Pedia Lecture Orthopedics PDF

ORTHOPEDICS (bone & joint) Dr. Faith Balisan-Domingo MD Growth & Development ▪ NORMAL FULL TERM ▪ 20-30 degree hip and knee flexion contractures ▪ contractures resolves by 4-6months ▪ HIP externally rotates in extension up to 80-90degrees ▪ limit...

ORTHOPEDICS (bone & joint) Dr. Faith Balisan-Domingo MD Growth & Development ▪ NORMAL FULL TERM ▪ 20-30 degree hip and knee flexion contractures ▪ contractures resolves by 4-6months ▪ HIP externally rotates in extension up to 80-90degrees ▪ limited internal rotation approx. 0- 10degrees Terminologies for Deviations CONGENITAL Anomaly that is apparent at birth DEFORMATION A normally formed structure that is 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; one that might not be present or apparent at birth 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 that is wrongly built; failure of embryonic origin BONE FORMATION or OSSIFICATION 2 DIFFERENT WAYS 1. ENDOCHONDRAL OSSIFICATION- mesenchymal cells undergo chondrogenesis to form cartilage that matures to become bone. - Axial and Appendicular skeleton 2. INTRAMEMBRANOUS OSSIFICATION – osteoblasts are formed by direct differentiation of mesenchymal cells into bone. - Flat bones of the skull and clavicle Centers of Ossification PRIMARY CENTER (growth) - Begins during fetal period, chondrocytes in the midshaft of the long bones form. - Bone eventually lengthens SECONDARY CENTER (ossification) - POST natal - Appear in the chondroepiphysis. - Direct the bone formation → growth (joint development). - AT birth: distal femur, proximal tibia, calcaneus, talus ANATOMIC Locations ▪ PHYSIS – growth plate located at the end of the bone. ▪ EPIPYSIS – secondary ossification, JOINT development. ▪ METAPHYSIS – Bone adjacent to the physis on the side away form the joint. ▪ 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 - grows longitudinally primary from the physes of the proximal humeral physis and the distal radial and ulnar physes. LOWER EXTREMITY - most longitudinal growth occurs around the knee, in the distal femoral and proximal tibial physes. SKELETAL GROWTH CONSIDERATIONS Arm span = STANDING HEIGHT (almost) HEAD is large at birth, 1:4 ratio → 1:7.5 at skeletal maturity LOWER EXTREMITIES- 15% of height at birth & 30% at skeletal maturity NOTE: 5 years old- birth height doubles, the child is 60% of adult height. 9 years old- 80% of final height. Puberty – standing height is 1cm/month BONE AGE is more important than chronological age in determining future growth potential ORTHOPEDIC EVALUATION ▪ HISTORY SYMPTOMS ✓ Location ▪ PHYSICAL EXAMINATION ✓ Intensity ▪ Inspection ✓ Quality ▪ Palpation ✓ Onset ✓ Duration ▪ Range of motion ✓ Progress ▪ Gait assessment ✓ Radiation ✓ Aggravating factors ✓ Alleviating factors ✓ Gait and Posture Diagnostic Imaging RADIOGRAPHIC ASSESSMENT 1. PLAIN radiograph: - FIRST step in evaluation of MOST musculoskeletal disorders. - ANTEROPOSTERIOR and LATERAL views of the involved area with one joint above & below. 2. ULTRASONOGRAPHY - Evaluate suspected fluid-filled lesions (popliteal cyst, hip joint effusions) - Fetal studies (extremities and spine, congenital anomalies: spondylocostal dysostosis, fractures – osteogenesis imperfecta, developmental dysplasia of the hip, joint effusions, occult spinal dystraphism, foreign bodes in soft tissues, popliteal cyst) 3. MRI - Imaging modality of choice for defining the exact anatomic extent of most musculoskeletal lesions (soft tissue) - Helpful in visualizing unossified joints in the pediatric population (shoulders, elbows, hips of young infants). 