Peds E3- Ortho & Rheum

What are the 4 types of scoliosis?

Idiopathic, congenital, neuromuscular, compensatory

What is Scoliosis?

Lateral curvature of the spine that is usually accompanied by rotation

What referral is necessary if pt is having pain with scoliosis?

Neuro- scoliosis should be painless!

How does Scoliosis present?

Asymmetry of the posterior chest wall on forward bending

What region of the spine is most commonly affected in scoliosis?

Right thoracic curve

Is idiopathic scoliosis more common in females or males?

Females

What demographic is Idiopathic scoliosis MC seen in?

Adolescent (11+ yo)

What is the MC brace used to treat idiopathic scoliosis?

Boston brace

When do you refer Scoliosis for surgery?

> 40 degree of curvature

What causes congenital Scoliosis?

hemivertebrae, congenital fusion, or combo

What other organ abnormality may be seen in pts with congenital scoliosis?

Unilateral renal agenesis

What is Neuromuscular scoliosis?

Scoliosis due to cerebral palsy, myelomeningocele, or muscular dystrophy causing muscle imbalance and lack of trunk control

What causes compensatory scoliosis?

leg length discrepancy

What do you need to do on your PE when assessing for Scoliosis?

examine for iliac crest symmetry/obliquity and Adams Forward Bend test

When do your refer pts w/ Scoliosis to ortho?

skeletally immature w/ curve of > 20 degrees

*mature > 40

When is bracing for Scoliosis needed?

20-40 degree curvature in skeletally immature

What is Spondylolysis?

defect of the pars interarticularis without forward slippage of the involved vertebra on to the one below

Who is Spondylolysis seen in?

Athletes who hyperextend the spine or do repeated jumping such as gymnastics, weightlifting, football lineman, ballet

What is Spondylolisthesis?

Forward slippage or displacement of the involved vertebrae

How do spondyolysis & spondylolisthesis present?

palpable “step off” at the lumbosacral area w/ a vertically oriented sacrum; hamstring tightness, localized back pain w/ bending backwards & worse w/ standing straight leg raise

What grades of Spondylolysis & Spondylolisthesis require spinal fusion for treatment?

2-4 (>25%)

What is Kyphosis?

Increased angulation in the thoracic or the thoracolumbar spine in the sagittal plane

What is a common cause of concern of parents who believe their child has kyphosis?

Bad posture

How do you differentiate kyphosis vs bad posture?

Bad posture has normal XR and can be voluntarily corrected

What is Scheuermann disease?

adolescence kyphosis -cannot correct in standing or prone

What is seen on XR of Scheuermann disease?

Schmorl nodes, narrow disc space, loss of ht, wedging

What is the tx for Scheuermann disease?

Corrective plaster cast, orthosis

What is Torticollis?

"Twisted neck", shortening of SCM

How does Torticollis present?

Ear pulled down toward the clavicle on the ipsilateral side and face looks up toward the contralateral side

What are the 2 phases of normal gait?

Stance phase & swing phase

What abnormal gait is caused by gastrocnemius contracture or leg-length discrepancy?

Toe-walking

Where do kids with chondromalacia patella have pain?

Anterior knee

What causes Chondromalacia patella/Patellar instability?

Running and climbing stairs elicit pain when knee is flexed

What is Nursemaid's elbow?

Annular/circular ligament that passes around the base of the radial head and partially slips off with the traction across the elbow

What causes Nursemaid’s elbow?

initiated by a jerk when child falls or when being swung by the arms

How does Nursemaid’s elbow present?

Elbow bent and hand is pronated; child refuses to use hand or cries when the elbow is moved

What is the tx technique for nursemaid's elbow?

Hyperpronate the arm by moving the hand in palm-down position with pressure over the radial head

(can also flex + supinate)

What is the MCC of Ankle sprains?

Inversion stress injury

Which fx line is perpendicular to the axis of a long bone?

Transverse fx

Which fx line is at an angle relative to the axis of a bone?

Oblique fx

Which fx is complete except for a portion of the cortex on the compression side of the fx, which is only plastically deformed?

Greenstick fx

Which fx line takes a curvilinear course around the axis of a bone?

Spiral fx

In which fx are bone ends are crushed together, producing an indistinct fx line?

Impacted fx

In which fx do fracturing forces produce more than 2 separate fragments?

Comminuted fx

In which fx do bones bend to the point of plastic deformation without fracturing?

Bowing fx

In which fx do bones buckle and bend rather than breaks?

Torus fx

Which fx line is parallel to the axis of a long bone?

Longitudinal fx

Salter Harris fx:

Epiphyseal separation through the physis

Type I

Salter Harris fx:

Fx through a portion of the physis but exiting across the metaphysis

Type II

Salter Harris fx:

Fx through the physis but exiting across the epiphysis into the joint

Type III

Salter Harris fx:

Fx line extending across the metaphysis, physis, and epiphysis

Type IV

Salter Harris fx:

Crush injury to the physis

Type V

What is the single greatest risk factor for hip dysplasia?

Breech position in 3rd trimester

What is the AAP recommendation for hip dysplasia screenings?

