Untitled Quiz

Orthopedics (Bone & Joint)

• Bones are categorized into flat, irregular, long, short, and sesamoid bones.
• Common bone structures include the sternum, femur, patella, vertebra, cuneiform bones.
• Normal hip and knee flexion contractures in newborns are 20-30 degrees.
• These contractures resolve by 4-6 months.
• Hip externally rotates up to 80-90 degrees in extension
• Internal Rotation is approximately 0-10 degrees in newborns

Terminologies for Deviations

• Congenital: An anomaly present at birth.
• Deformation: A normally formed structure pushed out of shape by mechanical forces.
• Deformity: A body part altered in shape from normal, outside the normal range.
• Developmental: A deviation that occurs over time.
• Disruption: A structure undergoing normal development that stops developing or is destroyed or removed.
• Dysplasia: A tissue that is abnormal or wrongly constructed.
• Malformation: A structure wrongly built; failure of embryonic origin.

Bone Formation (Ossification)

• Endochondral: Mesenchymal cells undergo chondrogenesis to form cartilage, which matures into bone (axial and appendicular skeleton).
• Intramembranous: Osteoblasts develop directly from mesenchymal cells into bone (skull and clavicle bones).

Centers of Ossification

• Primary: Forms during fetal development, chondrocytes in the midshaft of long bones; bone lengthens.
• Secondary: Occurs after birth in the chondroepiphysis; directs bone formation and joint development. Examples: distal femur, proximal tibia, calcaneus, talus.

Bone Development Stages

• Osteogenic cells → Hyaline cartilage model → Developing periosteum → Spongy bone → Compact bone → Medullary cavity → Epiphyseal plate.

Anatomical Locations

• Physis: Growth plate at the end of the bone.
• Epiphysis: Secondary ossification, joint development.
• Metaphysis: Bone adjacent to the physis on the opposite side of the joint from the epiphysis.
• Diaphysis: Central part or shaft of long bones.
• Perichondrial ring: Contributes to appositional growth, surrounds the physes, perichondrium around the epiphyses and periosteum, which surrounds the metaphysis and diaphyseal regions of the bone.
• Articular cartilage: Contributes to the growth of the epiphysis.

Growth Patterns in Upper/Lower Extremities

• Upper extremity: Longitudinal growth primarily from the physes of the proximal humeral physis, distal radial, and ulnar physes.
• Lower extremity: Longitudinal growth occurs around the knee, in the distal femoral and proximal tibial physes

Skeletal Growth Considerations

• Arm span is almost equal to standing height.
• Head is large at birth (1:4 ratio), becoming 1:7.5 at skeletal maturity.
• Lower extremities are 15% of height at birth and 30% at skeletal maturity.
• At 5 years old, birth height doubles, with the child being 60% of adult height.
• By 9 years old, children are 80% of their final height.
• Standing height increases by 1 cm per month during puberty.
• Bone age is more important than chronological age for determining future growth potential.

Orthopedic Evaluation

• History
• Physical examination (inspection, palpation, range of motion, gait assessment)
• Symptoms (location, intensity, quality, onset, duration, progress, radiation, aggravating factors, alleviating factors, gait and posture)

Radiographic Assessment

• Plain radiographs are the initial step for most musculoskeletal disorders.
• Uses anteroposterior and lateral views of affected areas, with one joint above and below included.
• Ultrasound evaluation of suspected fluid-filled lesions (popliteal cysts, hip joint effusions) or fetal studies.

Additional Imaging Modalities

• MRI, for defining the exact anatomic extent of most musculoskeletal lesions.
• Helpful in visualizing unossified joints in children.
• CT, for evaluating multiple musculoskeletal disorders, assessing bone involvement, cortical destruction, calcifications, or ossification, and fracture (articular fractures).
• Nuclear medicine imaging, using bone scans for septic arthritis, osteomyelitis, avascular necrosis, tumors, metastatic lesions, occult stress fractures, and child abuse cases.

Laboratory Studies

• Complete blood count (CBC)
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Cultures (blood, wound, joint, periosteum, bone)
• Rheumatoid factor

The Foot & Toes

• Forefoot (Phalanges & metatarsals)
• Midfoot (Cuneiform, cuboid, and navicular bones)
• Hindfoot (Talus & calcaneus)

Metatarsus Adductus

• Forefoot adducted relative to hindfoot.
• Forefoot is supinated and adducted.
• Common in newborns (frequently intrauterine molding).
• 50% of cases are bilateral.
• Careful hip and neck examination recommended.

