Ortho Block 3.2

In acute multiligamentous injuries, distal neurovascular status should be carefully assessed and recorded because limb-threatening vascular injury or severe neurologic deficits may be present. An ankle-brachial index less than ___ should prompt further imaging of the arterial system to rule out an intimal tear that can thrombose and cause a complete arterial occlusion.

. In acute multiligamentous injuries, distal neurovascular status should be carefully assessed and recorded because limb-threatening vascular injury or severe neurologic deficits may be present. An ankle-brachial index less than 0.9 should prompt further imaging of the arterial system to rule out an intimal tear that can thrombose and cause a complete arterial occlusion.

HIP DYSPLASIA A child with a positive ___ maneuver does not require hip ultrasonography prior to referral; the hip is, by definition, dislocated, and needs to be treated. A child with a positive ___ maneuver may be followed by a primary care physician or referred to an orthopaedic surgeon, since most of these cases resolve without treatment. Asymmetric hip abduction and limited bilateral hip abduction are red flags requiring further investigation and/or referral.

A child with a positive Ortolani maneuver does not require hip ultrasonography prior to referral; the hip is, by definition, dislocated, and needs to be treated. A child with a positive Barlow maneuver may be followed by a primary care physician or referred to an orthopaedic surgeon, since most of these cases resolve without treatment. Asymmetric hip abduction and limited bilateral hip abduction are red flags requiring further investigation and/or referral.

Anterolateral bowing of the tibia is typically associated with a congenital pseudarthrosis of the tibia. A congenital pseudarthrosis of the tibia is extremely difficult to treat and often is associated with ___ (genetically inherited disorders that cause tumors to grow in the nervous system), which must be ruled out.

A congenital pseudarthrosis of the tibia is extremely difficult to treat and often is associated with neurofibromatosis (genetically inherited disorders that cause tumors to grow in the nervous system), which must be ruled out.

A high-riding patella (patella alta) and abnormal lateral tracking (positive ___ sign) can contribute to lateral patellar instability

A high-riding patella (patella alta) and abnormal lateral tracking (positive J sign) can contribute to lateral patellar instability

A home exercise program for pfps should include exercises to strengthen the quadriceps, gain full flexion range of motion, and strengthen the ___

A home exercise program should include exercises to strengthen the quadriceps, gain full flexion range of motion, and strengthen the hamstrings

A large effusion and a ___ defect in the area of the rupture is pathognomic for an extensor mechanism disruption. The hallmark of a clinically substantial extensor mechanism disruption is the inability to extend the knee against gravity or perform a straight leg raise

A large effusion and a palpable defect in the area of the rupture is pathognomic for an extensor mechanism disruption. The hallmark of a clinically substantial extensor mechanism disruption is the inability to extend the knee against gravity or perform a straight leg raise

A ___ cyst, commonly known as a Baker cyst, is the most common benign synovial cyst in the knee

A popliteal cyst, commonly known as a Baker cyst, is the most common benign synovial cyst in the knee

All children with absence of toes or an obviously short limb should receive early consultation with an ___ surgeon and appropriate additional testing for associated disorders

All children with absence of toes or an obviously short limb should receive early consultation with an orthopaedic surgeon and appropriate additional testing for associated disorders

Although axial CT can help delineate the exact nature of the patellar and trochlear articulations, MRI can provide a more detailed assessment of the articular surfaces and the ___ patellofemoral ligament

Although axial CT can help delineate the exact nature of the patellar and trochlear articulations, MRI can provide a more detailed assessment of the articular surfaces and the medial patellofemoral ligament

In congenital deficiency of LE, Although surgical treatment usually is not performed until the child is at least ___ -___ months of age, formulating a comprehensive treatment plan takes time

Although surgical treatment usually is not performed until the child is at least 9 to 12 months of age, formulating a comprehensive treatment plan takes time

An ___ patellofemoral view, such as the Merchant or Laurin view, demonstrates the relationship of the patella to the femoral trochlea

An axial patellofemoral view, such as the Merchant or Laurin view, demonstrates the relationship of the patella to the femoral trochlea

Anterior knee pain is a common problem in active adolescents and preadolescents and is primarily the result of repetitive stress. The most common cause is ___. Anterior knee pain caused by altered patellofemoral forces secondary to growth and changing patellar tracking in the trochlear groove of the femur with growth and development is common; this pain has different names, including patellofemoral syndrome (PFS), miserable malalignment syndrome , and anterior knee syndrome.

Anterior knee pain is a common problem in active adolescents and preadolescents and is primarily the result of repetitive stress. The most common cause is patellar maltracking. Anterior knee pain caused by altered patellofemoral forces secondary to growth and changing patellar tracking in the trochlear groove of the femur with growth and development is common; this pain has different names, including patellofemoral syndrome (PFS), miserable malalignment syndrome (Figure 1), and anterior knee syndrome.

