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Peds Ortho

Terms in this set (132)

metatarsus adductus
-congenital deformity characterized by medial deviation of the forefoot
metatarsus adductus
-13% in full term infants
-may be associated with hip dysplasia in 10-15%
-most common cause is intrauterine posturing (creates flexible deformity)
lateral border
in metatarsus adductus the _____ _____ of the forefoot shows sharp angulation at the base of the 5th metatarsal
-the base of the 5th metatarsal is usually very prominent
fixed or flexible
metatarsus adductus
-the deformity can be _____ or _____
flexible
metatarsus adductus
-_____ deformity usually resolves spontaneously
-due to high spontaneous resolution rate, treatment may be delayed for 6 months
fixed
metatarsus adductus
-_____ deformity responds well to serial casting (usually every 2 weeks) during the first year
excellent
prognosis for metatarsus adductus?
club foot / talipes equinovarus
congenital deformity consisting of
cavus
adductus (forefoot)
varus (hind hoot)
equinus (hind foot
equinus
"plantarflex" seen in club foot / talipes equinovarus?
club foot / talipes equinovarus
-boys 2x >
-may be associated with other anomalies especially of the spine and hips
club foot / talipes equinovarus
with _____?
-serial casting begun shortly after brith offers best outcomes
Ponseti Method with achilles tentomy at end of serial casting
specific type of casting seen with club foot / talipes equinovarus?
2-3 years old
club foot / talipes equinovarus
-recurrence after casting most common in _____-_____ year old age group but can happen up to 5-7 years old
boots and bar
club foot / talipes equinovarus
-prevention of recurrence with _____ _____ _____ anti age of 4 with daily foot stretching
lengthen or release
club foot / talipes equinovarus
-about 50% will need some type of surgical procedure usually to _____ or _____ tendons
-affected foot in treated pt is usually 1 - 1 1/2 sizes smaller than the other foot
-calf muscles also usually smaller on affected side
2 complications as seen with club foot / talipes equinovarus?
flexible flat feet / pes planus
-lack of media or longitudinal arch
pronation and eversion
flexible flat feet / pes planus
-usually with _____ and _____ of the forefoot
-not usually developed in children until 2 years old, sometimes 5-6 years old
flexible flat feet / pes planus
symptoms
-fatigue
-pain of the foot, Anke or legs
-usually worse with prolonged standing or walking

signs
-pt appears to have medial arch when not standing
-upon bearing weigh the medial arch will flatten to the floor
flexible flat feet / pes planus
-aggressive treated UNWARRANTED
-good quality sports shoe may be helpful
-orthopedics $$$
-heel cord stretched are helpful... pain is often due to contracted Achilles Tendon
-refer if pt has shorted heel cord
tibial torsion
-rotation of the leg between the knee and ankle

-usually about 20 degrees at brith (due in part to laxity of knee ligaments)
16-18 months
when does tibial torsion neutralize?
Genu Varum / Bow Leg
-normal from infancy to 2-3 years old
-10-15 degree at brith is normal
-straightens to 0 degrees by 12-18 months
Genu Valgum / Knock Knee
-normal between 2 to 8 years old
-maximum of 10-15 degrees at 3-4 years old
-adult alignment of 5-10 degrees achieved by adolescence
1) persistent bowing past 2 years old
2) increasing vs decreasing bowing
3) unilateral bowing or significant asymmetry
3 times when Genu Varum / Bow Leg needs a referral?
1) assymetruc or excessive Genu Valgum / Knock Knee
2) pt is short of stature

(treated with hemiepiphysiodesis)
2 times when Genu Valgum / Knock Knee needs a referral?
femoral anteversion
-excessive internal rotation of the femur

-most common cause of toeing in in beyond 2-3 year olds

-girls 2x >
femoral anteversion
-spontaneous progressive decrease until 8 years old
-inward rotation approximately 40 degrees at brith and goes to 10-15 degrees by 8 years old
bracing or corrective shoes have shown NO BENEFIT beyond natural course
what are no benefit for femoral anteversion?
active external rotation exercises (ballet, skating, bicycling) may be helpful
what may be helpful with femoral anteversion?
osgood-schaltter disease
-most commonly girls 11-13 years old or boys 12-15 years old
-2-3x > in boys
-5x more common in those in active sports
patellar tendon
the _____ _____ attaches to the tibial tubercle
osgood-schaltter disease
osgood-schaltter disease
-area is prone to _____ during periods of rapid growth in late childhood to adolescence
osgood-schaltter disease
symptoms / signs
-swelling
-activity related pain
-bony prominence / tenderness over tibial tubercle
osgood-schaltter disease
Dx of ?
-clinical
-x ray to r/o other bony lesions especially if unilateral
osgood-schaltter disease
Tx for ?
-symptomatic pain relief
-ice after exercise
-NSAIDS prn pain
-stretching exercises (especially hamstrings)
-rest / restriction of activity prn
-rarely immobilization... removed once daily for bathing and ROM exercises
symptoms resolve within 12-24 months of closure of the growth plate
prognosis for osgood-schaltter disease?
osteochondritis dissecans
-area of bone adjacent to articular cartilage the becomes necrotic and separated from the underlying bone
lateral portion of the medial femoral condyle