Radiographic Evaluation (Metatarsus Adductus)

• Infants - not routinely performed
• Older children - AP and lateral radiographs, evaluating adduction of metatarsals at the tarsometatarsal joint, and increased intermetatarsal angles.

Talipes Equinovarus (Clubfoot)

• Malalignment of the calcaneotalar-navicular complex.
• Positional or postural, usually flexible, as opposed to congenital, often associated with underlying diagnoses or focal dysplasia.
• Treatment - Nonoperative or surgical (ponsetti method)

Hypermobile Pes Planus (Flatfeet)

• Common diagnosis (23% of the public).
• 3 types:
  1. Flexible flatfeet
  2. Flexible flatfoot with tendo-Achilles contracture
  3. Rigid foot
• Normal: Longitudinal arch disappears when standing and bearing weight, but the arch is present when weight bearing isn't present.
• Clinical Manifestations:
  1. Hindfoot collapses (valgus)
  2. Midfoot sag (evident)
  3. Generalized hypermobility and ligamentous laxity (observed)

Radiographic Evaluation (Flatfeet/Hypermobile Pes Planus)

• Not indicated for asymptomatic cases.
• Weight bearing AP and lateral radiographs to assess deformity.
• AP radiograph – widening of the angle between the longitudinal axis of talus and calcaneus; excessive heel valgus.
• Lateral view – distortion of the normal straight-line relationship between the long axis of the talus and the first metatarsal.

Treatment (Hypermobile Pes Planus)

• Non-prescription orthosis medical arch support
• Stretching exercises
• Physical therapy
• Flexible flatfoot with tight tendo-Achilles

Cavus Feet

• Deformity involving plantar flexion of the forefoot or midfoot on the hindfoot.
• May involve entire forefoot/medial column elevation.
• Commonly associated with hindfoot deformity.
• Treatment: Mild: Stretching through physical therapy or serial casting of the plantar fascia and contracted muscles.

Puncture Wounds (Foot)

• ER management.
  • Irrigation
  • Tetanus booster
  • Antibiotics
• Complications: Cellulitis.
  • Surgical drainage if necessary.
• Common organism: S. aureus, P. aeruginosa

Juvenile Hallux Valgus

• Prominence of the first metatarsophalangeal joint (MTP)
• Erythema and callus (chronic irritation)
• Great toe (pronated)
• Splaying of the forefoot
• Pes planus
• Pain on the region of the 1st Metatarsophalangeal joint (MTP) difficulty with shoe wear.

Bunion Severity Guide

• Mild, Moderate, Large, Severe

Radiographic Evaluation (Juvenile Hallux Valgus)

• Weight bearing AP and lateral radiographs.
• Analysis of angular relationships (1st and 2nd metatarsals, intermetatarsal angle, 1st metatarsal, proximal phalanx, and hallux valgus angle).
• Lateral view - analysis of the relationship between the talus and 1st metatarsal.

Treatment (Juvenile Hallux Valgus)

• Shoe modification (accommodating forefoot width, avoiding narrow toe boxes and high heels, soft uppers).
• Orthotics to restore medial longitudinal arch if pes planus present.
• Stretching exercises with tendo-Achilles contracture.
• Surgical treatment (for persistent pain).

Normal Limb Development

• 7th week of intrauterine life: lower limbs rotate medially.
• 11th week: hip joints form, proximal femur and acetabulum continue to develop.
• Femoral Neck: First component to rotate to 40° anteriorly at birth; anteversion decreases to 15-20 degrees by ages 8-10 years.
• Tibia: Second component to rotate, infants may have 30° medial rotation of the tibia; medial tibial torsion-excessive medial rotation.

Knee Deformities (genu varum/genu valgum)

• Genu varum (bowlegs): Physiological bowleg, common torsional combination secondary to normal in utero positioning. Spontaneous resolution is anticipated.
• Genu valgum (knock knees): Symmetric bilateral genu valgum, part of normal physiologic leg development in 4-6 yr olds. Most cases resolve spontaneously.