As the medial plica syndrome progresses, erosive changes in the femoral condyle cartilage can develop, because of the ___ of the thickened plica over the condyle

As the disease progresses, erosive changes in the femoral condyle cartilage can develop, because of the snapping of the thickened plica over the condyle

Asymmetric intoeing can represent ___ on the more severe side, although tibial torsion may be asymmetric; femoral anteversion should be symmetric, so asymmetry in hip rotation can represent ___ or underlying bony abnormalities

Asymmetric intoeing can represent spasticity on the more severe side, although tibial torsion may be asymmetric; femoral anteversion should be symmetric, so asymmetry in hip rotation can represent spasticity or underlying bony abnormalities

Hip dysplasia: Asymmetry in knee heights with the patient supine and the hips and knees flexed to 90° suggests shortening of one thigh (positive ___ sign). In ambulatory patients, gait asymmetry commonly occurs as a result of a functional limb-length discrepancy.

Asymmetry in knee heights with the patient supine and the hips and knees flexed to 90° suggests shortening of one thigh (positive Galeazzi sign). In ambulatory patients, gait asymmetry commonly occurs as a result of a functional limb-length discrepancy.

Because most DDH occurs in the absence of known risk factors (except being female), the periodic ____ for every child younger than 1 year is paramount for early detection of DDH

Because most DDH occurs in the absence of known risk factors (except being female), the periodic hip physical examination for every child younger than 1 year is paramount for early detection of DDH

Calcaneovalgus foot is a common newborn positional abnormality or deformation characterized by marked ___ of the ankle and ___ of the foot, where the foot may be pressed against the tibia. Most cases resolve spontaneously, although stretching and/or several serial casts may be required in some patients. Rarely, this deformity results from deficient activity of the plantar flexors from an underlying neurologic disorder such as a lipomyelomeningocele.

Calcaneovalgus foot is a common newborn positional abnormality or deformation characterized by marked dorsiflexion of the ankle and eversion of the foot, where the foot may be pressed against the tibia. Most cases resolve spontaneously, although stretching and/or several serial casts may be required in some patients. Rarely, this deformity results from deficient activity of the plantar flexors from an underlying neurologic disorder such as a lipomyelomeningocele.

Combining physical examination with AP and lateral radiography of the knee can mitigate the need for more advanced imaging of patellar rupture. The lateral projection demonstrates a patellar fracture or patella alta or baja. Patella alta (the patella is higher than usual) can indicate rupture of the patellar tendon, whereas patella baja (the patella is lower than usual) may be present with a rupture of the quadriceps tendon. On a standard lateral radiograph, the image is obtained at ___° of knee flexion. At this angle, the inferior pole of the patella should be in line with the Blumensaat line. MRI will confirm a tendon rupture but is rarely necessary in the presence of the clinical triad of palpable defect, inability to actively extend the knee, and patella alta or patella baja.

Combining physical examination with AP and lateral radiography of the knee can mitigate the need for more advanced imaging. The lateral projection demonstrates a patellar fracture or patella alta or baja. Patella alta (the patella is higher than usual) can indicate rupture of the patellar tendon, whereas patella baja (the patella is lower than usual) may be present with a rupture of the quadriceps tendon. On a standard lateral radiograph, the image is obtained at 30° of knee flexion. At this angle, the inferior pole of the patella should be in line with the Blumensaat line. MRI will confirm a tendon rupture but is rarely necessary in the presence of the clinical triad of palpable defect, inability to actively extend the knee, and patella alta or patella baja.

Congenital coxa vara is associated with a congenital short femur and proximal femoral focal deficiency. ___ coxa vara is secondary to metabolic or traumatic conditions. Developmental coxa vara is an idiopathic condition that appears in early childhood.

Congenital coxa vara is associated with a congenital short femur and proximal femoral focal deficiency. Acquired coxa vara is secondary to metabolic or traumatic conditions. Developmental coxa vara is an idiopathic condition that appears in early childhood.

Congenital curly toe is an idiopathic condition characterized by flexion and ___ rotation of the toe, often under the adjacent toe. Most children are asymptomatic. Strapping is ineffective. If problems develop with shoe wear, surgical treatment of the toe flexors often is successful.

Congenital curly toe is an idiopathic condition characterized by flexion and medial rotation of the toe, often under the adjacent toe. Most children are asymptomatic. Strapping is ineffective. If problems develop with shoe wear, surgical treatment of the toe flexors often is successful.

Congenital dislocation of the patella may not be apparent for several months after birth. Persistent ___ contracture of the knee and external rotation of the leg suggest this diagnosis. The patella may not be palpable in its dislocated lateral position. Ultrasonography helps confirm the diagnosis in a younger child whose patella has not started to ossify. Surgical treatment is necessary and involves releasing the tight lateral structures around the knee and essentially derotating the quadriceps mechanisms; the insertion of the patellar tendon often is quite lateral and must be surgically relocated.

