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54 Cards in this Set
- Front
- Back
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musculoskeletal embryology
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-mesodermal origin
-4-8 wks: limb bus develop from mesenchyme -6 wks: mesenchymal cells make cartilage matrix -7 wks: limbs rotate -7-12 wks: primary ossification centers for long bones develop |
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Bone formation stages
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1. mesenchymal cell condensation
2. chondrification: appositional growth, interstitial growth 3. Ossification: intramembranous, endochondral (slide 7) |
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Growth plate (physis)
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-longitudinal growth of metaphysis and diaphysis
-b/t the primary- secondary ossification centers -growth plate anatomy: reserve zone, proliferative zone, hypertrophic zone, metaphysis |
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Growth factors
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1. hormones
2. nutrition 3. metabolic features 4. local factors 5. compression |
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contribution to growth of the long bones of the arm and leg
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-humerus: proximal
-ulna: distal -femur: distal -tibia: proximal |
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Pediatric bone
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-woven bone replaced by lamellar bone in infancy
-mineral content decreased -strength: 1. weaker than adult 2. weaker in compression than tension 3. more plastic: allows more deformation -growth plate -remodeling: greater potential than in adults |
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Pediatric fxs
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-bones may bend/deform without breaking: greenstick fx, torus (buckle fx)
-thick periosteum helps to maintain reduction -fxs heal faster in children -most pediatric fxs treated with closed reduction and cast -fxs more common than ligamentous injuries -fxs though growth plate: salter -distal radius most common site |
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salter fxs
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I: through growth plate
II: through growth plate and metaphysis III: through growth plate and epiphysis IIV: through growth plate, metaphysis, and epiphysis V: compression fx through the growth plate Slice, Above, beLow, Through both, E,R (crush) |
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Refer to orthopedic specialist
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1. open fxs
2. spine, knee or elbow fxs 3. intra-articular fxs 4. displaced fxs |
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Rotational and angular deformities
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-usually a parental concern
-most are physiologic variations of nml -other etiologies: in utero positioning, sleeping/sitting positions, genetic, neurmuscular or neurologic disorders |
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rotational and angular deformities pt eval
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-hx
-birth and developmental hx -age -general health -nutrition -FH |
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rotational and angular deformities- PE
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-ht and wt
-limb length: ASIS to medial malleolus -screen for DDH and neuro disorders |
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Rotational profile
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1. observe walking and running gait
-foot progression angle 2. measure hip rotation -Internal and external rotation 3. assess thigh foot angle 4. inspect the foot for forefoot adductus |
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increased femoral anteversion
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-nml femoral neck projects anteriorly from coronal plane
-angle shoud gradually dec with age -slow/incomplete change may occur |
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inc femoral anteversion clinical presentation
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females>males
normal in 3-6 year old children “kissing patella” in-toeing gait “eggbeater” running gait increased internal rotation at hip (>70o) decreased external rotation at hip (<30o) |
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inc femoral anteversion tx
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-spont resolution in most cases by 9-10
-avoid "W" sitting -+/- night splinting -refer to ortho sugeon: sever limitation of hip motion, gait distrubances, deformity perisist ?10yrs |
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Internal tibial torsion clinical pres
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normal in children 1-2 years old
ankle and foot appear to be rotated inward relative to knee usually bilateral in-toeing and tripping gait patellas aim forward normal hip exam abnormal bimalleolar axis (MM posterior to LM) thigh foot angle <-10o (normal 0-20o) |
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Internal tibial torsion tx
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-spont resolution in most cases by 204 yrs old
-avoid sitting on top of inturned feet -avoid sleeping on knees with feet turned in -refer to orthopedic surgeon for night splint/special shoes/surgery |
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Metatarsus Adductus (Varus) clini presentation
