ORTHOPEDIC REVIEW
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Cerebral Palsy
Definition: non-progressive neurologic disorder in infants <3 yo
Number 1 risk factor: Pre-maturity
Types: A ARMS
Ataxic (5%), Athetoid (10%), Rigid (10%), Mixed (15%), Spastic (60%)
Athetoid is almost unheard of now due to the decreased frequency of Erythroblastosis Fetalis (ABO incompatibility)
Blecks Criteria (2=poor, 1=fair, 0=good chance will walk) (The chance the CP patient will ambulate 15m w/wo
forearm walker on level surface before 3yo)
F oot Placement (absence of is bad) “steppage”-brush dorsum of foot or anterior aspect of tibia on table
and the normal child will flex the hip and knee, dorsiflex ankle, and place the foot on the table
spontaneously.
E xtensor Thrust - apply pressure to sole of foot with hip in flexed position and the child will
extend entire leg. (In a normal child, this reflex will disappear at 2 months, persistence
is abnormal.)
M oro Reflex (persistence of is bad) startle reflex or quick extension of neck –The child will abduct and
extend all 4 extremities, extend the spine, extend and fan the digits except for flexion of the
distal phalanges of the index finger and thumb. This reflex normally disappears at 4 –6 months.
S ymmetric Tonic Neck Reflex
Place the child in the quadriped position: When you flex the neck the LE ext/UE flex, and
when you extend the neck the LE flex/UE ext. This reflex normally appears by 6 months.
N eck Righting Reflex - Place child supine-rotate head to one side and the normal patient will log roll
shoulders/pelvis as one to the same side.
A ssymmetric Tonic Neck Reflex (persistence of bad) fencers posture. Place patient supine and rotate head
to one side for 5 seconds then rotate to other side. The “face side” arm and leg will extend and
the “occiput side” arm and leg will extend. This reflex normally disappears at 4-6 months.
P arachute Reflex (absence of bad) Suspend patient and suddenly move head toward the floor. The
normal patient will extend his arms and wrists so as to break the force of the fall.
Spine/Scoliosis
Thoracolumbar (45%) C-shaped/paralytic curves
Lumbar (25%)
Thoracic (16%)
Double primary (14%)
Standing Postures:
1. Knees extended, Hips flexed, Excessive lumbar lordosis
2. Knees extended, Hips flexed, Forward lean of trunk
3. Knees flexed, Hips flexed (Jumpers position)
2 foot problems: equinus, planovalgus
Compensation for equinus: 1. Genu recurvatum
2. Midfoot break
3. Hindfoot valgus
1
SCFE
Epidemiology: 2:100,000, Age 10-15 yo, M:F 2-5:1, 2 years younger in females, 25-40% bilateral, L>R
Ant/lat displacement of the femoral neck on the head-head stays located in acetabulum
Present as pain in knee with limited IR/ER--mom brings kid in because of limp
Body types:
Tall, thin athletic male (rare)
Hypogonadal, obese, delayed sexual maturity
Etiology theories:
1.
S ynovial hypervascularity (increased height of growth plate) slip through zone of Hypertrophy
2.
E piphyseal cartilage weakening (dyschondroplasia)
3.
T hinning & weakening of the periosteum-lose support for head
4.
5.
6.
M etabolic (Radiation, Renal osteodystrophy, Scurvy)
E ndocrine (Hypothyroidism, GH, Sex hormone)
T rauma
7.
P hysical theory (Shear stress with oblique physis, deep acetabulum)
8.
E piphysiolysis (through zone of proliferation)
9.
T raumatic separation (through zone of calcification)
Anatomy: Perichondral ring is last structure to fail
Loder Classification:
1. Acute: <3 weeks, trauma, disabling pain, unstable
Stable(can walk on it) one pin
2. Acute on Chronic: >3 weeks, limp
Unstable(can’t walk on it) two pins
3. Chronic: most common
~47+% AVN rate (Loder et al)
Stages: Preslip-x-ray-widening of physis, +/- Blush sign
Minimal slip (<1 cm)
Moderate slip (1 cm-2/3 head)
Severe slip (>2/3 head)
Lovell/Winter Classification: I (0-33%), II (33-50%), III (>50%)
X-ray: Shentons line, Kleins line, Blush sign-osseous density in chronic slips in the metaphysis just below
epiphysis (healing bone) aka Steele's sign, pistol-grip deformity, Jones bone--reactive bone on medial side
Need to know: Chronicity-acute vs. chronic
Open/closed growth plates
Severity
Systemic diseases
Treatment: 1. cast
2. percutaneous pins (Stable--can walk on it--one pin, Unstable--can’t walk on it--two pins)
3. bone-peg epiphysiodesis
4. osteotomies (Southwick, Sutherland, Sugioka)--valgus and rotation
5. sex hormone manipulation--not recommended
6. open epiphysiodesis with bone graft
7. Dunn procedure--shortens femoral neck
Objectives:
Prevent further slip, and if acute, gently reduce slip but don't tell anyone
Cause early closure of physis
Prevent AVN/chondrolysis/DJD
Increase function of child
Complications: AVN – from unstable slips (47+% chance of AVN-Loder et al)
Chondrolysis (worst complication) from leaving pins proud through femoral head
Mosely approach/withdraw test-ROM under fluoro to check if pins are in joint space
"Safe zone" 8mm from subchondral bone
DJD, LLD
2
Perthes Disease
Epidemiology: 1:1200, M:F 4:1, 15% bilateral (AVN in different stages), Peak age 5-6yo, familial 10-15%
If bilateral think:
1. Meyers Dysplasia – AVN in same stage in both hips
2. Multiple Epiphyseal Dysplasia
3. Spondyloepiphyseal Dysplasia – spine involved--platyspondyly
If black think HgbSS
Etiology: Protein C & S or AT-III deficiencies, high lipoprotein a, hemophilia A/B,
secondary to trauma, other vascular diseases, exposure to cigarette smoking
Most commonly presents as PAINLESS limp
Classifications:
Goff-Aegeter-Ferguson---WAFR
I: Widened joint space--apparent (delayed growth of ossific nucleus, hypertrophied cartilage)
II: AVN (subchondral fx, crescent sign)
III: Fragmentation-subchondral comp fx with cystic irreg in head, metaphyseal cyst formation
