Pediatric Orthopedics

what are the ossification centers in the elbow? what order do they close in?

-capitellum

-radial head

-internal/medial epicondyle

-trochlea

-olecranon

-external/lateral epicondyle

-CRITOE

what order do the carpal ossification centers close in?

-capitate (1-3mo) → pisiform (8-12yo)

how long does it take for the distal radius ossification center to close?

-1yr

how long does it take for the distal ulna ossification center to close?

-5-6yr

what is the physis?

-epiphyseal plate found at ends of long bones responsible for longitudinal growth

what is the apophysis?

-traction physis that acts as the insertion site of a tendon at the physis

what is physeal arrest?

-growth arrest due to vascular injury & malnutrition of the physis

when is growth over for females?

-14-15yo

when is growth over for males?

-16-17yo

which is stronger: ligaments or physes?

-ligaments

what is periosteum?

-sheath that covers outer surface of bones & contains blood vessels, osteoblasts, & nerves

in a young child, which injury is more likely: fracture or sprain?

-fracture

in an adolescent patient, which injury is more likely: fracture or sprain?

-either

why are fractures more likely than sprains in a young child?

-b/c growth plates are weaker than ligaments & break before ligaments sprain

what is an occult fracture?

-fracture not visible on initial radiographs

what causes an occult fracture?

-fracture in physeal plate

-periosteal fracture

-secondary ossification center fracture

how is an occult fracture diagnosed?

-imaging

• MRI, CT, or US

• f/u x-ray in 10-14 days

-high clinical suspicion

what is a Salter Harris type 1 fracture?

-fracture thru growth plate

what is a Salter Harris type 2 fracture?

-fracture thru growth plate & metaphysis

what is a Salter Harris type 3 fracture?

-fracture thru growth plate & epiphysis

what is a Salter Harris type 4 fracture?

-fracture thru growth plate, metaphysis, & epiphysis

what is a Salter Harris type 5 fracture?

-crush injury of growth plate

what is the Tx for a Salter Harris fracture?

1. ensure no intra-articular widening if type 3 or 4

2. surgery if good alignment can’t be obtained or intra-articular widening is present

3. immobilization & non-weight bearing x 4-6 weeks

4. progression of motion & weight bearing

what are Harris growth arrest lines?

-transverse condensations of normal bone that slow or cause intermittent cessation of growth

what is a Monteggia fracture/dislocation?

-fracture of proximal 1/3 of ulna with radial head dislocation

what is the Tx for a Monteggia fracture/dislocation?

-supportive

• closed reduction + immobilization

-procedural/surgical

• surgery + immobilization

what are the possible complications of a Monteggia fracture?

-deformity

-nonunion

-stiffness

-nerve palsy

what is a Galeazzi fracture/dislocation?

-fracture of distal 1/3 of radius with dislocation of distal radioulnar joint

what are the PE findings of a Galeazzi fracture?

-tenderness over distal radioulnar joint

-laxity

-limited ROM with pronation & supination

how is a Galeazzi fracture diagnosed?

-imaging

• x-ray

what is the Tx for a Galeazzi fracture?

-supportive

• closed reduction + immobilization

-procedural/surgical

• ORIF if closed reduction fails

what is a Smith fracture?

-volar displaced distal radius fracture

what is a Colles fracture?

-dorsally displaced distal radius fracture

which fracture is associated with a dinner fork deformity?

-Colles fracture

what is the Tx for a Smith fracture?

-supportive

• closed reduction + immobilization

-procedural/surgical

• surgery if closed reduction fails

what is the Tx for a Colles fracture?

-supportive

• closed reduction + immobilization

-procedural/surgical

• surgery if closed reduction fails

supracondylar humerus fractures are MC in what patient demographic?

-3-10yo

what is the Tx for a supracondylar humerus fracture?

-class I = casting

-class II-IV = surgical reduction & fixation (CRPP) + immobilization

what are possible complications of supracondylar humerus fractures?

-nerve injury

-deformity

-stiffness

-vascular injury

-infection

what is a Seymour fracture?

-displaced distal phalangeal physeal fracture with an associated nailbed injury

what is the Tx for a Seymour fracture?

-supportive

• closed reduction

• nail bed repair

-pharm

• Abx

what is a both bone forearm fracture?

-fracture of radius & ulna

what is the Tx for a both bone forearm fracture?

-supportive

• closed reduction + immobilization

-procedural/surgical

• surgery

how does osteomyelitis present?

-(+/-) fever

-localized pain

-decreased use of limb

-limp or refusal to bear weight if LE involved

how does osteomyelitis typically spread in pediatric patients?

-hematogenous

what are common causative pathogens of osteomyelitis?

-S. aureus

-group A strep

-S. pneumo

-K. kingae

-H. flu

how is osteomyelitis diagnosed?

-imaging

• x-ray

• MRI

-labs

• CBC

• ESR/CRP

• CMP

• blood cultures

• (+/

what is a Brodie abscess?

-type of osteomyelitis where there is a region of suppuration & necrosis within an abscess at rim of sclerotic bone

what is the Tx for osteomyelitis?

-pharm

• IV Abx

-procedural/surgical

• (+) abscess = surgery

what are possible complications of osteomyelitis?

-chronic infection

-AVN

-premature physeal arrest

how does septic arthritis present?

-ill-appearing

-refusal to move joint or bear weight

-PE

• edema

• tenderness

• joint effusion

• painful PROM

septic arthritis of the hip impacts what parts of ROM?

-flexion

-abduction

-external rotation

what is the MC causative pathogen of septic arthritis?

