Phas 460 - Peds Ortho

Front 1

Metatarsus Adductus (in-toeing)

Back 1

Forefoot is adducted with respect to the hindfoot (starts distally – everything from heel up is normal, just forefoot is inverted)
- Generally non-rigid
- Due to intrauterine positioning

Front 2

Tx for metatarsus adductus

Back 2

Generally resolves spontaneously (90%) by 3 months
Referral and serial casting if persists

Front 3

Club Foot (Talipes Equinovarus)

Back 3

Severe medial, midline, plantar crease is present, forefoot is C-shaped with both the heel and forefoot turned inward
- Affected foot is small, wide, and stiff
- Diagnoses depends on 3 things - forefoot varus, heel varus, ankle equinus (pointed downward)

Front 4

Tx for Club foot

Back 4

- Serial casting to begin during the first week (up to 2 months)
- Surgery required 50-75%
- Delay surgery until 6-12 months

Front 5

Medial Tibial Torsion

Back 5

Excessive inward twisting of tibiofibular unit; knees point forward, feet turn inward
- Most common cause of in-toeing in <3y/o

Front 6

Tx for Medial Tibial Torsion

Back 6

Resolves spontaneously

Front 7

Medial Femoral Torsion

Back 7

- Most common cause of in-toeing after 3 y/o
- Due to increased anteversion of femoral neck relative to knee (the knee is not straight)
Tx: corrects with growth by 10 y/o

Front 8

Physiologic out-toeing of infancy

Back 8

Due to external rotary contracture of soft tissues surrounding hip secondary to intrauterine position
Tx: resolves by 18 months

Front 9

Lateral tibial torsion

Back 9

-may worsen with age due to normal lateral rotation of tibia with development Tx: rarely requires treatment

Front 10

Bow Legs (Genu Varum)

Back 10

- Common (normal variant) during first two years of life
- Referral if not corrected by 2 ½ (can consider this if it is pronounced)
- 10 cm rule – when you put medial mallelouses together, distance between knees > 10cm = referral); also, should refer if the bow legging is assymmetrical

Front 11

Knock-knee (Genu Valgum)

Back 11

- Physiologic condition between 3-4 y/o that resolves by 5-7 y/o
- Refer if not corrected by 8-9 y/o
- 10 cm rule (if when knees are together, distance between medial malleoluses is > 10cm)

Front 12

Risk for developmental hip dysplasia

Back 12

Girls > boys
Caucasions > AA
- infants born in the breech position
- positive family hx
- more common in firstborn

Front 13

Clinical presentation of DHD

Back 13

- Pos Ortolani (dislocated then reduced) or Barlow (unstable hip then dislocated)
- Asymmetric skin folds
- Limitation of hip abduction
+ Galeazzi sign - knee heights different
- Older kids - limp, toe walking

Front 14

Imaging for DHD

Back 14

X-ray shows dislocation
- not useful <4-6 months (femoral head not calcified)

Ultrasound is especially useful in neonates.

Front 15

Tx for DHD

Back 15

- Ortho consult

Pavlik harness - holds hip in flexion and abduction
- 4 weeks in newborns
- 1-2 X infant age (ex: 1 month old, wear harness for 1-2 months)
- >6 months - traction followed by casting
- >18 months - open reduction

Front 16

Legg-Calve-Perthes Disease

Back 16

Disorder of the femoral head, charaterized by ischemic necrosis, collapse, and subsequent repair (“staged” illness)
- 2-10 years old, peaks at age 6

Front 17

Clinical presentation of Legg-Calve-Perthes Disease

Back 17

Insidious onset, painless limp, only after activity
Vague pain: ache in groin, thigh, medial aspect of knee
Exam: Limited ROM of hip, especially abduction, internal rotation
X-Ray shows necrosis

Front 18

Tx for Legg-Calve-Perthes Disease

Back 18

Short-term therapy goal: reduction of pain and hip stiffness -restriction of activity -NSAIDs
-non-weight-bearing with crutches
-bracing, casting (femoral head is pressed into the acetabulum)

Front 19

Slipped Capital Femoral Epiphysis

Back 19

Displacement of head and neck of femur: separation of proximal femoral epiphysis through growth plate.

Children are generally very obese, very tall.

Front 20

Presentation of Slipped Capital Femoral Epiphysis

Back 20

Sx usually present for more than 2 weeks (acute on chronic):
- pain, altered gait
-deep groin or medial thigh pain present when walking, accentuated with running -non-radiating, dull ache (in groin or medial thigh)

Exam: -loss of internal rotation -diminished hip flexion

Front 21

Complications and tx of Slipped Capital Femoral Epiphysis

Back 21

Complication: avascular necrosis of the hip (lost blood supply)

Tx: urgent situation:bedrest, ortho consult (surgery)
Goal of therapy: prevent further displacement using percutaneous pin/screw fixation

Front 22

Toxic (Transient) Synovitis of the Hip

Back 22

Self-limited inflammatory condition (inflammation of the joint capsule)
Etiology: viral agent, esp URI; trauma