IV: Resolution (Normal, Coxa magna/plana/vara/breva, gr. troch overgrowth esp if <5yo
Catteral (Prognosis: I, II good/ III, IV poor)
I: Anterolateral head involvement
II: Central collapse (medial, lateral columns intact)
III: Central sequestrum (medial column intact, head within head)
IV: Whole head involvement
(III and IV physis at risk due to minimal support)
Salter-Thompson (True Perthes only with subchondral fracture-starts ant/lat, prognostic classification in
predicting eventual involvement of the femoral head - apply only after crescent sign)
A: less than half of the head (intact lateral margin)
B: more than half the head (absence of lateral margin)
Herring (Lateral pillar classification)-central/medial pillars are irrelevant
A: Minimal involvement lateral pillar
B: >50% Lateral pillar height remains => if <6yo=observe, >6yo=operate
C: <50% Lateral pillar height remains =>operate
Conway (bone scan stages-“biologic”)
I: total lack of uptake
II: lateral column uptake
III: gradual fill of ant/lat epiphysis
IV: base fill in epiphysis adjacent to physis
Sequence of events: (Salter) VCRR TOPS
1. Vascular compromise (see etiologies above)
\
2. Cessation of growth of bony epiphysis
_____ \ potential Perthes
3. Revascularization (from periphery)
/
4. Resumption of ossification which is fragile
/
5. Trauma leads to pathologic fracture (onset of True Perthes)
6. Onset of resorption
7. Plastic bone replacement
8. Subluxation....Residual deformity
Head at Risk
1. Gages Sign (lateral V-shaped lucency on the ossific center)
2. Lateral calcification (represents fracture through epiphysis extending into physis)
3. Subluxation (worst)
4. Metaphyseal cysts
5. Horizontal physis
Good prognosis: Less than half the head involved and less than a half dozen years of age
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Evaluation
Center-Edge angle
Center of femoral head ....Vertical line through this point.....Line from center of head to lateral
edge of acetabulum
Normal is 20-40
Pathologic <20, if <15 need to augment Salter with a shelf
Method of Mose: Radius= Good (w/in 2mm), Fair (2-4mm), Poor (>4mm)
Treatment Goals – essentially ROM and containment
1. Decrease initial irritability
2. Maintain ROM
3. Prevent subluxation
4. Obtain spherical head
Surgical Treatment:
Soft tissue releases – adductor longus, ileopsoas lengthening, medial capsulotomy
Salter: Age <6, Total head involvement, Congruity, Good ROM, Poor compliance w/ orthosis
Lengthens leg
VDRO: Procedure of choice w/ bilateral or dislocated hips
Complications: Short leg limp
Residual deformity – applied at skeletal maturity (Stulberg classification)
1. Round head, round acetabulum (congruent)
2. Sperical head with coxa magna/breva/vara, round/dysplastic acetabulum (congruent)
3. Mushroom head, dysplastic acetabulum (congruent)
4. Square head, square acetabulum (congruent)
5. Square head, round acetabulum (non-congruent)
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Developmental Dysplasia of the Hip (DDH)
Incidence: 1/1,000---AVN, the most devastating complication
Risks: First born, Female, Frank breech, Fair complexion, Family history, Facial twist (torticollis)
Diagnosis: Barlow/Ortolani initially, Galeazzi/Limitation of abduction (best after 2 mos of age)
Also on physical exam:
Nelaton's line: Line b/w ASIS & ischium on the lateral....greater troch should be lower
Klisic's line: Line from greater troch to ASIS....should extend cephalad to umbilicus
Asymetric thigh, gluteal folds
X-Ray: Shenton's line
Lateral displacement –Reimer Migration Index (Asymmetry b/w medial femoral metaphysis and midline)
Quadrant: Horizontal = Hilg., Vertical =Perkins (Normal: Medial prox femoral metaphysis
in medial/lower quadrant)
Pathologic: Acetabular index >30, CE angle <20
Van Rosens View: Adduct......Push......Abduct.......Internal rotation
Hourglass Deficiency: (Arthrogram) caused by Iliopsoas
Gage's Position: -1 = Above Hilgenreiners line
0 = Below Hilg. line, Above nl position
+1 = At normal level
+2 = Below normal level
Graf Classification (ultrasound)
Classification & Treatment (per AHC):
I: (<6 weeks) Pavlik harness - 3 mo treatment/ 1 mo of age
II: (6wk - 1 year)
Ortolani +: Pavlic
Ortolani -: TAAT (Traction, Adductor tenotomy, Arthrography, Trumpet cast)
III: (1-3 years): TAAT, +/- VDRO, Pelvic osteotomy
IV: (>3 years): Open reduction, femoral shortening, +/- pelvic osteotomy
In newborn with ultrasound +, but physical exam -, observation and repeat physical exam
Blocks to closed reduction (LT CLIP)
Hypertrophied Ligamentum teres
Transverse acetabular ligament
Medial Capsule
Inverted Labrum
Iliopsoas
Pulvinar
Signs of AVN (Salter):
AVN increases with age and d/l
1. No ossific nucleus by 1 year following tx
25% at 1yo
2. Failure of growth of ossific nucleus following tx
50% 3yo
3. Broadened femoral neck
67% with no tx.
4. Sclerosis, Fragmentation
5. Residual deformity (Coxa magna/plana/vara)
AVN resulting in a mushroom head will produce the xray finding of "the sagging rope sign"
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Clubfoot: Talipes Equinovarus
Incidence: 1/1,000, M(65%) > F, 30-40% bilateral
Etiology: PAAAG
1. Packing phenomenon
2. Arrested fetal development
3. Abnormal tendon insertions
4. Abnormal talus rotation
5. Germ plasm defect
Associations: PB PB MAD LSO
1. PFFD
2. Bifurcated femur
3. Pierre-Robin Syndrome – Micrognathia with glossoptosis (X-linked recessive)
4. Bilateral uni-digit foot
5. Myelodysplasia
6. AMC (Arthrogryposis)
7. Diastrophic dwarfism
8. Larsen’s Syndrome – Multiple congenital dislocations including ant. Dislocation of the tibia on the
femur, frontal bossing, flat facies, hypertelorism, depressed nasal bridge.
