Ortho Quick Management Review

Procedures

• Splints and Casts
• Aspiration/injection of the knee and shoulder.
• Trigger point injections.

Pediatrics orthopedics

1. Salter-Harris classification of fractures (SALTER)

• • I. S = Separated Growth Plate
  • II. A = Above Growth Plate
  • III. L = beLow Growth Plate
  • IV. T= Through Growth Plate
  • V. ER = Erasure of Growth Plate

1. Congenital disorders
   1. Hip dysplasia
      • < 2 months Tx:
        • mild dysplasia: observation w/ serial exams and US monthly basis
        • dysplasia worsens or persists: Pavlik Harness and Xray at 6 months old
        • Hip Abduction splint
        • Closed reduction with a spica cast
        • Open reduction with a spica cast
      • > 18 months – 6 Yo Tx:
        • Open reduction with a spica cast
      • > 6 Yo Tx:
        • Open reduction with a spica cast
        • Salvage osteotomies
   2. Tibial torsion
      • Tx:
        • Reassurance and observation
        • refer to ortho
   3. Anteversion
   4. Metatarsus adductus
      • < 6 months Tx:
        • observation
        • then passive stretching
        • refer to ortho if it persists > 6 months
   5. Club foot
2. Slipped capital femoral epiphysis
3. Apophysitis
   1. Osgood-Schlatter’s disease
   2. Sever’s disease
   3. Sindig-Larsen-Johansen syndrome
4. Osteochondritis dissecans
5. Orthopedic signs of child abuse

Congenital Hip Dysplasia

• Etiology:
  • -occurs when a child is born with an unstable hip
    
  • -caused by abnormal formation of the hip joint during their early stages of fetal development
    
  • -instability worsens as your child grows
    
  • -can lead to hip dislocation
    
  • -MC in girls
  • -low levels of amniotic fluid in the womb
    
  • -breech presentation
• Presentation:
  • -legs turn outward to appear to differ in length
    
  • -limited ROM
    
  • -folds on their legs and buttocks that are uneven when their legs extend
    
  • -delayed gross motor development
• Diagnosis:
  • -Ortolani maneuver: examiner grasps the medial aspect of the knee and abducts the hips while anterior force to the femur, resulting in a reduction of the hip joint (may feel a clunk)
    
  • -Barlow maneuver: examiner adducts the fully flexed hip while applying posterior force to the femur, resulting in dislocation of the hip
• Management:
  • -younger than 6 months -> Pavilk harness for 6-12 weeks
    
  • -surgery is an option

Slipped Capital Femoral Epiphysis

• Etiology:
  • -femoral head (epiphysis) slips posterior and inferior at the growth plate
    
  • -MC in 7-16 years, obese, AA, males during a growth spurt (due to the weakness of the growth plate and hormonal changes at puberty)
    
  • -if seen in children before puberty suspect hormonal/systemic disorders (hypothyroidism, hypopituitarism)
• Presentation:
  • -hip, thigh or knee pain with limp
    
  • -external rotation of the affected leg
• Management:
  • -nonweight bearing with crutches -> ORIF (increase risk of avascular necrosis)

Osgood-Schlatter Disease

• Etiology:
  • -ostochondritis of the patellar tendon at tibial tuberosity from overuse (repetitive stress) or small avulsions (due to quadriceps contraction on the patellar tendon insertion into the tibia)
    
  • -MC cause of chronic knee pain in young, active adolescents
    
  • -MC males, 10-15 years, athletes with “growth spurts” (bone growth faster than soft tissue growth, so quadriceps contraction transmitted through patellar tendon to the tuberosity)
• Presentation:
  • 1. activity related knee pain/swelling (running, jumping, kneeling)
    
  • 2. painful lump below knee, tenderness to the anterior tibial tubercle
• Diagnosis:
  • -radiographs show prominence or heterotopic ossification at the tibial tuberosity
• Management:
  • -RICE, NSAIDs, quadriceps stretching
    
  • -surgery only in refractory cases (if done, usually performed after growth plate has closed)
    
  • -usually resolves with time

Legg-Calve-Perthes Disease

• Etiology:
  • -idiopathic avascular osteonecrosis of the femoral head in children due to ischemia of capital femoral epiphysis in children
    
  • -MC in children 4-10 years
    
  • -4x MC in boys
    
  • -low incidence in AA
• Presentation:
  • 1. painless limping x weeks (worsen with continued activity especially at the end of the day)
    
  • -may have intermittent hip, thigh, knee, or groin pain
    
  • 2. restricted range of motion (loss of abduction and internal rotation)
• Diagnosis:
  • 1. hip radiographs
    
  • -early: increase density of the femoral head, widening of the cartilage space
    
  • -advance: deformity, crescent sign (micro-fractures with collapse of the bone)
• Management:
  • 1. observation
    • -because it is self-limiting with revascularization within 2 years, activity restriction (nonweight bearing initially) with orthopedic follow up i initial treatment in most cases
    • -can do protected weight-bearing during early stages until reossification is complete
    • -PT
  • 2. pelvic osteotomy may be indicated in some children > 8 years of age, especially lateral pillar B and B/C

Radial Head Subluxation (Nursemaid’s Elbow) 