Tibia Vara (Blount Disease)

• Developmental deformity of the medial aspect of the proximal tibial physis leading to varus angulation/medial rotation of the tibia
• 3 types: Infantile (1-3yrs), Juvenile (4-10yrs), Adolescent (11yrs +)
• Management: Stage of disease-dependent, age of the child, and presentation (deformity)

The Knee

• Synovial joint at 3rd - 4th fetal month, the largest joint.
• Modified hinge
• Secondary ossification (6th-9th fetal month - distal femur; 8th month - 1st postnatal month - proximal tibia)
• Patellar ossification does not appear until 2nd - 4th years in girls and 3rd-5th in boys.

Discoid Lateral Meniscus

• Congenital anatomical variation of the lateral meniscus.
• May be asymptomatic or cause snapping knee syndrome (occurs in 3-5% of children and adolescents).
• Up to 25% of cases are bilateral.
• 3 types (Watanabe classification): Complete, incomplete, and Wrisberg variant.
• Treatment: Asymptomatic: does not need treatment; symptomatic meniscal tears: surgical intervention (partial meniscectomy)

Popliteal Cysts (Baker Cysts)

• Simple cystic masses filled with gelatinous material that develop in the popliteal fossa.
• Rare in children.
• Treatment: Rest and leg elevation to promote drainage of the accumulating fluid.

Osgood-Schlatter Disease

• Irritation of the patellar tendon at its insertion into the tibial tubercle, a traction apophysitis of the tibial tubercle growth plate.
• Common in actively growing children (10-15 years old).
• Self-limited and resolves with rest.

Sinding-Larsen-Johansson Syndrome

• Insertional periostitis at the inferior pole of the patella.
• Anterior knee pain.
• More common in younger, physically active children.
• Treatment: Pain-free level 1-2 weeks of sports activities.

The Hip

• Ball and socket articulation between the femoral head and acetabulum, a pivotal joint.
• Develops in the 7th week of gestation with cartilaginous components.
• The hip joint has three osseous components: ilium, ischium, and pubis.

Developmental Dysplasia of the Hip (DDH)

• Congenital dislocation of the hip.
• Spectrum of pathology in the immature hip joint.
• 3 classifications: Acetabular dysplasia (abnormal morphology/development of the acetabulum), Hip subluxation (only partial contact between the femoral head and acetabulum), and Hip dislocation (no contact between the articulating surfaces).
• Etiology: Unknown (likely a combination of factors). Common pathway- laxity of the joint, family history, and 80% of cases are female.

Swaddling Techniques

• Tightly swaddled hips may lead to hip dysplasia and dislocation.
• Loosely swaddled hips allow for movement and prevent hip issues.

Clinical Findings (DDH—Neonate)

• Asymptomatic.
• Barlow and Ortolani tests.
• Hip click—high-pitched sensation felt during abduction.

Maneuvers of DDH (Barlow and Ortolani)

• Barlow maneuver: Examiner adducts the hip while applying a posterior force to the knee to promote dislocation.
• Ortolani maneuver: Examiner abducts the hip while applying an anterior force to the femur to reduce the hip joint.

Clinical Findings (DDH—Infant)

• Limited hip abduction.
• Apparent shortening of the thigh.
• Proximal location of the greater trochanter.
• Signs of Asymmetry in the gluteal or thigh folds.
• Limitation in abduction is the most reliable sign of a dislocated hip in this age group.

Clinical Findings (DDH—Walking Child)

• Limping, waggling gait.
• Affected side is shorter than normal.
• Child toe walks on the affected side.
• Trendelenburg sign: Positive in children. An abductor lurch is observed when the child walks.

Diagnostic Testing (DDH)

• Ultrasound- diagnostic modality before femoral head ossification. Recommended age ≥ 1 month old.
• Radiography - recommended once the proximal femoral head ossifies (recommended age 4-6 months).
• Hilgenreiner's line - horizontal line drawn through the top of both triradiate cartilages.
• Perkin's Line - vertical line through the most lateral ossified margin of the acetabulum drawn perpendicular.