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normal in newborn-12 months
usually bilateral association with DDH (2-15%) perform careful hip exam medial deviation of forefoot with normal midfoot and hindfoot flexible or fixed deformity convex lateral aspect of foot normal ankle motion |
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Metatarsus Adductus (Varus)- tx
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-spontaneous resolution in most cases by 12-18 months
-refer to orthopedic surgeon for splints/special shoes/serial casting/surgery |
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Genu Varum
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-bow legged
-nml physiologic deformity of infants <2yr -pronounced/persistent/asymmetric deformity; consider pathologic causes 1. blounts disease 2. rickets 3. osteogenesis imperfecta 4. idiopathic familial genu varum 5. trauma *obtain x-rays, refer and consider surgical repair |
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Genu valgum
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-knock knees
-nml from 3-5 yr -95% resolve b/t 5-8 yrs -pronounced/persistent/asymmetruc deformity: consider pathologic causes: 1. trauma 2. tumors 3. infxs 4. renal osteodystrophy |
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Clubfoot
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-Etiology: idiopathic, genetic, environmental, secondary to neuromuscular disorders'
-M>F -strong familial assoc -50% bilateral -high in hawaiians and polenesians |
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club foot clinical presentation
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-fixed foot deformity including >/= 1 of the following:
1. ankle plantar flexion 2. heel adduction 3. high arched midfoot 4. forefoot adduction -deep skin crease under arch of foot -difficult palpation of heel -small foot and calf -examine back, hips and knees -check sensory and motor function |
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club foot dx and tx
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-Dx: presentation, foot and ankle xrays (kite views)
-Tx: 2-6 months of manipulation and serial casting, surgical repair |
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Developmental dysplasia of the hip
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-femoral head dysplasia and/or instability, subluxation and dislocation
-genetic/mechanical/hormonal -F>M -L>R -assoc with metatarsus adductus and torticollis |
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Developmental dysplasia of the hip- risk factors
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1. female
2. oligohydramnios 3. breech birth 4. caucasian or native americam 5. FH 6. large fetal size 7. first bron 8. swaddling |
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Developmental dysplasia of the hip- clinical presentation
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-birth-3 months: Barlow, Ortolani test
->3mo: look for asymmetric thigh/gluteal/labial folds, Galleazzi sign, measure leg lengths -ambulatory pt: waddling or trendelenburg gait, hyperlordosis |
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Developmental dysplasia of the hip- dx
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-clinical pres: screen at well visit until 18 mo
-U/S: most useful <4 mo -xrays: most useful >4mo 1. increased acetabular angle 2. femoral head dysplasia 3. lateral superior displacement of femoral head 4. discontinuous Shenton’s line |
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Developmental dysplasia of the hip- tx
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-0-6 mo: Pavlik harness x 2-6 wks
->6 mo-15 mo: +/- traction, closed reduction, spica cast, +/- bracing and/or surgery after casting |
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Developmental Dysplasia of the Hip tx cont
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->15 mo-2 yrs: +/0 traction, open reduction, surgical repair, spica casting
->2 yrs: surgical repair |
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Legg-Calve-Perthes Disease
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-idiopathic osteonecrosis of the femoral head in kids
-4-10 yrs -small for age -M>F -unilat 90% -no seen in AA |
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Legg-Calve-Perthes Disease- clinical pres
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-2-3 wks insidious onset
-mild achy groin, proximal thigh or anteromedial knee pain -limp -sx inc with activity and dec with rest -dec hip abduction and int rotation -+ trendelenburg test - +/- thigh, calf or butt atrophy -+/- leg length inequality |
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Legg-Calve-Perthes Disease- dx
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-AP and frog leg pelvis xrays
1. initial stage (synovitis) -widened medial joint space -inc density of femoral head 2. fragmentation stage -crescent sign 3. reoccification stage 4. healing stage |
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legg- calve-perthes ds chart
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-slide 79
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Legg-Calve-Perthes Disease- tx
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-no tx if good prognosis: bone age <5, healing stage, no deformity, <50% femoral head involvement
-PT/bracing/surgery if poor prognosis: deformity and <8 years old clinical symptoms (decreased ROM, pain) > 8 years old radiographic signs |
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Slipped Capital Femoral Epiphysis (SCFE)