(may also occur at elbow and talus)
osteochondritis dissecans
-most common area?
osteochondritis dissecans
-etiology: unknown
-symptoms: gradual onset
-vague, episodic knee pain
-locking
-achiness after exercise
-muscle atrophy
-may have an effusion
x ray: notch view or tunnel view
osteochondritis dissecans diagnosis with x ray?
younger
osteochondritis dissecans course for _____ children
-revascularization occurs without cartilage damage
older
osteochondritis dissecans course for _____ children
-have greater change of cartilage fracture and loose body
11 y/o and younger
treatment for what age group with osteochondritis dissecans
-observation
-periodic x ray
-occasional MRI to assess degree of healing
-activity modification to protect from additional mechanical damage
-possible immobilization for 3-6 months
13 y/o and older
treatment for what age group with osteochondritis dissecans
-may need arthroscopy (especially if nose Boyd in joint)
-may include remove of nose body and or drilling areas to promote revascualrization
-unstable lesions require temporary intern fixation
popliteal cyst / bakers cyst
-herniation of the synovium into the back of the knee
-in children, it communicated with the joint less frequently
-most commonly occurs in middle childhood
popliteal cyst / bakers cyst
-swelling or fullness most commonly in medial aspect of the popliteal fossa
-may occur with or without pain or tenderness
popliteal cyst / bakers cyst
Dx for ?
-x ray WNL
-diagnosis by U/S or MRI
-aspiration should be done with extreme caution due to proximity or neurovascular structures
-also fluid may be gelatinous and difficult to remove
observation
-spontaneous resolution commonly seen in those younger than 10 y/o
-surgical excision in those with symptoms or progressive enlargement
Tx for popliteal cyst / bakers cyst?
developmental dysplasia of the hip
-multifactorial: many different factors may cause a lack of development of the acetabulum and femur
-the majority of pts have generalized ligamentous laxity
-hip is not dislocated at brith; it may be dislocatable
developmental dysplasia of the hip
-positive family history in 20%
-girls >... girls may be more sensitive to the maternal hormone relaxin which increases ligamentous laxity
-left hip affected more
at every well child visit until 1 year old!
developmental dysplasia of the hip
-must examine how often?
developmental dysplasia of the hip
-asymmetrical skin folds
-can be a norma finding in 25%

-may have a leg length discrepancy... Positive Allis / Galezzi Sign

-may have limitation of hip abduction
Positive Allis or Galeazzi Sign
developmental dysplasia of the hip
-leg length discrepancy title?
older
developmental dysplasia of the hip
-_____ children may present with
-limp
-waddle
-leg length discrepancy
Ortolani Test
-hip is flexed and ABDucted
-a recently dislocated hip may be reduced by lifting the femoral head anteriorly into the socket
Barlow Test
-hip is flexed and ADDucted
-thumb on inner thigh applied posterior pressure that will dislocate the unstable hip
U/S (newborns)
radiographs (after 4-6 months)
developmental dysplasia of the hip
-_____: more useful in newborns
-_____ may be used after 4-6 months of age
refer to orthopedics!
developmental dysplasia of the hip Tx?
birth
developmental dysplasia of the hip
--maintain the hip in flexion and abduction for 1-2 months
--this allows tightening of ligaments and stimulated normal growth and development
1-6 months
developmental dysplasia of the hip
---usually true dislocation at this age
-Pavlik harness used most
-keeps the hips flexed about 100 degrees and abducted 50-70 degrees
-allows redirection of head toward the acetabulum
-usually hip is relocated within 3--4weeks
-if not successful, closed reduction under anesthesia with subsequent hip spica cast for 3 months
6-18 months
developmental dysplasia of the hip
---usually closed reduction under anesthesia
-open reduction if significant instability
18 months - 8 years
developmental dysplasia of the hip
---now a severe progressive abnormality
-requires open surgical procedure
-hip spica worn after surgery 6-8 weeks
developmental dysplasia of the hip
complication of ?
-avascular necrosis of the capital femoral epiphysis
check baby wearing
proper swaddling
choosing the right baby carriers
3 preventions for developmental dysplasia of the hip?
transient synovitis of the hip
-also called irritable hip or toxic synovitis