Treatment (DDH)

• Maintain concentric reduction of the femoral head within the acetabulum to promote optimal development of both the femoral head and acetabulum.
• Newborns: Pavlik harness (<4 weeks of age). Normalizes in 3-4 weeks; re-examination of the newborn.
• Children (6 months-2 years old): Closed reduction under general anesthesia.
• Most important complication: Avascular necrosis of the femoral epiphysis.

The Spine

• Comprised of the cervical, thoracic, lumbar, sacrum, and coccyx segments.
• Curves: Anteroposterior (coronal) – straight; lateral (sagittal) – curvatures.

Scoliosis & Kyphosis

• Scoliosis: Idiopathic – due to congenital deformities or associated with a variety of conditions. -Concern- Cosmetic abnormalities.
• Kyphosis: Excessive outward curvature of the spine

Idiopathic Scoliosis

• Greek word "skolios" (bent or curved)
• 3D spinal deformity
• Defined in the coronal plane as a curve of at least 10° on PA radiograph of the spine
• Adams forward bend test – visible prominence.
• Etiology: Multifactorial (Females (2–10x)>Males, 32% in COL11A2collagen gene)

Types of Scoliosis

• Healthy, Thoracic, Lumbar, Thoraco-lumbar, Combined

Idiopathic Scoliosis (Treatment)

• 80% idiopathic
• Skeletal immaturity : ≤ 10 degrees equally between males and females, those requiring intervention occur in 7:1 ratio of female to male, 20-90% resolve spontaneously.
• Management: Brace treatment

Back Pain

• Frequent complaint among pediatric patients
• 7%-58% of adolescents
• Risk Factors: Increasing growth, Female gender, Family history, Excessive sport participation, Manual labor, and Heavy backpack

Back Pain - Clinical Evaluation

• History & PE
  • Trauma
  • Repetitive activities
  • Spondylolysis
  • Neoplastic vs Infectious
  • Associated symptoms
• Work-up
  • Radiograph and laboratory evaluation.
• Pain that is persistent. Associated symptoms include fever, chills, night sweats, weight loss, malaise.

Spine Infection (Spondylitis)

• Inflammation of the vertebrae (most commonly due to infectious or immune processes).

• Etiology: Hematogenous spread of bacteria.

• Common cause: Staphylococcus aureus.

• Clinical Manifestations: Back pain, abdominal pain, fever, malaise, and neurologic symptoms.

• Radiographic evaluation: Loss of lumbar lordosis is an early finding.

• Features: Disc space narrowing, loss of disc height, and irregularity of the adjacent vertebral end plates.

• Diagnosis: Technetium bone scan or MRI - most sensitive and specific for diagnosis of osteomyelitis and identification of abscesses/neural compression.

Spine Infection (Imaging Features)

• Disk narrowing
• Indistinct endplates
• Lytic changes in bone
• Altered signal intensity (bone +/- disk)
• Soft tissue thickening around disk
• Enhancement

Spine Infection (Treatment)

• 1st generation cephalosporins
• Semisynthetic antistaphylococcal penicillin
• Clindamycin (MRSA - more common)
• Obtain blood cultures when necessary

The Neck (Torticollis)

• Twisted neck, not a diagnosis but a clinical manifestation of a variety of underlying conditions.
• "Wry neck" or "cock-robin" deformity
• Congenital Muscular Torticollis
  • Most common diagnosis in infancy;
  • Contracture of the sternocleidomastoid muscle; tilts the head and neck ipsilaterally, rotating the head contralaterally.
• Etiopathogenesis: Hypotheses of intrauterine deformation or compression problem in the first pregnancy, often associated with a palpable mass of fibrous tissue with the SCM in 50% of cases.

Associated Findings (Congenital Muscular Torticollis)

• Plagiocephaly
• Facial asymmetry
• Positional musculoskeletal deformities (e.g., metatarsus adductus, calcaneovalgus feet)

Management (Torticollis)

• Stretching (90% successful when started within the first 3 months of life)
• Surgical release of sternocleidomastoid muscle for persistent deformity after conservative treatment failure.
• Typically delayed until ≥ 18 months of age; remodeling of facial asymmetry/plagiocephaly.
• Surgery only in cases needing significant intervention.