9. Amniotic Band Syndrome (Streeters Dysplasia)
10. Other Packing Phenomena (DDH, Torticollis)
Physical Findings:
X-Ray findings
1. Shorter leg
1. Forefoot adduction
2. Smaller calf
2. Parallelism of talo/calc on lat max
3. Tibia internally rotated (? Internal tibial torsion)
dorsiflexion
4. Talus internal/medial rotation
3. Decr. Kite’s angle on AP of foot
5. Lateral dimple over ant/lat talus
4. Plantar/medial subluxation of
6. Small/wider foot
navicular (ossifies @ 5yrs)
7. Cavus-midfoot
5. Stacking of metatarsals on lateral
8. Adduction-forefoot
(forefoot supination)
9. Varus-hindfoot
10. Equinus-hindfoot
Poor Prognosis: 1. Teratogenic (Myelomeningocele, AMC, Diastrophic dwarfism) (Crawfordism—MAD)
2. Short, fat, rigid foot
3. Physical findings: Keel-shaped heel, Midfoot crease, Atavistic great toe
4. Delay in treatment
5. Failure to respond to initial surgery
Turco’s Ball and Socket Ankle:
Ball = talus
Socket = calcaneus, cuboid, navicular, y-bifurcate ligament
Pathologic anatomy
1. Medial deviation of head and neck of talus
2. Navicular medially/plantarly subluxed
3. Calcaneus in varus (to articulate with abnormal talus position)
4. Medial subluxation of forefoot (navicular medial and plantar)
5. Calcaneus -cuboid articulation is medial to tib-fib interosseus space (medial spin)
Medial spin: Abnormal talus position causes calcaneus to spin medially (decreased Kites angle AP)
Must release lateral ligaments (CFL, PTFL) to correct spin
Kites Angle: Talo-calcaneal angle on AP (Normal 20-40, <30 infers varus)
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Treatment:
Manipulation (70 forefoot abduction, 20 heel valgus, 10 dorsiflexion)
Casting (1-1-2-2-1: 1 week, 1 week, 2 weeks, 2 weeks, 1 month)
Order of correction: CAVE
Cavus, Adductus, Varus, Equinus
Maximum lateral dorsiflexion film
If parallelism b/w calcaneus and talus then percutaneous HCL
Straight or reverse last shoes
Posterior medial release (most dangerous comp. =>osteotomizing talar neck looking for talo/nav joint)
Tendon lengthening: Heel cord, Post tib, FHL, FDL
Posterior capsulotomy at subtalar, tibiotalar joint
Ligament release: Talofibular, Calcaneofibular, Talocalcaneal, Y-bifurcate (calc-cuboid, calc-nav),
Spring (med plantar calc-nav)
Reduction and pinning Talonavicular joint
Further treatment for partially corrected, over corrected, or recurrent clubfoot
Soft tissue:
Anterior tibialis tendon transfer __\ corrects “pigeon toe” deform, allows foot to
Posterior tibialis tendon transfer / dorsiflex into neutral position
Heyman-Herndon-Strong tarsometatarsal capsulorrhaphy
Bony:
Metatarsal osteotomies (for residual forefoot adduction)
Evans calcaneal osteotomy (calcaneal-cuboid osteotomy / fusion)
Dwyer calcaneal osteotomy (medial opening wedge osteotomy)
Triple arthrodesis
Talectomy => especially in AMC
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Lower Extremity Abnormalities
Congenitally Short Femur & Fibular Hemimelia
Associated findings
1. PFFD
2. Hypoplastic lateral condyle
3. Hypoplastic tibial spines (absent cruciates)
4. Fibular hemimelia
5. Ball and socket ankle
6. Tarsal coalition
7. Absent lateral rays
PFFD
Aitken Classification
A: Head present, Coxa vara, +/- Pseudarthrosis-head not articulating with acetabulum
B: Head present, Pseudarthrosis at neck (Most common)
C: No head, spike pointing toward acetabulum
D: No head or acetabulum
Coxa Vara
Autosomal Dominant
Defn: Shaft-Neck angle <125 degrees, metaphyseal triangle
Associated with Congenitally Short Femur
Hilgenreiner-Epiphyseal Angle-angle subtended through physis from Hilg line
Normal is 20. Observe from 20-60.
>60 => valgus osteotomy-overcorrect to allow for growth
Tibial Bowing
Anterolateral -- >55% have Neurofibromatosis
Malignant - High risk of pseudarthrosis
Anteromedial Bowing--Think O.I.
Posteromedial bowing (Kyphoscoliosis tibia)-- Benign
Association: Calcaneovalgus deformity
Residual defect is LLD
Streeter's Dysplasia Congenital constriction band syndrome
Tx: Staged Z-plasties
Dysplasia Epiphysialis Hemimelica (Trevor's Disease)
Prevalence: 1: 1 million
M:F 3:1
Intra-articular osteochondroma which stops growing at maturity. Sx. – dec. ROM, pain
Multiple lesions 70% of the time
Medial side > lateral joint side
Most common in talus
Treatment is aggressive surgery
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Knee Disorders
Congenital Knee Dislocation
Classification (Finder)
1. Physiologic: 20 degrees hyperextension, Resolves by age 8
2. Simple: Physiologic that carries into adulthood
3. Subluxation: <90 degrees hyperextension, resisted flexion beyond neutral
4. Dislocation, tibia ant/prox to femur
5. Complex variants associated with AMC, MM
Physiologic Genu Varum
Normal under age 2
Association: Internal tibial torsion
Nail-Patella Syndrome-Onchoosteodysplasia
Autosomal Dominant
Absence of patellae with abnormal nail beds
Elbow flexion contractures
Short stature
Iliac wings => Fong’s Horns
Blount's Disease
Epidemiology: Blacks, Obese, Short, Early walkers
X-Ray: Fragmentation of medial tibial metaphysis
Failure of development of proximal tibial epiphysis
Drennan: Metaphyseal-diaphyseal angle (>11 or 14 degrees)