Congenital dislocation of the patella may not be apparent for several months after birth. Persistent flexion contracture of the knee and external rotation of the leg suggest this diagnosis. The patella may not be palpable in its dislocated lateral position. Ultrasonography helps confirm the diagnosis in a younger child whose patella has not started to ossify. Surgical treatment is necessary and involves releasing the tight lateral structures around the knee and essentially derotating the quadriceps mechanisms; the insertion of the patellar tendon often is quite lateral and must be surgically relocated.

Congenital dislocation, which results from intrauterine positioning, presents as a knee ___ deformity at birth. The spectrum of severity ranges from a mild positional deformity that responds readily to short-term splinting to a frank hyperextension/dislocation of the tibia on the femur that requires serial casting, and occasionally, open surgical reduction. Associated abnormalities such as hip dysplasia are common, and early ultrasonography should be considered even when the hip examination is considered normal.

Congenital dislocation, which results from intrauterine positioning, presents as a knee hyperextension deformity at birth. The spectrum of severity ranges from a mild positional deformity that responds readily to short-term splinting to a frank hyperextension/dislocation of the tibia on the femur that requires serial casting, and occasionally, open surgical reduction (Figure 2). Associated abnormalities such as hip dysplasia are common, and early ultrasonography should be considered even when the hip examination is considered normal.

Coxa vara is a relatively uncommon hip disorder characterized by a ___ in the neck-shaft angle of the femur

Coxa vara is a relatively uncommon hip disorder characterized by a decrease in the neck-shaft angle of the femur

Developmental dysplasia of the hip (DDH) represents a spectrum of pathology related to the growth and development of the immature hip, varying from subluxation or dislocation of the hip (the femoral head is partially or completely displaced from the acetabulum) to deformity of the femoral head and/or acetabulum. Risk factors for DDH are generally believed to be a positive family history, breech presentation, maternal oligohydramnios, first-born child, swaddling of the newborn's lower extremities, and ___ sex; of these factors, positive family history and ___ sex are most strongly associated.

Developmental dysplasia of the hip (DDH) represents a spectrum of pathology related to the growth and development of the immature hip, varying from subluxation or dislocation of the hip (the femoral head is partially or completely displaced from the acetabulum) to deformity of the femoral head and/or acetabulum. Risk factors for DDH are generally believed to be a positive family history, breech presentation, maternal oligohydramnios, first-born child, swaddling of the newborn's lower extremities, and FEMALE sex; of these factors, positive family history and FEMALE sex are most strongly associated.

___ deficiency is the most common long-bone deficiency. All patients require treatment of a limb-length discrepancy, but the magnitude of the projected discrepancy is quite varied.

Fibular deficiency is the most common long-bone deficiency (). All patients require treatment of a limb-length discrepancy, but the magnitude of the projected discrepancy is quite varied.

Genu varum (bowlegs) is an angular deformity at the knee with the tibia ___ deviated (varus) in relation to the femur

Genu varum (bowlegs) is an angular deformity at the knee with the tibia medially deviated (varus) in relation to the femur

Hip rotation is used to estimate ___ (rotational angle of the femoral head-neck relative to the distal epicondylar axis) and is tested with the patient prone (hips extended) and the knee flexed to 90°. With one of the examiner's hands on the patients' buttocks to stabilize the pelvis, the lower leg is rotated outward to test internal (medial) rotation, and inward to test external (lateral) rotation

Hip rotation is used to estimate femoral version (rotational angle of the femoral head-neck relative to the distal epicondylar axis) and is tested with the patient prone (hips extended) and the knee flexed to 90°. With one of the examiner's hands on the patients' buttocks to stabilize the pelvis, the lower leg is rotated outward to test internal (medial) rotation, and inward to test external (lateral) rotation

If left untreated, DDH can result in premature degenerative joint disease (osteoarthritis), causing pain and limited function. ___ missed complete DDH can result in limb-length discrepancies, ipsilateral knee pain and valgus instability, and gait disturbances; ___ missed complete DDH can result in back problems.

If left untreated, DDH can result in premature degenerative joint disease (osteoarthritis), causing pain and limited function. Unilateral missed complete DDH can result in limb-length discrepancies, ipsilateral knee pain and valgus instability, and gait disturbances; bilateral missed complete DDH can result in back problems.

In contrast to patients with patellar instability, the primary symptom in patients with symptomatic malalignment is ___ pain

In contrast to patients with patellar instability, the primary symptom in patients with symptomatic malalignment is retropatellar pain

In ____ Patients most commonly report diffuse, aching anterior knee pain that is worse after prolonged sitting (movie theater sign), climbing stairs, jumping, or squatting

In patellofemoral pain, Patients most commonly report diffuse, aching anterior knee pain that is worse after prolonged sitting (movie theater sign), climbing stairs, jumping, or squatting

Initial treatment of patients with ___ should include exercises that emphasize quadriceps strengthening and flexibility. An elastic brace with a lateral buttress (such as a lateral J-brace) can facilitate the return to occupational or recreational activities. Physical therapy modalities such as electrical stimulation or taping can be useful.