4. CT (Computed Tomography) - Evaluation of multiple musculoskeletal disorders. - BONE anatomy and its contiguous structures. - CT > MRI (for assessing bone involvement and cortical destruction, calcifications or ossification and fracture (articular fracture) 5. Nuclear Medicine Imaging - Bone scan (septic arthritis, osteomyelitis, avascular necrosis, tumors (osteoid osteoma), metastatic lesions, occult and stress fractures and cases of child abuse) LABORATORY STUDIES ▪ Complete blood count ▪ ESR ▪ C-reactive protein ▪ Cultures (blood, wound, joint, periosteum, bone) ▪ Rheumatoid factor THE FOOT & TOES METATARSUS ADDUCTUS ▪ Adduction of the forefoot Clinical Manifestations Forefoot- adducted (supinated) relative to the hindfoot. MIDFOOT and HINDFOOT- normal Lateral border of the foot is CONVEX ▪ Forefoot is supinated and adducted Base of the 5th metatarsal Prominent – metatarsus varus ▪ Newborns ▪ MOST FREQUENTLY (intrauterine molding) ▪ 50% cases, bilateral ▪ Careful hip & neck examination should be performed. METATARSUS ADDUCTUS RADIOGRAPHIC EVALUATION TREATMENT Infants- not performed routinely ✓ Base on the rigidity of the deformity ✓ NONOPERATIVE Older children ✓ Passive manipulation ✓ AP and lateral ✓ Stretching exercise ✓ AP ✓ Shoe reversal (22hr/day) ✓ adduction ✓ SERIAL Casting ✓ metatarsals at the ✓ If feet cannot be corrected tarsometatarsal articulation ✓ increased intermetatarsal angle between the 1st and 2nd metatarsals. TALIPES EQUINOVARUS (clubfoot) ▪ Congenital talipes equinovarus POSITIONAL/POSTURAL CLUBFOOT ▪ Deformity involving the - normal foot malalignment of the - Deformed in utero calcaneotalar-navicular complex. - Flexible in the nursery ▪ Predominantly a HINDFOOT ▪ KINDS: ▪ positional, ▪ congenital, ▪ associated with a variety of underlying diagnoses (neuromuscular or syndromic), ▪ focal dysplasia of musculoskeletal tissue distal to the knee). TALIPES EQUINOVARUS (clubfoot) CONGENITAL CLUBFOOT ▪ - Idiopathic or syndromic - Associated with Neuromuscular diagnoses or syndromes (myelodysplasia, arthrogryposis, trisomy 13 and chromosome 22q11) - 1: 1,000 births - 1:4 (sibling is involved) - Male> female TREATMENT ▪ NON-OPERATIVE after birth. ▪ TECHNIQUES: ▪ Taping ▪ Strapping ▪ Manipulation ▪ Serial casting ▪ Functional treatment ▪ SURGICAL release: 3-12 months ▪ PONSETI METHOD – standard initial treatment, involves a specific treatment, manipulation & The most difficult deformity is: HINDFOOT EQUINUS serial casting, minimally invasive. HYPERMOBILE PES PLANUS (flatfeet) ▪ Common diagnosis CLINCAL MANIFESTATIONS ▪ 23% of the public NORMAL: 3 Types of Flatfeet longitudinal arch (non-weight bearing position or standing on the toes, but the arch 1. Flexible flatfeet disappears when standing flat. 2. Flexible flatfoot with tendo- HINDFOOT collapses → valgus Achilles contracture MIDFOOT sag (EVIDENT) 3. Rigid foot Generalized hypermobility and ligamentous laxity (OBSERVED) HYPERMOBILE PES PLANUS (flatfeet) TREATMENT: ❖ Non-prescription orthosis medical arch support Symptomatic subset of patients: ✓ Hindfoot pain ✓ Abnormal shoe wear ✓ Fatigue after walking ❖ Stretching exercises: ❖ Physical Therapy ✓ Flexible flatfoot with tight tendo-Achilles. CAVUS FEET ▪ deformity involving plantarflexion of the forefoot or midfoot on the hindfoot, ▪ may involve the entire forepart of the foot or just the medial column → elevation of the medial longitudinal arch ▪ Commonly associated with hindfoot deformity. TREATMENT: MILD – stretching through physical therapy or serial casting of the plantar fascia and contracted muscles CAVUS FEET TREATMENT: ✓ stretching through physical therapy. ✓ serial casting of the plantar fascia and contracted muscles. ✓ Ankle-foot orthosis ✓ Surgical treatment GOAL: restore motion & alignment, improve muscle balance. Puncture Wounds (foot) ▪ Most puncture wound injuries ▪ ER management. TREATMENT: ✓ irrigation ✓ tetanus booster ✓ antibiotics COMPLICATIONS: Cellulitis