All newborns should have screenings until the are walking; selective imaging of pts with risk factors

Next step in pt with positive Barlow maneuver?

Hip surveillance to monitor for development of hip stability

What is the most important maneuver in examining the newborn hip?

Barlow maneuver

Next step in pt with positive Ortolani maneuver?

Refer to ortho surgeon for assessment and management

What imaging is done for hip dysplasia?

< 6 months = US

> 6 months = XR

What is the tx for hip dysplasia in pt from birth-6 months old?

Maintain hip in flexion/abduction for 1-2 mos, Pavlik harness

Pavlik harness is successful what percentage of the time?

95% successful in dysplastic or subluxated hips

What is the tx for hip dysplasia in pt from 6-18 months old?

Surgical closed reduction

What is the tx for hip dysplasia in pt from 18 months-8 years old?

Open reduction

What is SCFE?

Displacement of the femoral head from the femoral neck through the epiphyseal plate

How does SCFE present?

Painful limp without trauma; hip, thigh, knee pain; M > F, obesity, pubertal onset

What does PE of SCFE reveal?

LE externally rotated w/ limited ROM, antalgic gait w/ abductor lurch gait

What does an XR of SCFE show?

widened and radiolucent physis, frank deformity/displaced femoral head

What is Legg-Calve-Perthes disease?

Impairment of blood supply to the developing femoral head resulting in AVN

How does Legg-Calve-Perthes disease?

Painless limp, + Trendelenburg sign, flexion contracture of affected hip; 4-11 yo males; insidious onset, unilateral involvement

What is the tx for Legg-Calve-Perthes disease?

self-limited, last 1-2 yrs, surgery if needed

*if synovitis → anti-inflammatory meds

What can Legg-Calve-Perthes disease cause?

Transient synovitis

What is the tx for septic arthritis?

Surgical aspiration/washout, abx

What is Femoral anteversion?

Normal variation of lower extremity positioning in the developing child → femoral head internally rotated

How does Femoral anteversion present?

unsightly gait, tripping on heels, stands with thighs, knees & feet turned inwards

What is the tx for femoral anteversion?

pt education: reassurance, will correct with growth, AVOID "W" sitting position

How does Internal tibial torsion present?

Hips and knees are in normal alignment with patella facing forward, but lower leg and feet are turned inward

What is Genu varum?

"Bowlegs"

What is Genu valgum?

"Knock knees"

When does Genu varum resolve?

resolves w/ 6-12 months of independent ambulation; self corrects by 2 y/o

When does Genu valgum resolve?

Resolves with growth, normal knee alignment by 5-8 y/o

What causes Osgood schlatter disease?

response to stress on the tibial tuberosity (running, jumping)

How does Osgood Schlatter disease present?

Males, adolescent growth spurt, swelling, tenderness, and inc prominence of the tibia tubercle

What is the tx for Osgood schlatter disease?

rest/restriction of activities, NSAIDs are NOT usually beneficial; isometric exercise, strengthening of the quads, ice after activity

What is Talipes equinovarus?

Congenital clubfoot

What is Congenital clubfoot (Talipes equinovarus)?

pathological finding of rotational deformity of the subtalar joint; contractures of achilles and post tibial tendons as well as medial and subtalar joint capsules cause difficulty

What are the 3 components of how Congenital clubfoot (Talipes equinovarus) presents?

Entire foot in plantar flexion, hindfoot in fixed inversion, forefoot adducted and supinated

What is Metatarsus adductus?

Congenital foot deformity where metatarsals are deviated medially → "C" shape to the foot

What is the tx for metatarsus adductus?

Manipulation, + casting and surgery if severe

What is Calcaneovalgus foot deformity?

Foot is dorsiflexed and everted with loss of longitudinal arch; tight anterior tibial tendon and lax Achilles

What is the tx for calcaneovalgus foot deformity?

Serial casting

What is Pes planus?

"Flat foot"

What causes Pes planus?

laxity of soft tissues of the foot → loss of the normal longitudinal arch with pronation and eversion of the forefoot and valgus or lateral orientation of the heel

What imaging can be done for Pes planus?

weightbearing XRs →l loss of longitudinal arch without osseous abnormality

What is the tx for pes planus?

Corrective shoes with arch support (if symptomatic)

What is Osteogenesis imperfecta?

Brittle bone disease

What is a Genetic cause of osteoporosis?

*autosomal dominant

Osteogenesis imperfecta

What causes Osteogenesis imperfecta?

Generalized disorder of connective tissue caused by defects in type I collagen

What is the triad of osteogenesis imperfecta?

Fragile bones, blue sclerae, early deafness

What differentiates Osteogenesis Imperfect A & B?

dentinogensis imperfecta is present in subtype B but NOT in A

What type of osteogenesis imperfecta:

Blue sclerae, recurrent fx in childhood, presenile hearing loss

Type I (mild)

What type of osteogenesis imperfecta:

Stillborn or death within 1st year, small gestational age, fragile skeleton, fx of long bones in utero

Type II (perinatal lethal)