Initial treatment of patients with chronic recurrent maltracking or instability should include exercises that emphasize quadriceps strengthening and flexibility. An elastic brace with a lateral buttress (such as a lateral J-brace) can facilitate the return to occupational or recreational activities. Physical therapy modalities such as electrical stimulation or taping can be useful.

Intoeing is more common than excessive outtoeing. Intoeing may be secondary to foot deformities, due to inward rotation of the femur or tibia, or the result of a combination of these. Internal ___ torsion is the most common diagnosis in toddlers. Internal femoral torsion (increased femoral ___) is most common in children older than 4 years.

Intoeing is more common than excessive outtoeing. Intoeing may be secondary to foot deformities, due to inward rotation of the femur or tibia, or the result of a combination of these. Internal tibial torsion is the most common diagnosis in toddlers. Internal femoral torsion (increased femoral anteversion) is most common in children older than 4 years.

___ PCL injuries typically are treated with a rehabilitation program that initially concentrates on resolving swelling and restoring range of motion. After these goals have been achieved, progression to strengthening exercises may be initiated, with an emphasis on the quadriceps (short-arc terminal extension exercises from 30° to 0° of flexion

Isolated PCL injuries typically are treated with a rehabilitation program that initially concentrates on resolving swelling and restoring range of motion. After these goals have been achieved, progression to strengthening exercises may be initiated, with an emphasis on the quadriceps (short-arc terminal extension exercises from 30° to 0° of flexion

___ is an idiopathic osteonecrosis of the femoral head in children. It is most commonly diagnosed in boys between 4 and 8 years of age.

Legg-Calvé-Perthes disease (LCPD) is an idiopathic osteonecrosis of the femoral head in children. It is most commonly diagnosed in boys between 4 and 8 years of age.

Less common causes of anterior knee pain are pathologic plica and a symptomatic bipartite patella. A plica is a normal fold of the synovium that may become thickened and/or fibrotic secondary to repetitive stress. A bipartite patella is a failure of an ossification center of the patella to fuse, most commonly the ___ corner

Less common causes of anterior knee pain are pathologic plica and a symptomatic bipartite patella. A plica is a normal fold of the synovium that may become thickened and/or fibrotic secondary to repetitive stress. A bipartite patella is a failure of an ossification center of the patella to fuse, most commonly the superolateral corner

MRI provides the most comprehensive evaluation, including excellent soft-tissue detail. MRI with intravenous contrast material should be ordered when an ___ is in the differential diagnosis

MRI provides the most comprehensive evaluation, including excellent soft-tissue detail. MRI with intravenous contrast material should be ordered when an infection is in the differential diagnosis

Most PCL injuries result from a direct blow to the tibia, such as when the leg strikes a dashboard during a motor vehicle collision or on a fall to the ground with the foot ___

Most PCL injuries result from a direct blow to the tibia, such as when the leg strikes a dashboard during a motor vehicle collision or on a fall to the ground with the foot plantarflexed. ***The most sensitive test = posterior drawer

Most cases are sporadic, but both autosomal dominant and autosomal recessive forms have been identified in a limited number of patients. Other disorders that may be associated with ___ deficiency include congenital heart disease, cleft palate, imperforate anus, hypospadias, hernias, and gonadal malformations. Hand anomalies can be seen in up to one third of patients.

Most cases are sporadic, but both autosomal dominant and autosomal recessive forms have been identified in a limited number of patients. Other disorders that may be associated with tibial deficiency include congenital heart disease, cleft palate, imperforate anus, hypospadias, hernias, and gonadal malformations. Hand anomalies can be seen in up to one third of patients.

Most children younger than 6 years who have substantial involvement of the femoral head or less than 40° of ___ require further evaluation. Children 6 years or older require further evaluation

Most children younger than 6 years who have substantial involvement of the femoral head or less than 40° of abduction require further evaluation. Children 6 years or older require further evaluation

____, is the hallmark treatment for patellofemoral pain

Nonsurgical management, including physical therapy, is the hallmark treatment for patellofemoral pain

___ is the treatment of choice for an otherwise normal 3- to 4-year-old child with marked genu valgum

Observation is the treatment of choice for an otherwise normal 3- to 4-year-old child with marked genu valgum

IN A LIMPING CHILD ___ views (radiographs obtained at 90° to one another) of the area of interest must be obtained (for example, AP and lateral views); often, oblique views are also helpful