Surgical drainage if necessary MOST COMMON organism: S. aureus, P. aeruginosa Juvenile Hallux Valgus Clinical Manifestations: - Prominence 1st metatarsophalangeal joint (MTP) - Erythema & callus (chronic irritation) - Great Toe (pronated) - Splaying of the forefoot - Pes planus - Pain on the region of the 1st MTP joint - Difficulty with shoe wear Juvenile Hallux Valgus Radiographic Evaluation ▪ Weight bearing AP & lateral radiograph of the feet are obtained. ▪ AP view: angular relationships 1st & 2nd metatarsals (intermetatarsal angle, 10cm ▪ Deformities >15degrees & occurring after 6yrs of age. MANAGEMENT: Surgical for correction THE KNEE ▪ Synovial joint at 3rd-4th fetal month. ▪ Largest joint in the body. ▪ Modified hinge ▪ 2ndary ossification ▪ 6th-9th fetal month – distal femur ▪ 8th month- 1st post natal month – proximal tibia ▪ Patellar ossification: ▪ Does not appear until 2nd -4yr among girls and 3 and 5 among boys. Discoid Lateral Meniscus ▪ Congenital anatomic variation of the lateral meniscus. ▪ May be asymptomatic or cause the classic SNAPPING KNEE SYNDROME. ▪ Occurs in 3-5% of children & adolescents. ▪ Up to 25% of DLM cases- bilateral. NORMAL MENISCUS ▪ Attached around the periphery and at tips of the “C” anteriorly and posteriorly onto the tibia. ▪ With the DLM, the meniscal tissue trapped between the articular surfaces is PUSHED anteriorly → tears Discoid Lateral Meniscus ▪ 3 TYPES of DLM (Watanabe classification) Type I (complete discoid lateral meniscus) MOST COMMONLY produced symptoms thickened lateral meniscus with complete coverage of the tibial surface. Type II (incomplete discoid lateral meniscus) Lower percentage of tibial surfaces. Type III (Wrisberg variant lateral meniscus) No peripheral attachments posteriorly Stabilized by posteriorly by prominent meniscifemoral ligament (wrisberg) that secures the posterior horn of the lateral meniscus Discoid Lateral Meniscus CLINICAL MANIFESTATIONS - All types are ASSYMPTOMATIC. - Meniscal tear or absent peripheral attachments, allowing for the anterior extrusion during flexion and reduction with extension → SNAPPING KNEE. - 2yrs of age (presentation) - 6years old (PEAK) - DEGENERATION in the central portion of the DLM leads with direct weight bearing → injury and tears. TREATMENT: ▪ Asymptomatic – DOES NOT NEED treatment ▪ MENISCAL TEARS with limited activity- SURGICAL ▪ Partial meniscectomy POPLITEAL CYSTS (BAKER CYSTS) Simple cystic masses filled with gelatinous material that develop in the popliteal fossa filled with gelatinous material that develop in the popliteal fossa. RARE in children Resolve spontaneously. REST and leg elevation to promote drainage of the fluid accumulating within the cyst.  OSGOOD-Schlatter disease ▪ Irritation of the patellar tendon at its insertion into the tibial tubercle a traction apophysitis of the tibial tubercle growth plate. ▪ Accelerated growth. ▪ Most symptomatic 10 and 15 years of age ▪ Very physically active children SELF-LIMITED & resolves with REST  Sinding-Larsen- Johansson Syndrome ▪ Insertional periostitis at the inferior pole of the patella. ▪ Anterior knee pain ▪ Younger population ▪ Physically active children ▪ No associated trauma TREATMENT: Pain free level 1-2weeks sports THE HIP ▪ Hip-joint ▪ Ball & socket articulation between the femoral head and acetabulum. ▪ PIVOTAL joint of the lower extremity. ▪ Hip joint begins to develop at 7th week of gestation ▪ 11th wk of gestation- femoral head & acetabulum is fully formed cartilaginously. ▪ 3 osseous components ▪ ILIUM ▪ ISCHIUM ▪ PUBIS DEVELOPMENTAL DYSPLASIA of the HIP ▪ Congenital dislocation of the hip. ▪ Spectrum of pathology in the immature hip joint. CLASSIFICATION: 1. Acetabular dysplasia – abnormal morphology and development of the acetabulum. 