Pediatric orthopedics

the epiphyseal plate is _____

the main site of longitudinal growth

what type of fracture?

you see a buckle that is incomplete (doesn’t go to other side, heals fast

torus fracture

What type of fracture?

you see that the periosteum is intact on one side (when you follow the bone cortex it is only messed up on one side)

greenstick fracture

what type of physeal fracture is this?

growth plate

the fracture is through the zone of hypertrophy (straight across)

growth disturbances are uncommon

treat with casting or splinting

Salter Harris Type 1

What type of physeal fracture is this?

metaphysis and growth plate

occurs above the growth plate

usually will not cause functional limitations

salter harris type 2

what is the most common type of physeal fracture?

salter harris type 2

What type of physeal fracture is this?

epiphysis and growth plate

chronic disability due to extension of fracture into the articular surface

treatment is surgical

salter harris type 3

what is the salter Harris scale?

What type of physeal fracture is this?

epiphysis, growth plate, and metaphysis

intra-articular fracture

goes from the articular surface through the growth plate

salter harris type 4

What type of physeal fracture is this?

compression or crush fracture

rare

growth is affected

injury occurs at the growth plate

salter harris type 5

What are some things that would constitute a high degree of suspicion for child abuse

note: there are a lot, so try to name a few, but most importantly just read them and try to understand them rather than memorize

babies with bruises (esp less then 12mo when they aren’t really walking)

back and torso bruising

inconsolable ccrying

burns

whip marks

unkempt or dirty appearance

nervous parent

quiet child with poor eye contact

child with an overly serious demeanor

parental putting down of child

inappropriate sexual behaviors in a young child

What are two things we commonly see with shaken baby?

subdural hematoma (a coup contrecoup injury) and retinal hemorrhages

mechanical instability of the hip

risk factors: female, first born, breeched, prenatal factors like not enough amniotic fluid, and swaddling

developmental dysplasia of the hip

What are the tests for DDH and what do we use to confirm?

barlow test: try to provoke hip dislocation

ortoloni test: move a dislocated hip back into acetabulum

galeazzi test: eval for current hip dislocation

use ultrasound to confirm

How do we treat DDH (developmental dysplasia of the hip)?

pavlik harness or spica cast

idiopathic avascular necrosis of the femoral head

male predominant

diagnosis made by radiography

Legg-Calve-Perthes disease

clinical presentation:

pain at hip, knee, groin, or anterior thigh

limp with or without pain and Trendelenburg gait

hip ROM decreased: esp abduction and internal rotation

Legg-Calve-Perthes disease

what are some ways we can treat Legg-Calve-Perthes disease?

minimal weight bearing

pain control

PT

bracing (Petrie cast)

if severe, surgery will be required

seen in obese, pubertal children during their growth spurt

more common in boys

you see: hip, thigh, groin, or knee pain, a limp, external rotation with flexion and decreased ROM

slipped capital femoral epiphysis

you see Salter harris type 1 fracture of the proximal femoral epiphysis and slippage through zone of hypertrophy

slipped capital femoral epiphysis

How do we treat slipped capital femoral epiphysis?

surgery

osteochondritis of the tibial tuberosity

pain and swelling at tibial tubercle

anterior knee pain made worse with kneeling, running, and jumping

Osgood-Schlatter disease

how do we treat Osgood-schlatter disease?

rest, ice, and ibuprofen

involves both the muscular and skeletal parts of the foot

treated with serial casting and possible surgery

you see plantar flexion of first ray, adduction of the forefoot/midfoot on the hindfoot, hindfoot points inward, and plantar flexion of the hindfoot

clubfoot

when you draw a line through heel you should cross through the second toe, but instead you cross lateral to the second toe

treatment involves stretching the foot (can be done by parent at home)

metatarsus adductus

pathogenesis: acute hematogenous spread, direct spread from adjacent infection, or direct inoculation

you see an initial site of infection, then an abscess forms

bacteriology: Staph aureus most common (E coli in neonates)

you see: fussiness, poor movement, point tenderness, etc.

for diagnosis need 2+: purulence of bone, positive culture, localized erythema, or positive imaging

acute osteomyelitis

How do we treat acute osteomyelitis?

IV therapy for minimum of 2-3 weeks

starts empiric until you get culture results

empiric: clindamycin, vancomycin, or linezolid

you see:

± fever

subtle onset

± limp

normal ESR (no inflammatory markers in blood)

a prior illness (usually viral or GI infection)

normal x-ray and ultrasound

transient synovitis

you see:

high fever

sudden onset

limp present

high ESR (inflammatory markers in blood)

no prior illness

abnormal x-ray and ultrasound

bacterial septic arthritis (medical emergency)

disorder of Ca and PO4 homeostasis

severe prolonged vit D deficiency

bones are softer and weaker so they bow

nutritional deficiency most common

Rickets

calcipenic versus phosphopenic rickets; what should we know?

calcipenic is more common; vitamin D deficiency or resistance

x-ray findings: bowing, rachitic rosary, and fraying at the ends of the bones

rickets