Orthogonal views (radiographs obtained at 90° to one another) of the area of interest must be obtained (for example, AP and lateral views); often, oblique views are also helpful

Outtoeing in older children and adolescents may be due to ___ tibial torsion or external femoral torsion. External femoral or tibial torsion is unlikely to improve or resolve spontaneously, and in the few patients with chronic or disabling symptoms, the torsion can be corrected by derotational osteotomy

Outtoeing in older children and adolescents may be due to external tibial torsion or external femoral torsion. External femoral or tibial torsion is unlikely to improve or resolve spontaneously, and in the few patients with chronic or disabling symptoms, the torsion can be corrected by derotational osteotomy

Pain is localized to the distal third of the medial tibia, the site of the origin of the ___ muscle. The patient may demonstrate pes planus associated with overpronation.

Pain is localized to the distal third of the medial tibia, the site of the origin of the tibialis posterior muscle. The patient may demonstrate pes planus associated with overpronation.

Painful plica typically is localized to the ___ side of the patella, whereas pain associated with bipartite patella occurs at the ___ pole. The hip should be examined to exclude the possibility of hip pathology (slipped capital femoral epiphysis, Legg-Calvé-Perthes disease), which can present as thigh or knee pain.

Painful plica typically is localized to the medial side of the patella, whereas pain associated with bipartite patella occurs at the superolateral pole. The hip should be examined to exclude the possibility of hip pathology (slipped capital femoral epiphysis, Legg-Calvé-Perthes disease), which can present as thigh or knee pain.

Parental concern is the usual reason for the visit, although children and adolescents with substantial ___ deformity may present with activity-related pain in the medial aspect of the knee.

Parental concern is the usual reason for the visit, although children and adolescents with substantial varus deformity may present with activity-related pain in the medial aspect of the knee.

Patellofemoral instability usually occurs in a ___ direction as the patella glides over the trochlea and ranges from subluxation to dislocation

Patellofemoral instability usually occurs in a lateral direction as the patella glides over the lateral trochlea and ranges from subluxation to dislocation

In baker's/popliteal cysts, Patients describe a sensation of fullness or swelling in the ___ aspect of the knee without a known history of trauma. This subjective feeling may be accompanied by pain or tenderness. Occasionally, a larger cyst can cause a "mass effect" and produce symptoms (such as numbness of the plantar surface of the foot) consistent with tibial nerve neuropathy

Patients describe a sensation of fullness or swelling in the posterior aspect of the knee without a known history of trauma. This subjective feeling may be accompanied by pain or tenderness. Occasionally, a larger cyst can cause a "mass effect" and produce symptoms (such as numbness of the plantar surface of the foot) consistent with tibial nerve neuropathy

Patients with patellar instability demonstrate apprehension with attempts to manually translate the patella ___

Patients with patellar instability demonstrate apprehension with attempts to manually translate the patella laterally

Physiologic bowing requires only reassurance. Patients diagnosed with infantile ___ disease, which causes a progressive varus deformity due to growth disturbance of the proximal posterior and medial tibial physes, usually require treatment. Bracing is controversial but can be considered in patients younger than 3 years with early stages of disease. Surgical realignment with an osteotomy is most successful if performed by 4 years of age

Physiologic bowing requires only reassurance. Patients diagnosed with infantile Blount disease, which causes a progressive varus deformity due to growth disturbance of the proximal posterior and medial tibial physes, usually require treatment. Bracing is controversial but can be considered in patients younger than 3 years with early stages of disease. Surgical realignment with an osteotomy is most successful if performed by 4 years of age

Posteromedial bowing of the tibia is an idiopathic deformity that is most obvious and rather striking at birth and is commonly associated with a ___ foot, which often lies along the lateral aspect of the distal tibia

Posteromedial bowing of the tibia is an idiopathic deformity that is most obvious and rather striking at birth and is commonly associated with a calcaneovalgus foot, which often lies along the lateral aspect of the distal tibia

Radiographs are typically delayed until 2 years of age in patients suspected of having physiologic genu varum, but they may be obtained earlier if the child is below the ___th percentile for height, if the varus is relatively severe for the child's age, or if substantial asymmetry exists between the two extremities.

Radiographs are typically delayed until 2 years of age in patients suspected of having physiologic genu varum, but they may be obtained earlier if the child is below the 25th percentile for height, if the varus is relatively severe for the child's age, or if substantial asymmetry exists between the two extremities.