The Shoulder

• Ball and socket joint; very shallow.
• More prone to dislocation; Shoulder range of motion (ROM) is greater than hip ROM.
• Glenohumeral joint, center of the shoulder.
• Sprengel Deformity (congenital elevation of scapula, high scapula, and limited scapulothoracic motion).
• Scapula originates at 4th cervical vertebra but descends below the 7th cervical vertebra.
• Treatment: surgical repositioning of the scapula with rebalancing of parascapular muscles.

The Elbow (Panner Disease)

• Congruent joint in the body.
• Stability from bony congruity and medial/radial collateral ligaments.
• Panner disease: Disruption of blood flow to the articular cartilage and subchondral bone of the capitellum.
• Age 5-13yr olds are most affected.
• Symptoms: Lateral elbow pain, loss of motion, or mechanical symptoms (loose bodies)
• Treatment: Conservative (rest, activity modification, patient education).

Common Fractures

• Trauma- leading cause of death and disability in children
• Immature skeletons (more fractures)
• Physis (most resistant to traction, least resistant to torsional forces)
• Periosteum - often injured but less likely to have complete rupture.
• Types of bone fractures include: Greenstick, Transverse, Spiral, Comminuted, Compound.

Fracture Remodeling

• Remodeling is the final phase of fracture healing, preceded by inflammatory and reparative phases.
• Skeletal maturity in post-menarcheal girls (13-15) and in boys (15-17).
• Overgrowth – physeal stimulation from hyperemia associated with fracture healing; prominent in lower extremities (femur).
• Femoral fractures in children (<10 yrs): 1–3 cm of overgrowth.
• Stages of fracture remodeling include Hematoma formation, Fibrocartilaginous callus formation, Bony callus formation, and Bone remodeling

Pediatric Fracture Patterns (Plastic Deformation)

• Plastic deformation is unique to children.
• Most common in the forearm and fibula.
• Due to microscopic failure on the tensile side of the bone.
• Radiograph: No fracture lines visible.

Pediatric Fracture Patterns (Buckle or Torus Fracture)

• Failure in compression of the bone (usually at the junction of the metaphysis and diaphysis).
• Most common location: Distal radius.
• Stable fracture with associated angulation.
• Simple immobilization heals in 3-4 weeks.

Pediatric Fracture Patterns (Greenstick Fracture)

• When the bone is bent; failure along the tensile (convex) side of the bone.
• Fracture line does not propagate to the concave side of the bone.
• Evidence of microscopic failure with plastic deformation is on the concave side.

Pediatric Fracture Patterns (Complete Fracture)

• Fractures completely propagating through the bone.
• Classified as:
  1. Spiral
  2. Transverse
  3. Oblique

Pediatric Fracture Patterns (Epiphyseal Fractures)

• Epiphysis (growth plate) fractures - potential for growth disturbance.
• Potential for deformity and long-term observation.
• Distal radius epiphysis - Most common injured physis.

Salter-Harris Classification

• Used to categorize epiphyseal fractures.
• Types (I-V) based on location.
• S (separated), A (above), L (below), T (through), ER (erasure).

Pediatric Fracture Patterns (Clavicular Fractures)

• Neonatal fracture – direct trauma during birth (narrow pelvis, shoulder dystocia).
• Most common fracture site: junction of the middle and lateral thirds of the clavicle.
• Potential for brachial plexus injury and tenderness at the fracture site.
• Radiograph: Overlap of fragments.
• Treatment: Figure-of-8 clavicle strap.

Pediatric Fracture Patterns (Complications)

• Growth arrest in physeal fractures
• Unacceptable alignment and loss of motion or limb malalignment
• Fracture malunion
• Compartment syndrome associated with diaphyseal tibia or high-energy/open fractures (both bone forearm).

Osteogenesis Imperfecta (OI)

• Brittle bone disease: Generalized disorder of the connective tissue.
  • Most common genetic cause of osteoporosis.
• Etiology: Structural or quantitative defects in type I collagen.
  • Autosomal dominant.
  • Collagen, bone structural mutations.
• Bones: Abnormal type I collagen fibrils, increased level types III and IV.
• Types of OI (I to VII) based on clinical severity and features: Typical features may include normal height or mild short stature; blue sclera; no deformities (Type I).