-etiology: unknown

may be
-viral
-traumatic
-allergic
transient synovitis of the hip
what is one of the most common cause of limping in a normal child?
transient synovitis of the hip
-usually 3-8 year olds (mean age 6 years old)
-males 2-3x >
70% have URI 7-14 days prior
transient synovitis of the hip
-acute onset of pain in the groin, anterior thigh or knee
-usually ambulatory but with painful limping gait
-may refuse to walk
-may have restriction of abduction and or internal rotation
-septic arthritis (may need artherocentesis)
-osteomyelitis
-other lesions
-Lyme disease
must rule out what 4 things with transient synovitis of the hip?
limit
may _____ the diagnostic workup if
-1-3 days duration
-afebrile
-child doesn't appear ill
-no guarding with movement of the hip
-ony mild restriction in abduction

-seen with transient synovitis of the hip
-usually WNL but may have SLIGHT elevation in ESR

-high ESR should make you rule out other conditions
transient synovitis of the hip labs?
arthrocentesis
transient synovitis of the hip
(procedure)
-usually normal
-may have effusion
transient synovitis of the hip
imaging studies of ?
-x ray (AP and Frog lateral) usually negative
-may show soft tissue swelling around joint
-may show widening of the joint space
-ultrasound may be useful
transient synovitis of the hip
Tx of ?
-usually a self limiting disorder
-bed rest or non weight bearing until pain removes in 3-14 days (average 7 days)
-then limited activity for 1-2 weeks to avoid exacerbation of symptoms
-NSAIDS may shorten the course of the disease
NSAIDs
what medication with transient synovitis of the hip may help shorten the course of the disease?
transient synovitis of the hip
complications of ?
-usually no one term sequelae
-Legg-Calve-Perthes Disease in a small percentage
x ray
transient synovitis of the hip
-get _____ in 6 weeks if persistent pain or limp
-if negative, refer to pediatric rheumatology
Legg-Calve-Perthes Disease
-an idiopathic avascular necrosis of the capital femoral epiphysis
-males >
-ages 2-12 (mean 7 years)
-bilateral in 10-20%
Legg-Calve-Perthes Disease
-mid or intermittent pain in anterior thigh, groin, or knees
-limp (sometimes painless limp)
-exacerbated with activity

-mild short stature
-antalgic gait
-muscle spasm
-restricted ROM (especially abduction and internal rotation)
-may have proximal though atrophy
AP and Lauestein (Frog) Lateral Radiographs needed
with Legg-Calve-Perthes Disease... what radiologic dx is needed?
Legg-Calve-Perthes Disease
-joint effusion with widening of joint space and peri-articular swelling may be an early sign
-decreased bone density in a few weeks
-necrotic ossification center will appear denser than surrounding structures
-eventually collapsed or narrowed femoral head will be apparent
local, self healing disorder

1) eliminate hip irritability
2) restore and maintain good ROM
3) prevent epiphyseal collapse or subluxation
4) attain spherical femoral head at healing
Legg-Calve-Perthes Disease Tx? and goals of treatment?
Legg-Calve-Perthes Disease
Tx of ?
-under 6 years old: expectant observation
-intermittent bed rest
-abduction stretching to maintain mobility
-surgical containments of the femoral head in acetabulum to act as a mold for reossification...Petrie Casting
(nonsurgical containment of the femora head by orthosis have fallen out of favor)
-degenerative arthritis

50%. require hip replacement in late, middle, and adult ears
prognosis best with onset of symptoms before 6 years old
complications of Legg-Calve-Perthes Disease?
slipped capital femoral epiphysis
-displacement of the proximal femora epiphysis due to disruption of the growth plate
slipped capital femoral epiphysis
what is the most common adolescent hip problem?
slipped capital femoral epiphysis
-most common adolescent hip problem
-ages 11-16 males
-ages 10-14 females
-bilateral in 30-50% --2nd slide may occur 1-2 years after the initial episode
-usually in obese adolescents with delayed skeletal maturation (postulated low sex hormone)
-very tall, thin adolescents with recent growth spurt (postulated high sex hormone)
obese adolescents
postulated LOW sex hormone?
tall, thin adolescents
postulated HIGH sex hormone?
hypothyroidism and growth hormone (suppression)
etiology of slipped capital femoral epiphysis

-unknown
-endocrine basis suggested due to association with growth differences
-it is associated with _____ and _____ _____ suppression*
-may be associated with trauma, especially shearing forces
slipped capital femoral epiphysis
-pain most commonly in the anterior proximal thigh
-may also be in distal thigh or lower leg
-pain exacerbated by activity