2. Hip subluxation –only partial contact between the femoral head and acetabulum 3. Hip dislocation – a hip with no contact between the articulating surfaces of the hip. DEVELOPMENTAL DYSPLASIA of the HIP 2 major groups of DDH: 1. Typical – normal patients without genetic syndromes and genetic conditions 2. Teratologic- identifiable causes like; arthrogryposis or a genetic syndrome, occur before birth. ETIOLOGY: unknown Final common pathway: LAXITY of the JOINT ▪ Family history – 12-33% of affected patient ▪ 80% among females – hormone: relaxin which increases ligamentous laxity. DEVELOPMENTAL DYSPLASIA of the HIP CLINICAL FINDINGS: The NEONATE - asymptomatic - BARLOW and ORTOLANI test HIP CLICK is the high pitched sensation (or sound) felt at the very end of the abduction during testing for DDH with Barlow & Ortolani maneuvers. DEVELOPMENTAL DYSPLASIA of the HIP The INFANT: ✓ 2nd-3rd month of life ✓ Barlow & Ortolani (not reliable) Physical findings: ✓ Limited hip abduction ✓ Apparent shortening of the thigh ✓ Proximal location of the greater trochanter ✓ Asymmetry of the gluteal or thigh folds. LIMITATION of ABDUCTION – most reliable sign of a dislocated hip in this age group. GALLEAZI SIGN – shortening of the thigh, best appreciated by placing both hips 90deg flexion and comparing the height of the knees (asymmetry) DEVELOPMENTAL DYSPLASIA of the HIP The WALKING CHILD: ▪ If there is limping, waggling gait and leg-length discrepancy. ▪ affected side is shorter than the normal extremity ▪ child toe-walks on the affected side. TRENDELENBURG SIGN is positive in this children, an abductor lurch is observed when the child walks. Excessive Lordosis is a presenting complaint DEVELOPMENTAL DYSPLASIA of the HIP DIAGNOSTIC TESTING: Ultrasound – diagnostic modality of choice before the appearance of the femoral head ossific nucleus (4-6months). At least 1month of age. RADIOGRAPHY – recommended once the proximal femoral head ossifies, 4-6months. More effective, less costly and less operator dependent. Hilgenreiners’ line – a horizontal line drawn to the top both triradiate cartilage (the clear area in the depth of the acetabulum). Perkin’s Line – a vertical line through the MOST lateral ossified margin of the roof of the acetabulum, drawn perpendicular. DEVELOPMENTAL DYSPLASIA of the HIP TREATMENT Maintain a concentric reduction of the femoral head within the acetabulum to provide the optimal environment for the normal development of both the femoral head and acetabulum. NEWBORNS: PAVLIK harness < 4 weeks of age, normalizes in 3-4weeks with re- examination of the newborn. Children 6months – 2years old: CLOSED reduction under General anesthesia MOST IMPORTANT COMPLICATION: Avascular Necrosis of the femoral ephiphysis. THE SPINE SCOLIOSIS & KYPHOSIS – the most common spinal deformities. Scoliosis – idiopathic, due to congenital deformities or associated with a variety of conditions. Concern- cosmetic abnormalites NORMAL CURVATURE of the SPINE Anteroposterior (CORONAL)→ Straight but normally has curvatures in the lateral (sagittal) plane. Idiopathic Scoliosis Greek word skolios (bent or curved). Scoliosis is a 3-dimensional spinal deformity, defined in the coronal plane as a curve of at least 10degrees on the PA radiograph of the spine. ADAMS forward bent test – visible prominence. ETIOLOGY – multifactorial Females (2-10x) > Males 32% in COL11A2collagen gene Idiopathic Scoliosis MOST COMMON Type of spinal curvature. 