In LCP of peds Range-of-motion testing will reveal restriction, especially in ___ and ___ rotation, and there may be guarding at the extremes of motion. A flexion contracture also can develop. The gait examination will reveal an abductor lurch or Trendelenburg gait, and atrophy of the gluteal muscles also may be identified. Standing on the affected limb will often show a Trendelenburg sign when compared with the opposite, unaffected limb

Range-of-motion testing will reveal restriction, especially in abduction and internal rotation, and there may be guarding at the extremes of motion. A flexion contracture also can develop. The gait examination will reveal an abductor lurch or Trendelenburg gait, and atrophy of the gluteal muscles also may be identified. Standing on the affected limb will often show a Trendelenburg sign when compared with the opposite, unaffected limb

Rarely, a cyst will impinge on the ___ nerve and cause numbness on the plantar surface of the foot or will rupture and cause pain in the posterior calf that, with the swelling, may mimic a deep vein thrombosis.

Rarely, a cyst will impinge on the tibial nerve and cause numbness on the plantar surface of the foot or will rupture and cause pain in the posterior calf that, with the swelling, may mimic a deep vein thrombosis.

In a limping child, Routine studies for infection, neoplasia, or inflammatory disease include a complete blood cell count with a manual differential, a C-reactive protein level, and an ___

Routine studies include a complete blood cell count with a manual differential, a C-reactive protein level, and an erythrocyte sedimentation rate

Surgical repair is the treatment of choice for a complete rupture of the quadriceps or patellar tendon and for a displaced patellar fracture. Partial tendon tears and nondisplaced fractures can be treated with a period of immobilization, including either a ___ cast or knee immobilizer.

Surgical repair is the treatment of choice for a complete rupture of the quadriceps or patellar tendon and for a displaced patellar fracture. Partial tendon tears and nondisplaced fractures can be treated with a period of immobilization, including either a cylinder cast or knee immobilizer.

HIP DYSPLASIA: ___ of the lower extremities is the only modifiable risk factor for DDH and should be avoided in all newborns

Swaddling of the lower extremities is the only modifiable risk factor for DDH and should be avoided in all newborns

Systemic signs or symptoms such as fever and malaise, weight loss, bruising, or other generalized symptoms increase the likelihood of an underlying infectious, inflammatory, or neoplastic process. Activity-related discomfort, which is relieved by ___, is characteristic for various overuse syndromes of childhood and adolescence. Pain that awakens a patient from sleep (night pain) is worrisome for infection or ___. Stiffness when the patient wakes in the morning suggests an underlying ___ disease. A ___ limp often relates to a congenital or developmental process, for example, Legg-Calvé-Perthes disease. A family history of musculoskeletal conditions (juvenile idiopathic arthritis or other inflammatory diseases, hip dysplasia) can suggest a similar disorder in the child.

Systemic signs or symptoms such as fever and malaise, weight loss, bruising, or other generalized symptoms increase the likelihood of an underlying infectious, inflammatory, or neoplastic process. Activity-related discomfort, which is relieved by rest, is characteristic for various overuse syndromes of childhood and adolescence. Pain that awakens a patient from sleep (night pain) is worrisome for infection or tumor. Stiffness when the patient wakes in the morning suggests an underlying inflammatory disease. A painless limp often relates to a congenital or developmental process, for example, Legg-Calvé-Perthes disease. A family history of musculoskeletal conditions (juvenile idiopathic arthritis or other inflammatory diseases, hip dysplasia) can suggest a similar disorder in the child.

HIP DYSPLASIA: The ___ maneuver is provocative; it attempts to displace the femoral head posteriorly from the acetabulum. To perform this test, the infant's hips and knees are flexed to 90° and the examiner's thumb is placed along the medial thigh and the long finger along the lateral axis of the femur. Gentle pressure is applied to the knee in a posterior direction while the femur is adducted. The ___ maneuver is positive if a "clunk" occurs as the femoral head dislocates posteriorly over the acetabular margin

The Barlow maneuver is provocative; it attempts to displace the femoral head posteriorly from the acetabulum. To perform this test, the infant's hips and knees are flexed to 90° and the examiner's thumb is placed along the medial thigh and the long finger along the lateral axis of the femur. Gentle pressure is applied to the knee in a posterior direction while the femur is adducted. The Barlow maneuver is positive if a "clunk" occurs as the femoral head dislocates posteriorly over the acetabular margin

LCP in PEDS: The ___ sign, which represents a subchondral fracture, is seen on frog-lateral radiographs in many patients

The crescent sign, which represents a subchondral fracture, is seen on frog-lateral radiographs in many patients

In genu varum, The distance between ___ should be measured with the patient standing and the medial malleoli apposed.

The distance between the medial femoral condyles (intercondylar distance) should be measured with the patient standing and the medial malleoli apposed.