Classification (Langenskiold - applies only to infantile)
1. Irregularity <3yo
Ignorant
2. Beaking 2-4yo
Butt-heads
3. Depression of physis 4-6yo
Don’t
4. Step-off 5-10yo
Study
5. Two epiphyses
Their
6. Bony bar
Books
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Common Foot Problems
Calcaneovalgus
Common (1/1000)
Findings: Forefoot dorsiflexed (against tibia), Everted, Abducted
Tx: Stretching exercises (Casting if rigid)
Flatfeet
Types: 1. Flexible: Ligamentous laxity, No treatment
2. Rigid: Insole supports if symptomatic (R/O CVT, Tarsal coalition)
Congenital Vertical Talus (Rocker Bottom foot, Serpentine foot, Persian slipper foot)
0.5:1000, associated with AMC, MM
Findings: Fixed equinus of hindfoot, Fixed dorsiflexion of forefoot (Post tib/Per longus=dorsiflexors)
Sine qua non=navicular is dorsally dislocated and sits on anterior head/neck of talus
*X-Ray: No reduction of talonavicular joint on maximum plantarflexion view, Meary’s Angle >0
** can’t see nav until approx 5yo, so talus doesn’t line up with meta-tarsals
** if talus does line up with the meta-tarsals it is called an OBLIQUE VERTICAL TALUS
Type A: Calc-cuboid located
Type B: Calc-cuboid d/l
Coleman/Stelling Tx:
Stage 1- Stretching, Casting
Stage 2- Release/lengthen anterior dorsiflexors, Triple capsulotomy, ORIF talo/nav and talo/calc
with pins
Stage 3- HCL, Posterior capsulotomy, Kidner procedure (Post tib transfer under navicular)
Older kids, may have to excise navicular
Zed Foot/Skew Foot
Navicular is lateral to talus, forefoot adduction, hindfoot valgus
Peroneal Spastic Flatfoot
Sx: Flatfoot, Pain over lateral calf
Etiology: Tarsal coalition, Trauma, JRA, Neoplasms
Tarsal Coalition
Age: 8-12 yo
Sx: Multiple ankle sprains, Decr subtalar ROM
Types: 1. Calcaneonavicular (Most common) pain in sinus tarsi with decr in subtalar ROM
X-Ray: Sloman's view, Anteater nose
Webster/Steward Tx: BKC first => Excision w/ peroneus brevis interposition
2. Talocalcaneal
X-Ray: CT is best, if middle facet not horizontal => coalition
Dorsal beaking of talar neck, narrow subtalar jt, broad lateral talar process
Tx: BKC (walking), if still painful: Excise if <50% joint, o/w fuse (triple is last resort)
Hallux Valgus
F>M, increase IMA (>100), first MTPA (>200)
Tx:
1. Release adductor hallucis
2. Medial capsulotomy, Attach adductor tendon to 1st metatarsal
3. Resect exostosis, Proximal opening wedge osteotomy of 1st metatarsal (medially)
4. Medial MTP capsulorrhaphy
Most common complication: recurrence
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Intoeing
Metatarsus Adductus (Neonate to 18 months)
Etiology: Packing phenomenon
Differences from clubfoot
1. Can correct forefoot and hindfoot
2. Hindfoot often in valgus (not varus)
3. Talocalcaneal divergence on AP X-Ray
4. Talocalcaneal convergence on Lateral X-Ray
Types: I. Corrects spontaneously (Tx: Observation)
II. Passively corrects (Tx: Stretching)
III. Rigid (Tx: Casting, surgery)
Internal Tibial Torsion (18-36 months)
Normal: Transmalleolar axis = 20 degrees of external rotation
Femoral Anteversion (3-8 years)
Newborn ~ 40 degrees, Adult ~ 15-20 degrees
Etiology:
1. Hereditary
2. Packing phenomenon
3. Pull of iliopsoas
4. Sleeping position
5. TV squat position, “W” position
Types: A - Compensation: Tibia externally rotated, Valgus feet
B - No compensation
Tx: Osteotomy indications: >8 yo, <10 degrees external rotation (Stehali)
Osteochondroses and Pseudoosteochondroses
Koehler's Disease (AVN of navicular)
Sever's Disease (Calcaneal apophysitis)
Iselin’s Disease ( Prox. 5th metatarsal apophysitis)
Diaz’s Disease (Talus AVN)
Pump Bump (Bursitis at tendoachilles attachment)
Freiburg's Infraction (AVN of 2nd MT head)
Van Neck's Disease (normal appearance in ischiopubic fusion)
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Upper Extremity Disorders
Klippel Feil Syndrome
Failure of segmentation of upper cervical spine
Triad (seen <50%): Low hairline, Decreased ROM, Short neck
X-Rays: look for omovertebral bone connecting spinous process to scapula
Associated findings:
1. Scoliosis-congenital (60%)
4. Hearing (30%)
2. Sprengel's (40%)
5. Synkinesia (18%) mirror-like movements
3. Renal (35%)
6. Heart (14%)
Torticollis
Associations: DDH (20%)
Tx: Release before 5-6 yo (Ocular righting reflex)
Acquired must r/o;
AA rotatory subluxation
Posterior fossa tumors
Spinal canal tumors
Retropharyngeal abscess
Sprengel's Deformity
Failure of scapular descent (normal C4 to T7)
Sx: Cosmesis, Decreased ROM
Associations: Scoliosis (Klippel-Feil), Torticollis, Hairlip, Renal disorders
Tx: most common complication is brachial plexopathy => clavicle ostectomy/morcelization to avoid
Woodward: Muscular release at spinous processes
Green: Muscular release at scapula.....Brought down.....Secured
Clavicle Pseudarthrosis
Location: Right side (Think dextrocardia if on left side)
Congenital Fusion of Elbow (Boomerang Elbow)
Association: Idiopathic scoliosis
Congenital Radioulnar Synostosis
No limits in function
Radial Clubhand
Autosomal dominant (~1/100,000)
Classification (Bayne) -- (SHIT)
I.
Short radius---Short
II.
Hypoplastic radius---Hypoplastic
III.
Partial absence---Isn't all there
IV.