• Path:
  • -lifting/swinging/pulling a child (MC 2-5 years) while the forearm is pronated and extended -> radial head wedges into the stretched annular ligament
• Presentation:
  • -children present with arm slightly flexed, refuses to use arm (usually no swelling)
    
  • -tenderness to palpation of the radial head
• Management:
  • -reduction (pressure on the radial head with supination and flexion)
    
  • -observe child for normal function
    
  • -if child uses the arm after 15 mins then no radiographs needed
    
  • -if no use after 15 mins -> can do radiographs to rule out fracture or reattempt
  • reduction

Scoliosis

• Etiology:
  • –lateral curvature of spine > 10 degrees
    
  • -can be associated with kyphosis (humpback) or lordosis (sway back)
    
  • -MC begins at 8-10 years of age
    
  • -MC in girls (with a positive family history)
    
  • -if associated with cafe au lait spots, skin tags, and axillary freckles -> neurofibromatosis type I
• Diagnosis:
  • –adams forward bending test most sensitive
    
  • -cobb’s angle measured on AP/lateral films
• Management:
  • -observation in most cases
    
  • -can brace (if 20-40 degrees)
    
  • -surgical correction if > 40 degrees

Juvenile Idiopathic Arthritis (Rheumatoid)

• Etiology:
  • -autoimmune mono or polyarthritis in children < 16 years (often resolves by puberty)
    
  • -3 types:
    • pauci articular
    • systemic acute febrile
    • polyarticular
• Pauci-Articular (Oligoarticular):
  • -50%
    
  • -< 5 joint involvement in the 1st 6 months
    
  • -MC large joints (knees, ankles), can be small joints
    
  • -type I associated with iridocyclitis (anterior uveitis), often iridocyclitis is asymptomatic (but may cause blindness if not treated)
    
  • -joint involvement is usually asymmetric
    
  • -type II associated with increase incidence of AS
• Systemic/Acute Febrile (Still’s Disease):
  • -20%
    
  • -daily arthritis, diurnal high fever within the 1st 6 months, both small and large joints
    
  • –salmon colored/pink migratory rash often accompanies the fever (can have Koebner phenomenon)
    
  • -no iridocyclitis but associated with hepatosplenomegaly, hepatitis, LAD, serositis (pericardial and pleural effusions)
• Polyarticular:
  • -arthritis ≥ 5 small joints within the 1st 6 months (usually symmetric)
    most similar to adult RA
    
  • -hip involvement is common (may present as a limp)
    
  • -increase risk of iridocyclitis, may have low grade fever
    
  • -systemic symptoms not as common
    
  • -rheumatoid factor negative disease associated with better prognosis than RF positive patients
• Diagnosis:
  • -clinical diagnosis
    
  • -increase ESR/CRP
    
  • -positive ANA seen in oligoarticular
    
  • -positive RF only in 15%
• Management:
  • -NSAIDs and/or corticosteroids
    
  • -methotrexate or leflunomide
    
  • -frequent eye exams to detect iridocyclitis

Geriatric orthopedics

1. Degenerative joint disease
2. Hip replacement
3. Osteoporosis
4. Paget’s Disease of Bone
5. Bony metastases

Neurological Injuries

1. Peripheral neuropathies
2. Reflex sympathetic dystrophy
3. Entrapment syndromes
4. Compartment syndromes
5. Radiculopathies

Fractures and Dislocations

1. cervical fracture
2. clavicular fracture
3. humeral neck fracture
4. humeral shaft fracture
5. supracondylar elbow fracture
6. radial head/neck fracture
7. radial shaft fracture
8. distal radial fracture
9. scaphoid fracture
10. metacarpal fracture
11. phalangeal fracture
12. rib fracture
13. femoral neck fracture
14. femoral shaft fracture
15. tibial plateau fracture
16. tib/fib fracture
17. distal fibular fracture
18. distal tibia fracture
19. calcaneal fracture
20. metatarsal fracture
21. toe fracture
22. facial fracture
23. skull fracture
24. stress fracture
25. finger dislocation
26. radial head dislocation
27. glenohumeral dislocation
28. patellar dislocation/subluxation
29. depression fractures
    1. Tx:
       • simple= pain meds
         
       • complex-surgical intervention

Soft Tissue Injuries

1. cervical sprain/strain
2. low back strains
3. AC joint sprain
4. sternoclavicular sprain
5. medial collateral ligament sprain (elbow)
6. triangular fibrocartilage complex tear
7. muscle contusions
8. medial collateral ligament sprain (knee)
9. lateral collateral ligament sprain (knee)
10. anterior cruciate ligament sprain
11. posterior cruciate ligament sprain
12. meniscus tear
13. ankle sprain
14. calf sprain
15. rotator cuff tendinopathies
16. medial and lateral epicondylitis
17. patellofemoral syndrome
18. ITB friction syndrome
19. tendinitis/bursitis
20. plantar fasciitis
21. symptomatic plica

Casts and Splints

1. Short leg cast
2. Short arm cast
3. Posterior elbow splint
4. Posterior ankle splint
5. Ulnar gutter splint
6. Thumb spica splint
7. Sugar tong splint
8. Shoulder immobilizer
9. Tennis elbow splint
10. Knee immobilizer
11. Ankle air cast
12. Wrist splint
13. Finger splints

Referral to Orthopedics