-decreased internal rotation especially when hip is flexed to 90 degrees
-decrease in abduction and extension (occasionally flexion)
slipped capital femoral epiphysis
Radiology of ?
-AP and Launestein (Frog) Lateral radiograph show widening of the growth plates and epiphyseal slippage
-when slippage occurs the CFE STAYS in the acetabulum and the femora neck rotates anteriorly (sometimes superiorly)
mild
< 30 degrees?
moderate
30-50 degrees?
severe
> 50 degrees?
pre slip
slipped capital femoral epiphysis
-widening but no slippage
acute SCFE
slipped capital femoral epiphysis
-no antecedent symptoms or less than 3 weeks
-acute slippage with pain to prevent ambulation
-considered unstable
acute on chronic
slipped capital femoral epiphysis
-an acute slippage causing sudden exacerbation of pain after a > 3 week period of prodromal symptoms (pain, limp, or out toe gait)
-unstable
chronic
slipped capital femoral epiphysis
-most common
-worsening symptoms with progressive slippage
-few months of vague groin pain referred to anteriomedial thigh
-20% only plain of knee pain
-walks with antalgic, external roasted gait
-stable
-weight bearing prohibited at diagnosis

-epiphysiodesis
2 Tx for slipped capital femoral epiphysis?
epiphysiodesis
_____ is a Tx for slipped capital femoral epiphysis; this is the percutaneous pinning of the epiphysis with cannulated screws under fluoroscopy
-avasallar necrosis
-chondrolysis
complications of slipped capital femoral epiphysis?
chondrolysis
_____ is degeneration of articular cartilage

-seen in slipped capital femoral epiphysis
slipped capital femoral epiphysis
prognosis
-usually good
-may result in approx 1.25 cm shortage of leg with slight external rotation
scoliosis
-curvature of the spine in the frontal plane
scoliosis
-slightly more common in females
-girls 7x more likely to progress and need treatment

-20-30% have other family members with scoliosis
-severity of curve is NOT familial

-progression of curve is most common between 10-16 years oldl
NO
-severity of curve is not familia
is the severity of curve familial with scoliosis?
10-16
progression of scoliosis curve between what ages?
scoliosis
-idiopathic is most common type
-80% of these are adolescents
scoliosis
-usually asymptomatic
-severe curvature can progress to pain in adult years
-extreme cases may cause decrease in pulmonary function due to decreased volumes secondary to deformity
-usually 70 degree curve
scoliosis
-observe first from standing position from behind
-observe shoulders and scapula for symmetry
-check level of the pelvis

-have pt bend forward with hands together
-look for curve of the spine
-look for characteristic hump from rotation of the spine
PA and lateral standing x ray should be obtained for measurements
what type of x rays for scoliosis?
based on age of patient and degree of curve
Tx treatment is baed on what?
pre-monarchal
_____ girls with degrees > 20 are more likely to progress
-less likely if 1-2 years post mencharche
less than 20 degree curve
_____ curve--- oversee q 4-6 months with x rays
progressive 20-40 degree curve
_____ curve --- usually orthoses
-does not provide correction but does control progression
> 40 degree curve
_____ curve --- surgical
annular ligament
subluxation of the radial head (nursemaids elbow)
-the _____ _____ passes around the neck of the radius, just below the radial head; provides stability between the radius and the ulna
entrapped
subluxation of the radial head (nursemaids elbow)
-longitudinal traction when the arm is in extension* causes the annular ligament to slide down around the head and become _____ between the radius and ulna
when child falls with outstretched hand
when does subluxation of the radial head (nursemaids elbow) most commonly occur?
subluxation of the radial head (nursemaids elbow)
-hand is held in pronated position with elbow slightly flexed
-child usually refuses to use it
-cries when elbow is moved
-may have point tenderness over the radial head
subluxation of the radial head (nursemaids elbow)
Tx of ?
-rotate hand to supinated position with pressure over the radial head
-flex at the elbow
-may feel or hear a "click"
-child will begin using the arm within minutes to a few hours of reduction
-recurrences are common
course for subluxation of the radial head (nursemaids elbow)?
4
subluxation of the radial head (nursemaids elbow)
-at age _____, radial head usually developed enough to stop recurrences
ganglion cyst
-synovial fluid filled cyst usually around the wrist
dorsum
ganglion cyst
-usually on the _____ of the wrist near the radiocarpal joint or over the volar aspect of the radius
ganglion cyst
-defect in joint capsule
-fluid in the soft tissue
-walled off by reactive fibrous tissue
-most disappear in children with time
-if large and painful can be aspirated and injected with cortisone
-excision with removal of tract to joint is curative
Tx for ganglion cyst?
excision with removal of tract to joint is curative
what is the creative Tx for ganglion cyst?
pediatric trigger thumb
-difficulty intending finger due to fibrous thickening arming A I pulley
pediatric trigger thumb
Tx for ?
-NSAIDs, injection, surgery
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