Total absence (most common)---Totally not there
Absence of radial artery and nerve, absent distal biceps tendon
Associations:
TAR (Thrombocytopenia, Absent Radius)
Holt-Oram (cardiac septal defects)
Fanconi syndrome (aplastic anemia)
VATER (Vertebral, Anal atresia, Tracheo-Esophogeal, Radial)
VACTERLS (Vertebral, Anal, Cardiac, Tracheo-Esoph., Renal, Limb def,
Single umbilical artery)
Treatment: Bora- soft tissue release with realignment over ulna
Delorme centralization procedure- metallic rod to stabilize hand over ulna
Madelung's Deformity
Prominence of distal ulna, abnormal ulnar aspect of distal radial physis
Types: 1. Congenital: Triangulation of proximal carpals
F>M, Usually bilateral
2. Traumatic:
due to distal radius fx--volar/ulnar physis growth cessation, no triangulation
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Scoliosis
Non-Structural
Etiology: LLD, hip flexion contractures, neuromuscular imbalance, postural
Flexible on bending films, correct with supine films
Structural
WAR: Wedging, Angulation, Rotation
Treat WARP: Wedging, Angulation, Rotation, Progression
1. Idiopathic
Epidemiology: 8-11% of children 10-13 yo
0.3% require treatment, 0.03% require surgery
Family Hx (Risk): Mom (10x), Mom + older sister (20x), Older sister (<50x), Both parents (80x)
Complications: cosmesis, pain, neurologic, cardiopulmonary (if apex above diaphragm)
Cardiopulmonary: >100-110
-Correction: No change in tidal volumes; V-Q ratio, oxygenation improved
-Thoracic lordosis: Early decompensation, Mitral valve prolapse
Types: Infantile (0-3 yrs), Juvenile (3-10 yrs), Adolescent (10-maturity)
Infantile: Great Britain, Left thoracic curves, RVAD < 20 good prognosis
Vertebral maturity: Fusing of vertebral apophysis (best indicator)
Curve patterns: 1. Right thoracic (most common)
[Worst cosmesis]
2. Thoracolumbar (second most common)
3. Lumbar curve
4. Double primary (R thoracic, L lumbar) [Best cosmesis]
Milwaukee brace
-Indications: Curve <33 degrees, Progressive, Skeletal immaturity
-Contraindications: Curves >40-45, Thoracic lordosis, Psych probs, Poor cosmesis
Surgery
>45 degrees, Progressive
Spinal Cord Monitoring
Risk of progression:
1. SSEP
1. Lonstein table
2. MEP
Curve 5-19
20-29
3. EMG
Risser 0,1
22%
68%
4. Stagnara wake-up test
2,3,4
1.6%
23%
2. Weinstein table
10-12 yo
13-15 yo
>16 yo
<19 degrees
25%
10%
0%
20-29 deg
60%
40%
10%
30-59 deg
90%
70%
30%
60 deg
100%
90%
70%
Kings Classification: 5 distinct idiopathic thoracic curve patterns
I. L>T: T more flexible
II. T>L: L more flexible, L must cross midline
III. T-L curve: L doesnt cross midline, apex usually at T 7/8, fuse L 1/2
IV. Long T curve: L4 points into curve, L5 balanced over sacrum
V. Double thoracic curve (not double major!) T1 tilts into concavity, elevation of left shoulder
Surgery tips:
Fuse primary curve only
Fuse neutral (not rotated) to neutral vertebrae (Moe)
Lowest vertebrae fused must also be stable (centered over lumbosacral junction)
Avoid L4 and L5 when possible
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2. Congenital
Etiology: Failure of Segmentation (bar) vs Formation (hemivertebrae)
Most progressive:
1. Unilateral unsegmented bar (Most malignant)
2. Multiple unilateral hemivertebrae
3. Unsegmented bar with convex hemivertebrae
4. Hemivertebrae w/ kyphosis
Anomalous takeoff: congenital element at LS junction with compensatory curve above
3. Neuromuscular
Treatment: Fuse to sacrum (Bracing not effective)
Indications:
1. Cosmesis
2. Pain prevention
3. Improve pulmonary function
4. Improve function
5. Improve nursing
-Curve >50 degrees in standers, >30 degrees in sitters
4. Mesenchymal
Morquio’s, Marfan’s, AMC, Dwarfs, OI, Scheuermann’s
Myelodysplasia
-Fuse to sacrum (high incidence of infection, pseudarthrosis) => may stop walking
-Hydromyelia: Suspect if sudden worsening curve
5. Neurofibromatosis
-Short segments, Sharply angulated
Types: 1. Dysplastic (Pseudarthrosis common after fusion-17%)
-Wedging, Rotation of apical vertebrae, Scalloping of vert bodies, Spindling of
transverse processes, Enlarged foramina, Pencil ribs
2. Idiopathic
3. Kyphosis: >50 degrees.....Fuse anterior and posterior
-Pseudarthrosis common
6. Trauma
7. Miscellaneous
post radiation
Kyphosis: normal is 20-40, measure from T3-T12 on lateral
Scheurman's Kyphosis
Def: >3 successive vertebrae with >5 degrees wedging (Sorenson's rule)
Fixed deformity at puberty
Treatment:
-Four 6's (Curves < 60)
1. 6 weeks - Risser
2. 6 months - Milwaukee Brace
3. 6 weeks - Wean (8 hours out per day)
4. 6 months - Nighttime brace
-Surgery
1. Kyphosis >70 deg
2. Wedging >10 deg
3. Pain
4. Neurologic findings
5. Progressive deformity
14
Juvenile Roundback
Flexible, treatment is postural exercises
Congenital Kyphosis
Types: I. Failure of formation
II. Failure of segmentation
III. Mixed
Treatment: Early PSF (<3 yo if rapidly progressive)
Halo-femoral traction contraindicated => high risk of paralysis
Spondylolysis/Spondolisthesis
Population: gymnasts, football players, weight-lifters, divers, eskimo’s (Never in non-ambulators)
Sx: Low back/buttock/thigh pain, Tight hams, Waddling gait, Neuro findings
Etiology: Hammer (Inf. facet of L4), Anvil (Sup. sacral facet) creates fx/defect in pars interarticularis (usually L5)
Classification (Wiltse-Newman-Macnab 1976)
Classification of degree of slip (Meyerding):
I. Dysplastic (Congenital, 94% Spina bifida occulta)
Grade I: 0-25%
II. Isthmic (elongated pars)
Grade II: 25-50%
III. Traumatic
Grade III: 50-75%
IV. Degenerative
Grade IV: 75-100%
V. Pathologic
Grade V: >100% => spondyloptosis
Anatomy (Scotty Dog):
x-ray = Napolean’s hat sign
Face: Transverse process
Body: lamina
Eye: Pedicle
Front leg: Inferior facet
Ear: Superior facet
Hind leg: Transverse process
Neck: Pars interarticularis
Tail: Spinous process
Nerve root involvement: Isthmic type – L5, Dysplastic type – S1
Diastematomyelia
Epidemiology: F:M 4:1, lesion of spinal column which protrudes from posterior midline dividing cord (usually L1L3)
Suspicion:
1. Congenital scoliosis
2. Neuromuscular Def (Neuro. bladder, Gait abnorm., Uni. Clubfoot / Cavus / Flatfoot)
3. Cutaneous abnormality – hairy patch
4. X-Ray: Widened inter-pedicular distance
Midline spike
Narrow disk space
Myelomeningocele
Level: Lowest root level of active muscle
Increased incidence of latex allergy and UTI
Ambulatory status (Hoffer): Community
Household
Non-functional (In gym/PT only)
Non-walker
Factors affecting ambulation
1. Extent of paralysis
5. Hydrocephalus
2. Spinal deformity
6. Intelligence
3. Hip instability
7. Home environment
4. Obesity
Foot:
Hip:
Valgus deformity often truly ankle valgus (get AP of ankle if fib physis above mortise = ankle valgus)
Must have strong quads (lesion L3 or lower) before surgically address hip dislocation
Surgery: External oblique transfer to greater trochanter => improves sitting balance, trunk stability
Mustard: Iliopsoas transfer through anterior ilium notch to greater troch
15
(Increased abductor power)
Sharrard: Iliopsoas transfer through post-medial ilium to greater troch
(Increased abductor & extensor power)
Lower extremity management
< 2 yo: Stretching
No surgery until able to sit independently
>2 yo: Put in standing braces when able to sit independently
Spine: 80% have scoliosis
consider ant/post
fuse to sacrum
Galveston: rods between inner/outer tables
Warner: through S1 foramen
Dunn/McCarthy: place bars over sacrum anteriorly
Sacral Agenesis
Mother always has insulin dependent diabetes mellitus
Types: Renshaw classification (Type 2 most common)
1. Partial or total unilateral absence of sacral elements
2. Complete loss of lower sacral/coccygeal elements, stable articulation between ilia
3. L5/S1 non-union, no sacrum, ilia articulate with the sides of the lowest vertebra present
4. No L5/S1 junction, no sacrum, caudal end plate of the lowest vertebra fused to ilia or an iliac
amphiarthrosis
Muscular Dystrophy
Duchennes
Features:
1.
