
Typically same as that of a hip fracture: bracing, casting, surgical reshaping of femoral head, surgical pinning of femoral head to epiphysis.

Prognosis depends on how early it was detected and if it was chronic or not. 30% suffer with AVN. May have slippage on contralateral sside up to 2 years after primary episode.
What is the treatment and prognosis for slipped capital femoral epiphysis?
Range from subacute to acute. Tenderness over the thigh with limited hip/leg motion. Thigh atrophy present.
What are the symptoms of Legg-Calve-Perthes disease?
Bracing in abduction and internal rotation. Core decompression (may shorten leg). Prognosis varies with extent of deformity and cooperation with bracing .
How do we treat legg-Calve-Perthes disease?
Good job!
Review the table provided in the orthpedics PDF handout for the Hip.
Pathological. Whether painful or painless, it is pathological until proven otherwise.
A limp in a child should always be considered...
1. Growing pains.
2. Bone or joint abnormalities
3. Slipped capital femoral epiphysis
4. Legg-Calve-Perthes disease
5. Bursitis/tendonitis
6. Bone or muscle infections - often following trauma or upper respiratory infections
7. Polio
8. TB
9. Lyme disease
10. Ingrown toenail
11. Arthritis
12. Metabolic disorders
13. Sickle cell anemia
14. Cancers
15. Drug reactions
List as many causes of a limp as you can.
Vitamin A. Child's hair will be falling out.
What hypervitaminosis can cause juvenile arthritis?
Under 7 yoa, fatigue, weight loss, appetite changes, focal pain/tenderness, night waking.
What are the red flags for a pediatric low back pain?
Worse with activity and better with rest
Mechanical low back pain will be worse with ___________ and better with ________
Muscular strain, spondy, scheuermans, scliosis, disc
Give some causes of mechanical low back pain.
Disc (radiculopathy, bowel/bladder changes), spondy, fracture
What are your top 3 DDXs that must be ruled out with LBP with an acute traumatic onset?
Worse with rest and better with activity
An inflammatory cause of low back pain is worse with ______ and better with ___________
1. Family history
2. Stooped posture
3. Difficult taking deep breath
4. Anorexia
5. Fatigue
6. LE Joint pain
Give symptoms of ankylosing spondylitis
Joint pain, stiffness, swelling, fever, eye inflammation
Give symptoms of juvenile rheumatoid arthritis
Waxing and waning symptoms which progress to motor weakness, gait alterations or muscle rigidity.

Pain is present in 25-60% of cases.
Spinal cord tumors typically present with what history and symptoms?
Bacterial discitis is most common between the ages of 1-5. It typically progresses over 2-4 weeks.
Bacterial discitis is most common between the ages of _______. It typically progresses over _________ weeks.
Signs: Pronation of arm and refusal to use.
Exam Findings: Tenderness over anteromedial aspect of radial head. Diminished/painful supination. Normal x-ray. US may reveal increased radiocapitular distance.
What are the symptoms and exam findings for a nursemaids elbow?
Adjust for immediate relief. In order to put it back into place, supinate child's arm and bring it in front of them. With forearm fully supinated, fully extend and then fully flex the arm. It should click into place.
How do we treat nursemaids elbow?
28% of 12-15 yo have HA 1 time per week
How common is a headache in children?
1. Acute or progressive
2. lethargy
3. Mood/personality changes
4. Declining academics
5. Papilledema
6. Paralysis
7. Drowsiness
8. Confusion or loss of conciousness
What are the symptoms for a space occupying lesion?
Similar to tumor and inflammation symptoms.

1. Worse when laying down
2. Papilledema
3. Optic nerve pallor
What are the symptoms of increased intracranial pressure?
Sitting or standing
Decreased intracranial pressure will be worse when...
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