Front 23

Clinical Presentation of Toxic (Transient) Synovitis of the Hip

Back 23

- Child doesn’t want to bear weight on the leg; usually report knee pain.
- Not systemically ill
- Pain in hip/knee and a limp
- Limitation of active/passive ROM, esp internal rotation

Front 24

Diagnostic Tests for Toxic (Transient) Synovitis of the Hip

Back 24

Dx of exclusion - septic until proven otherwise
- Ultrasound may detect hip effusion
-clear fluid, no echo shadows
- Normal CBC, ESR
- Gold standard: aspiration of joint, may be necessary (need to see if it’s infected)

Front 25

Tx for Toxic (Transient) Synovitis of the Hip

Back 25

- Crutches (most of these kids are in the age range that their parents just carry them)
- NSAIDs (for pain), close follow-up, limitation of activities
- 90% resolve within 4 weeks
- Recurs in 5-15% of cases, usually within 6 months (warn parents)

Front 26

Septic hip

Back 26

Often in infants, young children.
Signs/sx: toxic, febrile, joint pain, point tenderness, decreased ROM, inability to bear weight, generally one hip
- Hematogenous spread most common; less likely through trauma
- Etiology: S aureus most common

Front 27

Diagnostic tests for septic hip

Back 27

- Elevated WBC, ESR (90%)
- Ultrasound: detect effusion
- Diagnosis: aspirate joint fluid (culture)
- Blood cultures positive in 40% of cases

Front 28

Tx for septic hip

Back 28

- Open surgical drainage in operating room
- IV/PO antibiotics, cefuroxime or nafcillin (4-6 weeks)

Front 29

Osgood-Schlatter

Back 29

- Repetitive microtrauma causes partial avulsion of the patellar tendon at its insertion on the tibia
- Presentation: localized prominence, swelling, and tenderness over tibial tubercle
- Most common in physically active males

Front 30

Tx for Osgood-Schlatter

Back 30

- Self-limited condition (several months)
- Restriction of activity
NSAIDs
- Stretching of quadriceps and hamstrings
- Band tx – place elastic band above the joint and band acts as a fulcrum – muscle is pulling from band and not from tibial tubercle = less strain and less pain

- Immobilization (if necessary)
- 5-10% become chronic and may require surgery

Front 31

Calcaneal Apophysitis (Sever disease) and Sx

Back 31

Overuse & microtrauma from pull on the calcaneal apophysis by the achilles tendon
Sx: characterized by pain in post aspect of heel after activity in prepubertal child

Front 32

Tx of Calcaneal Apophysitis

Back 32

Ice, ibuprofen, short-term activity restriction, heel lift/cushion (takes some stretch away from the tendon, relieves a lot of pain)

Front 33

Toddler's Fracture

Back 33

- Rotational injury to lower leg; generally in 9 months to 3 years old.
- Unwillingness to bear weight
- Exam: localized tenderness of tibial shaft
- X-Ray shows subtle, oblique/spiral, non-displaced fracture of tibia
Tx: Immobilization for 4 weeks

Front 34

Nursemaid Elbow

Back 34

- Subluxation of radial head
- Tx: Rapid, firm supination and flexion of arm with application of pressure over radial head (if that doesn’t work, completely extend the arm downward; if can’t relocate, send for x-ray)

Front 35

Growing Pains

Back 35

- Idiopathic leg pains
- Commonly involves front of thighs, calves
- Short in duration (minutes), bilateral
- Dx of exclusion

Front 36

Tx of Growing Pains

Back 36

Tx: reassurance, heat, massage, analgesics
**Check for signs of bone tumor or leukemia**

Front 37

Congenital Muscular Torticollis

Back 37

- Positional abnormality of the neck resulting in tilting and rotation of the head due to contracture of SCM
- Head tilt toward affected side, chin pointing to opposite side

Front 38

Exam for Muscular Torticollis

Back 38

- Decreased lateral rotation to affected side, decreased lateral tilt to opposite side.
- Firm, non-tender mobile mass may be palpated within the SCM
- Check the hips – these kids are more likely to have congenital hip dysplasia

Front 39

Tx for Muscular Torticollis

Back 39

- Passive stretching exercises (ear to shoulder, chin to shoulder)
- Position baby to encourage looking in desired direction

Front 40

Scoliosis

Back 40

- Lateral curvature of the spine
- Presentation: asymmetry of shoulder heights, scapular prominence or position (may stick out more or be higher than the other), and waistline or pelvic height discrepency, painless

Front 41

Scoliosis dx

Back 41

- Location of curve is defined by the apical vertebrae (i.e., T7) – where the curve starts
- The direction of the curvature by the direction of the convexity (curves out)
- The degree of curvature is determined by X-Ray (> 15 degrees is abnormal)
- Cobb’s angle = degree of deformity

Front 42

Tx for Scoliosis

Back 42

- Curves < 20-25 degrees monitored (repeat x-rays every 6mo)
- Curves b/w 25-45 degrees – no bracing in skeletally mature, Milwaukee brace in growing children (to prevent further curve)
- Curves > 45 degrees may require surgery regardless of skeletal maturity (Harrington Rod or post spinal fusion)