2.
3.
4.
5.
6.
Age 2-7, stop walking avg. 8-10yo
Sex-linked recessive
Clumsy gait (Gowers sign - use hands to stand up from floor)
Pseudohypertrophy of calves – 80% of patients
Weak proximal muscle masses (Shoulder and Pelvic girdle muscles affected first)
Hip flexion, Iliotibial band/Tensor fascia, knee flexion, foot plantar flexion contractures
[Hip and knee extension lag test: >90 deg contracture then release]
7. Lumbar lordosis (Protuberant abdomen)
8. Posterior tib. tendon tends to retain power over long period of time
Histology: (Do not biopsy at previous EMG site)
1. Muscle fibers vary in size
2. Central nuclei
3. Signet ring (infiltration of fat), Chicken-wire fence [End stage disease]
Functional Assessment Scale (10 parts, based on walking, stair climbing...)
Scoliosis
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Types: 1. J-type: Most common, Windswept hips
2. Z-type: Pelvis OK, Translation at L-S junction
Treatment: Surgery if curve >30 deg in sitter (May cease walking)
Becker's
5.
Tend to live longer
Sx: Chest protuberance, Scapular winging, Calf hypertrophy
Spinal Muscular Atrophy (Auto Recessive)
Anterior horn cell degeneration
Classification:
I. Infantile (<12 mos), Oppenheimers Dz, Floppy Baby, no sit or walk, die ~4 yo
II. Intermediate (3-18 mos), Werding-Hoffmans, sit OK, no walk, live >4 yo
III. Juvenile (>2 yo), “Kugleburg-Weidlander”, can sit w/ support, may walk, live to adult
Fascioscapulohumeral Dystrophy (Landouze-Dejerine MD)
Autosomal Dominant
Findings:
1. Upper extremity weakness
2. Scapular winging
3. Increased trapezius mass
4. Popeye forearms
5. Can't blow up balloon, puff cheeks, purse lips, or whistle
deltoids usually spared
Dwarfism
Achondroplastic Dwarfism
Characteristics:
1. Short stature
2. Paddle-shaped ribs
3. Alphabet block vertebrae
4. Narrowed inter-pedicular space
5. Lumbar kyphosis
6. Horizontal sacrum
7. Genu varum
8. Coxa valga
9. Trident hands
10. Frontal bossing
11. Saddle shaped nose
12. Short mid-face
Pseudo-achondroplasia
Characteristics:
1. Short limb
5. Odontoid hyperplasia
2. Normal head
6. Epiphysis and Metaphysis affected
3. Flame vertebra (platyspondyly) 7. Joint hyperlaxity
4. Normal interpedicular distance
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Ellis van Crevald
Characteristics:
1. Short stature
2. Poor dentition
3. 6 digit hands
4. Immunodeficiencies
Diastrophic Dwarfism
Characteristics
1. Short limbs
2. Scoliosis
3. Hitchiker thumb – short 1st metacarpal
4. Cauliflower ears
5. Equinovarus
6. Flexion contractures
7. Usually distal femoral epiphysis not ossified at birth
Metabolic Disorders
Osteopetrosis (Marble-bone Disease, Marie-Alber-Schoenberg Dz)
Osteoclast disorder, don’t respond to PTH tx.
X-ray: Erlenmeyer flask, Rugger jersey spine
Associations: Anemia, Immunodeficiency => BMT to cure
Rickets
Types:
1. Vitamin D Deficient (Dietary rickets)
-Rare
-Age 6 mos - 3 yrs
-Low Vit D > Decr Ca, PO4 absorption > Incr PTH (Low-nl Ca, Low PO4)
-Associations: Prematurity, Hyperalimentation, Anti-convulsants (Compete
with Vit D uptake)
-Sx: Weakness, Lethargy, Bowlegs, Protuberant abdomen, Cranio tabes (large
forehead), Rachitic rosary (large osteochondral rib articulation)
-Tx: Vit D, Calcium
2. Vitamin D Resistant (Renal tubular insufficiency, Familial hypophosphatemic rickets)
-X-linked dominant (F:M.....2:1)
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-Impaired renal reabsorption of PO4 (GFR normal) > Low PO4, Nl Ca, incr alkphos
-Impaired response to Vitamin D
-Sx: Bowing, Frontal bossing, Incr lumbar lordosis, Poor teeth, Short
-Tx: Phospate, Vitamin D3 (High dose, Stop before surgery)
3. Renal Insufficiency (Chronic renal failure)
-tx = high dose Vit D, dialysis => kid txp
X-Ray: Widened physis
Metaphyseal flaring (Trumpeting)
Physeal cupping, Serrated metaphyseal edge
Loosers lines (Fracture on compression side of bone)
Milkmans fracture (Pseudofracture)
Osteogenesis Imperfecta
Defect in collagen synthesis – Type 1 collagen-(alpha 2)
Classification (Sillence):
I.
AD, Blue sclera, hearing loss, most common, most mild (Familial)
IA.
Dentinogenesis absent
IB.
Dentinogenesis present
II.