OI (Clinical findings, Complications)

• Clinical Findings: Vary from mild, non-deforming OI, to perinatal lethal forms of OI with significant growth abnormalities, scoliosis, and variable severe skeletal abnormalities. Blue sclerae are typical in most affected individuals.
• Complications: Include cardiopulmonary conditions (Recurrent pneumonia), neurologic complications, bone pain, blue sclerae, hearing loss, weak or brittle or misaligned teeth, difficulty breathing, and curved spine).

Osteomyelitis

• Bone infection in children (common).
• Femur and tibia are the most frequent sites of involvement in acute hematogenous osteomyelitis.
• Etiology: Staphylococcus aureus Bacterial infections often occur in all age groups, including newborns. Group B strep. Group A strep (10% cases). Streptococcus pneumoniae is also involved in children <24 months and those having Sickle Cell disease before vaccinations.

Osteomyelitis (Caused by Bacteria - Staph. Aureus)

• Direct inoculation (open fracture)
• Contiguous infection (foot ulcer overlying bone)
• Hematogenous spread (bacteremia).

Osteomyelitis (Clinical Manifestations)

• Earliest signs: focal tenderness over long bone.
• Important finding: Local swelling/redness in osteomyelitis
• Beyond Metaphysis & into the periosteal space (secondary soft-tissue inflammatory response).
• Principal involvement is in long bones.
• Brodie abscess: Radiographic lucency & surrounding reactive bone. (Focal tenderness over a long bone, pseudoparalysis (pain with movement) of affected extremity).
• Other findings include: no fever (50%) in the presentation or localized findings (edema, erythema, warmth, pain, limp, refusal to walk 50% of patients).

Osteomyelitis (Diagnosis)

• Blood culture - performed in all cases.
• Aspiration/biopsy.
• Gram stain, culture, and PCR if necessary (K. kingae).
• Bone histology
• Complete blood count (CBC), ESR, and CRP (normal 1st few days)
• Radiograph (plain) - at 72 hrs from the onset of symptoms, showing displacement of deep muscle plain, showing widening of joint capsule, soft edema, and obliteration, lytic bone changes (30-50%).

Osteomyelitis (Differential Diagnosis)

• Trauma (accidental or abuse)
• Cellulitis
• Myositis/pyomyositis

Osteomyelitis (Treatment)

• Antimicrobials. Neonates: Nafcillin or Oxacillin (150 – 200 mg/kg/24hr q6h IV) plus Cephalosporins (Cefepime (100-150mg/kg/24 hrs IV)). MRSA resistant: Cefazolin (150mg/kg\24 hr IV) or Nafcillin (150 – 200 mg/kg/24 hr q6 hrs IV). Vancomycin is the gold standard (60 mg/kg/24 hr q6 hrs IV) for treating invasive MRSA infections. Alternative: Clindamycin (40 mg/kg/24 hr divided q6 hrs IV). Most infections resolve within 21 – 28 days (with resolution within 5-7 days, CRP is normal). 4-6 weeks of therapy may be necessary.
• Surgical therapy: Chronic osteomyelitis - surgical removal and sequesturm. Normal ESR and CRP levels.
  • Months of treatment.
  • Physical therapy, failure to improve/worsen in 48-72 hours.
  • Surgical intervention (ESR and CRP monitoring).

Septic Arthritis

• Staphylococcal aureus (most common cause in all ages).
• MRSA (25%), Group A Streptococcus, Streptococcus pneumoniae (10–20%), and Kingella kingae are other pathogens.
  • Neonates: frequent causative agents: Group B hemolytic strept and gram-negative enteric bacilli.
• More common in young children (2-5 years).
• Adolescents and neonates: potentially due to Gonococcal septic arthritis.
• Pathogenesis: Hematogenous spread (most infections).

Septic Arthritis (Clinical Manifestations)-

• Monoarticular (most septic arthritis cases).
• Knee - most common involved joint.
• Clinical manifestations: age dependency; older infants/children-fever, pain, and localizing signs (swelling, erythema, warmth of affected joint; pseudoparalysis (pain with movement)).

Septic Arthritis (Diagnosis)

• Blood cultures
• Joint fluid aspiration
• Gram stain, culture, and PCR if indicated (K. kingae).
• Radiograph, showing widening of joint capsule; soft tissue edema; and obliteration.

Septic Arthritis (Treatment)-

• Same treatment approach as for osteomyelitis as in antibiotics and potential surgical therapy.