IN PEDS WITH IN/OUT TOEING: The examination documents a ___profile, which includes measuring the foot progression angle, or the angle that the foot makes relative to the line of progression as the child walks ; hip rotation, or femoral rotation ; thigh-foot axis, or tibial rotation ; and the foot alignment

The examination documents a rotational profile, which includes measuring the foot progression angle, or the angle that the foot makes relative to the line of progression as the child walks ; hip rotation, or femoral rotation ; thigh-foot axis, or tibial rotation; and the foot alignment

The extremities are aligned in 10° to 15° of ___ (bowlegged) at birth and gradually straighten to neutral alignment by 12 to 18 months of age. The limb develops valgus alignment at or after 2 years of age, with maximal valgus (10° to 15°) observed between 3 and 4 years of age. This gradually improves to the adult mean of approximately 5° to 7° of valgus (normal range, 0° to 10°) by 11 years of age

The extremities are aligned in 10° to 15° of varus (bowlegged) at birth and gradually straighten to neutral alignment by 12 to 18 months of age. The limb develops valgus alignment at or after 2 years of age, with maximal valgus (10° to 15°) observed between 3 and 4 years of age. This gradually improves to the adult mean of approximately 5° to 7° of valgus (normal range, 0° to 10°) by 11 years of age

HIP DYSPLASIA: The goal of treatment of instability in the neonate and infant is to achieve a concentric reduction of the femoral head and maintain the reduction while the acetabulum develops. If DDH is detected within the first few months, most hips will reduce with a dynamic positioning device, such as a ___ harness. The ___ harness is typically used in infants up to approximately 6 months of age.

The goal of treatment of instability in the neonate and infant is to achieve a concentric reduction of the femoral head and maintain the reduction while the acetabulum develops. If DDH is detected within the first few months, most hips will reduce with a dynamic positioning device, such as a Pavlik harness. The Pavlik harness is typically used in infants up to approximately 6 months of age.

The initial treatment of an ___ includes application of a protective brace with the knee in extension, oral analgesics, frequent application of ice in the first 24 to 48 hours, and modified weight bearing.

The initial treatment of an acute patellar subluxation or dislocation includes application of a protective brace with the knee in extension, oral analgesics, frequent application of ice in the first 24 to 48 hours, and modified weight bearing.

The major problem associated with posteromedial bowing is ___, and almost all patients will require some form of treatment. Because the mean discrepancy is approximately 4 cm at skeletal maturity, most patients will require either a shoe lift or an epiphysiodesis.

The major problem associated with posteromedial bowing is limb-length discrepancy, and almost all patients will require some form of treatment. Because the mean discrepancy is approximately 4 cm at skeletal maturity, most patients will require either a shoe lift or an epiphysiodesis.

A plica is a fold of the synovium of the knee. The synovium of the knee joint has five basic plicae, which are usually asymptomatic. Three (suprapatellar, medial, and infrapatellar) are distinct structures, whereas two others are less pronounced and are considered to be minor folds. The ___ plica is the plica that most often becomes pathologic.

The medial plica is the plica that most often becomes pathologic.

LCP of PEDS: The overall goal of any treatment is to achieve an outcome in which normal ___. During the early phases, the patient is treated with activity restriction (with or without short periods of bed rest) and anti-inflammatory drugs, and symptoms and range of motion are monitored closely.

The overall goal of any treatment is to achieve an outcome in which normal sphericity of the femoral head and congruence is maintained between the femoral head and the acetabulum. During the early phases, the patient is treated with activity restriction (with or without short periods of bed rest) and anti-inflammatory drugs, and symptoms and range of motion are monitored closely.

when considering genu valgum, The tibiofemoral angle can be measured using a goniometer, and the ___ distance is measured as the distance between the medial malleoli with the patient standing with the medial femoral condyles touching.

The tibiofemoral angle can be measured using a goniometer, and the intermalleolar distance is measured as the distance between the medial malleoli with the patient standing with the medial femoral condyles touching.

IN PEDS WITH IN/OUT TOEING: Treatment focuses on ___ for the family, as most cases will improve or resolve spontaneously. Derotational osteotomy of the affected bone (femur or tibia) is reserved for the less than 1% of patients with severe torsional abnormalities.

Treatment focuses on education and reassurance for the family, as most cases will improve or resolve spontaneously. Shoe modifications, braces, and exercises do not alter the normal rotational development of the femoral and tibial axes. Foot deformities may require specific treatments, such as casting for persistent or rigid metatarsus adductus. Derotational osteotomy of the affected bone (femur or tibia) is reserved for the less than 1% of patients with severe torsional abnormalities.

what are the 3 phases of treatment for patellar tendinitis

Treatment is directed primarily at relieving symptoms and involves three critical aspects: relative rest and pain control, restoring pain-free motion and strength, and resuming activities.

Treatment of a symptomatic bipartite patella is similar to that of symptomatic ___.

Treatment of a symptomatic bipartite patella is similar to that of symptomatic plica.

____ is becoming an increasingly useful modality for imaging popliteal cysts. In addition to its role in characterizing the location and extent of the cyst, ___ is useful in localizing needle placement for cyst aspiration. Cyst aspiration without ___ guidance should be approached with caution because of the proximity of neurovascular structures in the popliteal fossa. Cyst fluid may be gelatinous and not easily retrievable with a standard-bore needle.