AR or AD, Blue sclera (perinatal fatality)
III. AR, Normal sclera, fractures at birth, progressive and deforming (Auto Recessive)
IV. AD, Normal sclera, bowing of long bones, improves at puberty, normal hearing (Sporadic)
IVA: nl teeth
IVB: Dentinogenesis imperfecta
Surgery: Sofield-Miller (Shish-kebob)
Correct scoliosis if curve > 45, use PMMA to augment and segmental fusion techniques
Increased risk for malignant hyperthermia
Ehlers-Danlos Syndrome
Defect in collagen metabolism
Sx: Skin hyperextensibility (Cigarette paper skin), Joint hypermobility, Bruisability, Soft tissue
calcification, Bone fragility, Bursa formation, Osteopenia
Many types
Mucopolysaccharidosis
Features:
1. Proportionate short stature
2. Anterior beaking of vertebrae (platyspondyly)
3. Bullet-shaped metacarpals
4. Wide pelvis
Types: 1. Hunter 2. Hurler 3. Morquio 4. San-Filippo
5. Scheie 6. Maroteaux-Lamy 7. Sly
Hypothyroidism
Congenital (Cretinism)
F>M
Dwarfism, Mental retardation, Osteopatia cretinoidia (~Perthes)
Acquired
SCFE
Scurvy
Age 6-12 mos
Sx: Decr appetite, Slow wt gain, Bleeding gums, Subperiosteal hemorrhage
X-Ray: Wimbergers ring (density around cartilaginous ossific nucleus)
[Subperiosteal hemorrhage Differential: Scurvy, Menkes Kinky Hair Syndrome, Abuse, Neglect]
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Wormian bones
C leidocranial dysostosis – retarded ossification of membranous as well as cartilaginous precursors of
bone. Congenital absence of clavicles combined with softness of the calvarium.
H ypothyroidism
O steogenesis Imperfecta
M einkes Kinky Hair Syndrome
P yknodysostosis – form of osteopetrosis showing short stature, separated cranial sutures, delayed closure
of fontanelles and hypoplasia of the terminal phalanges.
Helmet Heads
O.I.
Frontometaphyseal Dysplasia
Dentoagenesis
Neurofibromatosis: Tumors of neural crest/mesodermal origin
Types: 1. NF-1 (von Recklinghausen, Peripheral NF) => chromosome 17- (long arm)
2. NF-2 (Central NF, Acoustic neuroma) => chromosome 22
Diagnosis for NF1: (2 out of 7)
1. Cafe-au-lait spots: Five >5mm (child), Six > 1.5cm (adult)
2. Neurofibroma (2) or Plexiform (1)
3. Freckles (axillary, groin)-Crowe Sign
4. Osseous lesions- sphenoid dysplasia or thinning of cortex of a long bone (+/- pseudarthrosis)
5. Optic glioma
6. Lisch nodules
7. Primary relative with NF
Findings: 1. Spinal deformity (Scoliosis, Kyphosis, or both)
23.6% of patients (Most common bone abnormality) Short segmented, Sharply angulated
2. Tibial pseudarthrosis (congenital tibial dysplasia): Antero-lateral bow-5.7%
Types I: Dense cortex, Canal OK [Observe]
IIA: Failure of tubulation [Brace]
IIB: Cystic lesion or pre-fracture [Bone graft]
IIC: Frank Fracture- “sucked candy” appearance of bone[Bone graft +/- Amputate]
Other Classifications of congenital pseudarthrosis of the tibia: Incidence 1/190,000 M>F
Boyd
Anderson
20
I.
Fx present at birth
II.
Hourglass constriction
Dysplastic
III.
Bone cysts
Cystic
IV.
Sclerotic segment
Sclerotic
V.
Dysplastic fibula
Fibular
VI.
Intra-osseous NF
Clubfoot or congenital band type
3. Hemihypertrophy - 1.4%(Subperiosteal bone proliferation)
4. Bone erosions: Secondary to pressure from neurofibroma (Dumbell lesion in vertebrae)
5. Neoplasias (Leukemia, Wilms tumor, Rhabdomyosarcoma (UG tract))
6. Pectus deformity – 4.3%
7. Plexiform neurofibroma 25%
8. LLD – 7.1%
Diagnosis for NF2: (need 1)
1. Bilateral CN VIII neuromas
2. 1 relative with NF2
Gait
Determinants of Gait:
1. Pelvic rotation
2. Pelvic tilt
3. Knee flexion after heel strike in stance
4. Foot and ankle motion
5. Knee motion
6. Lateral Displacement of Pelvis
Limb Lengthening
Indication: 8-12 yo, Discrepancy > 4cm
Wagner: open corticotomy, distract, plate, bring back later and bone graft
Ilizarov: perc corticotomy (don’t violate medullary canal), ring fixator, wait 5-7 days, distract 1mm/day
De Bastiani; same as Ilizarov, except use unilateral ex-fix (OrthoFix)
Tumor
Epidemiology:
Benign - 3 most common -> UBC, Osteochondroma, NOF
Malignant - 3 most common -> Osteosarcoma > Ewings > Rhabdomyosarcoma
Work-up: H&P, X-Ray, Bone scan, CT, MRI, Angiogram, Lung CT
Enneking Staging
5 yr Survival
IA
Low grade
Intra-comp
No mets
97%
IB
Low grade
Extra-comp
No mets
89%
IIA
High grade
Intra-comp
No mets
73%
IIB
High grade
Extra-comp
No mets
45%
III
Mets
8%
Osteochondroma: Most common tumor--failure of differentiation/tubulation at prox metaphysis
Multiple hereditary exostosis (Ehrenfried’s Dz)
Autosomal dominant
Short stature
X-ray: trabeculae flow into lesion, lesions point away from physis
Tx: Excise if - Limit ROM, Pain, Neurovascular compromise
Malignant degeneration: 5-15%
Enchondroma
Unilateral, Monomelic
Olliers Dz (Multiple enchondroma)--Maffucis Syndrome (Ollier's+Hemangioma->risk of malignancy)
Unicameral Bone Cyst--usually in proximal humerus (fallen leaf sign)
21
Type: Active (w/in 1 cm of physis), Latent (>1cm from physis)
Tx: Aspiration, Steroid injection (Scaglietti), possible Nancy nail
Aneurysmal Bone Cyst
Multiple loculations with septa
X-Ray: Cyst is wider than metaphysis
Histo: vascular lakes, with giant cell laden epithelized septa
Osteoid Osteoma--common in prox fem metaphysis (calcar), and posterior elements of the spine
Pea in a pod” sclerotic nidus <1cm
Symptoms: night pain relieved by ASA, exacerbated by EtOH
Histiocytosis (EG)