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-Adolescent hip disorder characterized by displacement of femoral neck resulting in abnormal hip function
-Etiology: 1. mechanical stress 2. weak physeal area 3. open and unstable growth plate 4. hormonal 5. trauma |
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Slipped Capital Femoral Epiphysis (SCFE)- epidemiology
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mean age in females-11 years old (9-15)
mean age in males-13 years old (10-16) male > female increased incidence in African Americans and Polynesians athletic obese endocrinopathies 25-40% bilateral |
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Slipped Capital Femoral Epiphysis (SCFE)- clinical pres
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-patterns: chronic (>3wks), acute, acute on chronic, preslip
-ant thich, groin or knee pain -antalgic gait -painful decreased hip internal rotation and abduction -+/- leg length discrepancy -+/- thigh and gluteal atrophy |
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Slipped Capital Femoral Epiphysis (SCFE)- dx ad tx
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-Dx; AP and frog leg lateral x-rays of pelvis/hips
1. displacement of femoral neck/head 2. kleins line 3. widened physis -Tx: NO reduction, non wt bearing upon dx, in situ fixation with pins or screws |
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Scoliosisis
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-lateral curvature of the spine >10 degrees + assoc rotation of the vertebrae
1. structural 2. nonstructural: -leg length discrepency -herniated disk -back spasm |
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idiopathic scoliosis
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-unknown case
-possible genetic link -F>M -intantile, juvenile and adolescent forms |
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idiopathic scoliosis- clinical pres/eval
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1. parental or school concern
2. typically nonpainful 3. adam forward bend test 4. inspect for pelvic, shoulder, scapula, flank crease symmetry/asymmetry 5. plumb line 6. check skin, limb length, gait, neuro exam |
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idiopathic scoliosis dx
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-standing long film PA and lat xrays of spine from occiput to iliac crest
-cobb angle -risser sign |
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scoliosis tx
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<10o curve
-PE and x-ray follow up at 4-6 months 10-20o curve -PE and x-ray follow up every 4-6 months 20-40o curve or curve progression 5-10o -bracing 16-24 hours/day with F/U Q 4-6 mo >40o curve; problems with brace; pain; neuromuscular disease or pulmonary compromise -surgical fusion and instrumentation |
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Nursemaid elbow
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-"pulled elbow"- annular ligament slips off the radial head allowing subluxation to occur
-1-4 years old (usually 2-3) -L>R -from sudden traction on extended pronated forearm |
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Nursemaid’s Elbow-Clinical presentation
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-affected arm held in slight flexion and pronation
-refusal to use extremity -resisted movement of elbow or arm -no swelling -+/- local tenderness at radial head |
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Nursemaid’s Elbow-dx and tx
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-Dx: clinical presentation, X-rays only needed if atypical findings or situation to rule out other pathology
-tx: closed reduction- place thumb over radial head; gently supinate extend and flex the elbow and listen for snap/click |
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antalgic gait
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-most common type of limp
-dec wt bearing of 1 limb caused by pain |
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trandelenburg gait
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-pelvis tilts away from affected side during stance phase due to weak hip abductors
-limp etiology is most commonly in spine, pelvis or lower extremity |
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PE of limping child
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-general assessment and temp
-table/lap exam -standing exam -check back and spine -gait examination- walking and running (with and without shoes) -special tests: trendelenburg test, leg length discrepency, galeazzi test, faber test (flexion, abduction, ext rotation) -consider abd or GU exam |
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most common causes of limps
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1-3 yo: fxs, soft tissue injury
4-10 yo: fxs, soft tissue injury 11-16: fxs, soft tissue injury, overuse |
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Transient synovitis of the hip
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-self limiting sterile effusion of the hip
-#1 cause of nontraumatic hip pain in kids -most common age 2-5 -acute or gradual onset of limp -+/- fever -+/- groin or thigh pain with +/- painful ROM of hip -+/- elevated WBC and ESR |
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Septic arthritis
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-bacterial infx in the joint
-most freq in kids <2 -ill appearing, fever -severe restricted PROM/AROM if any at all -elevated ESr, bands, CRP -delay in tx can lead to permanent disability and destruction |