80% idiopathic. Skeletal immaturity 1%-3% population. Most curves do not require treatment with only 0.5% >20deg and 0.3% exceeding 30deg. ≤ 10 degrees occur equally between males and females, those requiring an intervention occur in a 7:1 female to male ratio. Infantile idiopathic scoliosis resolve spontaneously 20-90% of cases. MANAGEMENT: Brace treatment BACK PAIN ▪ Frequent complaint among pediatric patients ▪ 1yr prevalence rates ▪ 7%-58% of adolescents RISK FACTORS: ▪ Increasing growth ▪ Female gender ▪ Family history ▪ Excessive sport participation ▪ Manual labor ▪ Heavy backpack BACK PAIN CLINICAL EVALUATION: - History & PE - Trauma - Repetitive activities - Spondylolysis - Neoplastic vs Infectious - PAIN is not relieved by rest. - Associated symptoms: fever, chills, night sweats, weight loss, malaise. WORK-UP Radiograph and laboratory evaluation. SPINE INFECTION ▪ Spondylitis – inflammation of the vertebrae, ▪ MOST COMMONLY due to infectious or immune processes. ETIOLOGY: hematogenous spread of bacteria. Staphyloccocus aures –MOST COMMON cause. CLINICAL MANIFESTATIONS: 1. Back pain 2. Abdominal pain 3. Fever – 30% of patients 4. Malaise 5. Neurologic - rare SPINE INFECTION RADIOGRAPHIC EVALUATION: Loss of Lumbar Lordosis – earliest radiographic finding. Features: ✓ Disc space narrowing ✓ Loss of disc height ✓ Irregularity of the adjacent vertebral end plates. Diagnosis: technetium bone scan or MRI MRI – most sensitive and specific imaging to diagnose osteomyelitis and to identify abscess of neural compression SPINE INFECTION TREATMENT: ✓ 1st generation- cephalosporins ✓ Semisynthetic antistaphyloccal penicillin ✓ Clindamycin – MRSA more common Obtain blood culture 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 during infancy. Contracture of the SCM tilting of the head and neck ipsilaterally toward the side of the contracted muscle with head rotation contralaterally toward the opposite side. THE NECK ETIOPATHOGENESIS: - hypothesis: intrauterine deformation or compression problem – 1st pregnancies. - May be associated with presence of palpable mass of fibrous tissue with the substance of the SCM in 50% cases. ASSOCIATED FINDINGS: - Plagiocephaly - Facial asymmetry - Positional musculoskeletal deformities (metatarsus adductus 15% & calcaneovalgus feet) THE NECK MANAGEMENT: - Stretching 90% successful (CMT) when started within 1st 3months of life. - Surgical release of the SCM in patients with persistent deformity after failure of conservative treatment. - Typically delayed until >18months of age. - Remodeling of facial asymmetry and plagiocephaly. - Surgery only on required minor cases. THE SHOULDER ▪ Ball and socket joint ▪ Very shallow ▪ More prone to dislocation. ▪ Shoulder Range of Motion is greater than hip. ▪ Center- glenohumeral joint. SPRENGEL DEFORMITY (Congenital elevation of the 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 MOST congruent joint in the body. Stability: bony congruity as well as through the medial and radial collateral ligaments. PANNER DISEASE - disruption of the blood flow to the articular cartilage and subchondral bone to the capitellum. Age 5-13 yrs old. Symptoms: ✓ Lateral elbow pain ✓ Loss of motion ✓ Mechanical symptoms of the elbow (loose bodies) TREATMENT: conservative (rest, activity modification and patient education). COMMON FRACTURES ▪ TRAUMA – leading cause of death and disability in children > 1year old. ▪ Immature skeleton (more fractures). ▪ Damage to the physis is more likely. ▪ PHYSIS – most resistant to traction and least resistant to torsional forces. ▪ PERIOSTEUM – usually injured in all fractures but less likely to have complete circumferential rupture. (loose attachment of the shaft). Fracture remodeling ▪ Remodeling is the third and final phase in biology of fracture healing, preceded by the inflammatory and reparative phases. ▪ Skeletal maturity is reached in POST menarchal girls between 13 and 15 yr old and in boys 15-17yrs old. ▪ OVERGROWTH ▪ Physeal stimulation from hyperemia associated with fracture healing. Prominent in lower extremities (FEMUR). ▪ Femoral fractures