EG of spine - Vertebrae plana (platyspondyly) aka Calves vertebrae
Hans-Schuller-Christian Dz: Histiocytosis, Skin & Bone...., Pituitary (DI, Exophthalmos)
Letterer-Siwe Dz: HSC Dz w/ MR, Cystic manifestations
Fibrous Dysplasia
Failure of complete remodeling of immature bone, Shepherd’s Crook in prox femur
Cafe-au-lait spots: Coast of Maine [Neurofibromatosis: Coast of California]
Albrights Syndrome: 1. Fibrous dysplasia (“Shepherds crook” deformity if in hip) + 2. Endocrinopathies
(precocious puberty) + 3. Cafe-au-lait spots
Ewings
Age 10-30 yo
Sx: Pain, Mass, Tenderness, Systemic sx (fever)
Location: Diaphyseal, Femur #1, in pts >20yo, flat bones more common
X-Ray: Onion skinning due to periosteum trying to wall off soft tissue expansion
Histo: + PAS, monotonous sheets of round cells
Osteosarcoma
Sx: Swelling, Tenderness, Decr ROM, Warmth, Pathologic fx
Differential Dx: Infection, Ewings, Metabolic disease, Traumatic, Congenital lesion
Chemo: MAP: methotrexate, adriamycin, platinum) OR
COMPAdra: cytoxin, O(vincristine), methotrexate, prednisone, adriamycin
COMMON IN THE SPINE--ant elements: EG, Hemangioma
post elements:Osteoid Osteoma, Osteoblastoma, ABC
Growth Plate
Zones:
Resting
- Lipid/glycogen/proteoglycan production, Low oxygen tension
- Lysosomal storage diseases
Proliferative
-Align longitudinally, Chondrocytes multiply, Linear growth
-Achondroplasia
Hypertrophic
-Cells increase 5x, Matrix preparation, Calcification
-Rickets, Enchondromas, Mucopolysaccharidosis, Fractures
Maturation
Degeneration
Provisional Calcification
Most common fractures:
SH I Distal fibula
SH II Distal radius
SH III Distal tibia
SH IV Distal femur
Growth:
Lower Extremity:
Proximal femur 10
Distal femur
40
Proximal tibia
30
Distal tibia
20
Individual Bones:
Prox. Humerus
22
80%
Prox. Femur
30%
Dist. Humerus
Prox. Radius
Dist. Radius
Prox. Ulna
Dist. Ulna
20
25
75
20
75
Ossification sequences:
Ankle: Middle (at Poland’s hump), Medial, Lateral
Elbow:
Appearance:
Come Rub My Tool Of Love
Capitellum
6 months
Radial head
2 yrs
Medial epicondyle
4
Trochlea
6
Olecranon
8
Lateral epicondyle
10
Dist. Femur
Prox. Tibia
Dist. Tibia
Prox. Fibula
Dist. Fibula
70
57
43
60
40
Closure:
TLC OR ME
Trochlea
Lateral epicondyle
Capitellum
13 yrs
Olecranon
Radial head
15 yrs
Medial Epicondyle
17 yrs
Epiphyseal Centers present at birth: Full Term Children Have These Centers
1. Distal femur
2. Proximal tibia
3. Calcaneous
4. Proximal humerus
5. Talus
6. Cuboid
Hemoglobinopathies (Sickle Cell Disease)
Sx: Small size (due to persistent anemia, or decr O2 at growth plate)
Osseous manifestations:
1. Marrow hyperplasia
2. Infarction
3. Growth disturbances
4. Osteomyelitis
5. Pathologic fracture
X-Ray: Vertebrae - Most common involved bone, Cup-like biconcavity in central endplate -Step-deformity
Skull - Thick cortex, Widened diploe, Porcupine quill, Hair-on-end
Joints - Bone crisis, Bone infarcts
Hip: AVN, Osteochondritis, Coxa vara
Differential Dx: Perthes (SS = Older [age > 10yo], Black)
Chung/Ralston classification
Group 1: Total head involvement ~ Perthes
Group 2: Localized involvement ~ OCD
Group 3: Late changes
Hand-Foot Syndrome
Age < 2yo
Sx: Painful soft tissue swelling of hands/feet
X-Ray: Periosteal new bone, Lytic lesions
Osteomyelitis
Sx: ~ Bone crisis
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Organism: Salmonella
Juvenile Rheumatoid Arthritis (Stills Disease)
Sx: Fever, Rash, Anemia, Splenomegaly, Multiple joint involvement
Age: < 6yo, 10-15 yo
Dx: Synovitis of joint (Knee, ankle, elbow, wrist) > 6 weeks
Types: Monoarticular, Pauciarticular (2-4 joints), Polyarticular (>4 joints)
Septic Arthritis
Epidemiology:
Age 1-3yo
Organisms: Staph A., Streptococcus, Pneumococcus, H. flu (#1 <6 mo)
Diagnosis: Joint fluid (Incr WBC [>35,000], Inc protein, Dec glucose[40 < blood Glc])
Diff Dx (Septic hip):
1. Osteomyelitis
4. Iliopsoas abscess
7. Perthes
2. Toxic synovitis
5. JRA
3. Diskitis
6. Rheumatic fever
Sequelae (Septic hip):
1. Dislocation of hip
4. Coxa magna
2. Osteomyelitis of fem neck
5. Coxa vara
3. AVN
6. Leg length discrepancy
Poor Prognosis:
1. Delay in diagnosis (>5 days)
2. Hip joint
3. Associated osteomyelitis
4. Younger age (diagnosis difficult in infants)
Osteomyelitis
Seasonal (Spring, Fall)
Etiology: 1. Hematogenous
2. Direct extension
3. External
24
Organisms: Staph A., H. Flu (infants), Salmonella (Sickle cell)
Location: Femur > Tibia > Humerus
Metaphysis (Sludging of blood flow in sinusoidal vessels)
Differential Diagnosis:
1. Septic arthritis
5. Blood dyscrasias
2. Cellulitis
6. Tumor
3. Syphilis
7. Hypervitaminosis A
4. Sickle cell crisis
8. Caffes Dz (Infantile cortical hyperostosis)
X-Ray: 7-10 days: Soft tissue swelling
> 10 days: Lucency or Opacity
Sequestrum (localized area of dead bone) & Involucrum (periosteal new bone formation)
Complications:
1. Bone overgrowth
2. Growth Arrest
3. Pathologic Fracture
4. Amyloidosis
5. Epidermoid Carcinoma
Treatment: 3 weeks IV ABX, then PO ABX until ESR returns to normal; Immobilization
-Sickle cell pts: Serial aspirations (No I&D due to risk of Staph wound infxn)
Diskitis
Sx: Refusal to walk (<3 yo), Abdominal pain (3-9 yo), Back pain (>9 yo)
X-Ray: Crosses disk space
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Last revised 7/02
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