-S. aureus

what is the expected causative pathogen of septic arthritis in a patient < 3mo?

-group B strep

what is the expected causative pathogen of septic arthritis in an unvaccinated patient?

-Hib

what is the expected causative pathogen of septic arthritis in a sexually active patient?

-N. gonorrhoeae

what is the expected causative pathogen of septic arthritis in a patient with recent tick exposure?

-B. burgdorferi

what is the expected causative pathogen of septic arthritis in patients 6-36mo?

-K. kingae

what is transient synovitis?

-transient irritation of synovial fluid

how does transient synovitis present?

-recent viral illness

-rapid onset

-pain

-limited ROM

-limp

-afebrile

-healthy appearing

what is the MC site of transient synovitis?

-hip

what is the Kocher criteria used for? what are the data points?

-differentiating between hip septic arthritis & hip transient synovitis

-Hx of fever

-non-weight bearing

-ESR > 40

-WBC count > 12,000

-each 1pt

-score of 3-4 → highly likely for septic arthritis

a Kocher criteria score of _____ is highly suggestive for septic arthritis?

-3-4

if a patient has a Kocher criteria score of 1, what are the next steps?

-proceed with supportive management of hip transient synovitis

if a patient has a Kocher criteria score of 4, what are the next best steps?

-go to OR for joint washout due to septic arthritis

what is the Tx for transient synovitis?

-supportive

• pain control = NSAIDs (toradol)

what are possible complications of septic arthritis?

-premature physeal arrest

-femoral head AVN

-joint damage

what is the Tx for septic arthritis?

-supportive

• ABCs

-procedural/surgical

• emergent surgical debridement

-pharm

• IV Abx

what is scoliosis?

-3-dimensional rotational curve of the spine with a lateral curve > 10*

what are the screening recommendations for scoliosis?

-female: 10yo & 12yo

-male: 13yo or 14yo

what are essential PE components for identifying scoliosis?

-Adams forward bend test

-neuro exam

-spine palpation

how is scoliosis diagnosed?

-imaging

• x-ray = PA & lateral views

what is the Tx for scoliosis?

-< 20*: monitoring with x-rays q4-6mo

-20-40*: bracing with TLSO

-> 40-50*: surgical posterior spinal fusion with instrumentation

how is scoliosis staged?

-Risser scale

what is thoracic hyperkyphosis?

-thoracic kyphotic curvature > 45*

what is Scheuermann’s kyphosis?

-rigid thoracic hyperkyphosis with anterior wedging > 5* across 3 consecutive vertebrae

what is the Tx for Scheuermann’s kyphosis?

-> 75*: surgery with fusion & instrumentation

what is spondylolysis?

-fracture of pars interarticularis

how is spondylolysis diagnosed?

-imaging

• x-ray = may not be visible

• MRI or CT

what is spondylolisthesis?

-anterior subluxation of 1 vertebral body over the adjacent inferior vertebral body

how does spondylolysis present?

-ASx

-insidious onset of LBP with activity

how does spondylolisthesis present?

-LBP

-hamstring tightness

-(+/-) L5 radicular pain

-PE

• midline tenderness

• step-off deformity

• limited lumbar flexion & extension

• (+) straight leg raise test

what is the Tx for spondylolysis?

-ASx: observation

-supportive

• PT & activity restriction x 6mo

• TLSO bracing if PT fails

what is the Tx for spondylolisthesis?

-supportive

• PT + activity restriction x 6mo

• TLSO bracing if PT fails

-procedural/surgical

• surgical fusion for high-grade slip

what are the expected PE findings of developmental dysplasia of the hip in a patient < 3mo?

-(+) Barlow

-(+) Ortolani

-(+) Galeazzi (flexed hips & knees while supine → (+): LLD)

what are the expected PE findings of developmental dysplasia of the hip in a patient > 3mo?

-limited hip abduction

-hip click

-LLD → unilateral toe walking, Trendelenburg gait

how is developmental dysplasia of the hip diagnosed?

-imaging

• < 6mo: hip US

• > 6mo: AP x-ray of pelvis

what is the Tx for developmental dysplasia of the hip?

-supportive

• peds ortho referral

• observation

• Pavlik harness

  • no improvement = abduction brace

-procedural/surgical

• abduction brace failure = surgery

how does a SCFE present?

-unilateral hip, groin, &/or knee pain

-(+/-) weight bearing

-limited hip flexion & internal rotation

how is a SCFE diagnosed?

-imaging

• AP pelvis x-ray

• bilateral lateral frog view x-rays

-labs

• TFTs

• vitamin D

what is the Tx for a SCFE?

-supportive

• emergent peds ortho referral

• non-weight bearing

-procedural/surgical

• surgical fixation

what are possible complications of a SCFE?

-AVN

-contralateral slip

-chronic pain

-arthritis

what is Perthes?

-AVN of proximal femoral epiphysis

how does Perthes present?

-subacute onset of hip pain

-intermittent limp

-Trendelenburg gait

-limited hip internal rotation & abduction

how is Perthes diagnosed?

-imaging

• AP x-ray of pelvis

• bilateral lateral frog view x-rays

• MRI

what is the Tx for Perthes?

-supportive

• monitoring

• bracing

• casting

• traction

-procedural/surgical

• surgery

what is preaxial hand polydactyly?

-thumb duplication

what is postaxial hand polydactyly?

-small finger duplication

what is the Tx for hand polydactyly?

-procedural/surgical

• surgical resection

• tie off

what is the Tx for foot polydactyly?

-supportive

• observation

-procedural/surgical

• surgery if painful or difficult shoe-wearing