Ultrasonography is becoming an increasingly useful modality for imaging popliteal cysts. In addition to its role in characterizing the location and extent of the cyst, ultrasonography is useful in localizing needle placement for cyst aspiration. Cyst aspiration without ultrasonographic guidance should be approached with caution because of the proximity of neurovascular structures in the popliteal fossa. Cyst fluid may be gelatinous and not easily retrievable with a standard-bore needle.

___ is especially useful during the first few months of life, before the femoral head has ossified, to establish the diagnosis and to monitor the effects of treatment , but should not be done prior to age 6 weeks because of the high false-positive rate associated with normal neonatal laxity.

Ultrasonography is especially useful during the first few months of life, before the femoral head has ossified, to establish the diagnosis and to monitor the effects of treatment, but should not be done prior to age 6 weeks because of the high false-positive rate associated with normal neonatal laxity.

Valgus alignment is inward angulation of the extremity in the frontal plane, with the tibia ___deviated relative to the femur

Valgus alignment is inward angulation of the extremity in the frontal plane, with the tibia laterally deviated relative to the femur

In pediatric genu valgum/varum, When the deformity is severe or when the patient has insufficient growth remaining for a hemiepiphysiodesis, an ___ is required to realign the limb

When the deformity is severe or when the patient has insufficient growth remaining for a hemiepiphysiodesis, an osteotomy is required to realign the limb

With a long-standing patellar tendinitis, quadriceps atrophy, especially of the vastus ___, can develop.

With a long-standing condition, quadriceps atrophy, especially of the vastus medialis obliquus, can develop.

With a pathologic medial plica, tenderness is localized to the medial aspect of the ___ and can be palpated.

With a pathologic medial plica, tenderness is localized to the medial aspect of the patella and can be palpated.

With congenital short first metatarsal, shortening of the great toe is obvious and often is associated with hallux ___ or medial deviation of the great toe. Surgical treatment is warranted if problems with shoe wear develop. A short first metatarsal also can be seen in fibrodysplasia ossificans progressiva, a rare condition associated with progressive and diffuse ossification within various soft tissues.

With congenital short first metatarsal, shortening of the great toe is obvious and often is associated with hallux varus or medial deviation of the great toe. Surgical treatment is warranted if problems with shoe wear develop. A short first metatarsal also can be seen in fibrodysplasia ossificans progressiva, a rare condition associated with progressive and diffuse ossification within various soft tissues.

Shin splints (medial tibial stress syndrome) is a condition characterized by the gradual onset of pain in the posteromedial aspect of the ___ third of the leg

distal

genu ___ = knock knees genu ___ = bow-legged

genu valgum = knock knees genu varum = bow-legged

In congenital vertical talus: Because of the rigidity of the deformity, most patients require an extensive soft-tissue release for reduction. A new technique has been reported (the reverse ___) that involves serial casting, followed by percutaneous release of the Achilles tendon. This method may reduce the need for more extensive surgical releases

ponseti

surgery is the tx of choice for patellar tendon rupture. These require intervention within ___ of injury. Retears usually occur within the first ___ months of surgery.

surgery is the tx of choice for patellar tendon rupture. These require intervention within 1 w of injury. Retears usually occur within the first 6 months of surgery.

Hip dysplasia: The ___ maneuver attempts to relocate a dislocated hip. With the hips and knees flexed to 90°, the hip/thigh is manually abducted while the examiner applies gentle pressure from posterior to anterior with the long finger placed behind the greater trochanter. The ___ maneuver is positive when a "clunk" of reduction occurs as the femoral head slides over the posterior lip and into the acetabulum. Of these two maneuvers, the ___ is controversial because it almost always resolves spontaneously and therefore has little predictive value for future DDH. If performed too vigorously, it can actually create hip instability

the Ortolani maneuver attempts to relocate a dislocated hip. With the hips and knees flexed to 90°, the hip/thigh is manually abducted while the examiner applies gentle pressure from posterior to anterior with the long finger placed behind the greater trochanter. The Ortolani maneuver is positive when a "clunk" of reduction occurs as the femoral head slides over the posterior lip and into the acetabulum. Of these two maneuvers, the Barlow is controversial because it almost always resolves spontaneously and therefore has little predictive value for future DDH. If performed too vigorously, it can actually create hip instability

Congenital ___ talus is rare and appears as a flatfoot with a convex sole (rocker-bottom or "Persian slipper" foot), which is diagnosed shortly after birth or in infancy

vertical

____ men between ages 40 and 60 years have a predilection for quadriceps tendon ruptures, and middle-aged ___ men have a predilection for patellar tendon rupture.

white men between ages 40 and 60 years have a predilection for quadriceps tendon ruptures, and middle-aged African American men have a predilection for patellar tendon rupture.