1yr - 10kg

5yr - 20 kg

10yr - 30 kg

birth - 20inch

1yr - 30 inch

3 yr - 3ft

Birth average -  35 cm

0 to 2yrs - increase 1cm/mo

2+ yrs - 10 cm growth for the rest of life

Ballard Scale

FYI, not on exam...

The Physical criteria

1. Skin

2. Ear/Eye

3. Lanugo Hair

4. Plantar Surface

5. Breast bud

6. Genitals

The Neurological criteria

1. Posture

2. Square Window

3. Arm Recoil

4. Popliteal Angle

5. Scarf sign

6. Heel to Ear

to determine quickly whether a newborn needs immediate medical care - at 1 and 5 minutes.

Rate the following from 0 (poor) to 2 (perfect): 

Appearance (color)

Pulse (should be greater than 100)

Grimace (relflex irritability)

Activity (muscle tone, resisting extn)

Respiratory (breathing, strong cry)

total perfect score-10

TORCHeS

T: toxoplasmosis

O: other (HIV, parvovirus B19)

R: rubella

C: cytomegalovirus (most common)

He: herpes simplex virus

S: syphilis

A Shortened glascow coma scale.

A - Alert

V - response to voice

P - response to pain

U - unresponsive.

Anything less than A needs immediate medical attn.

HR 120-160

RR 30-60

take temp rectally

milia

[image]

posterior closes at 2 months

anterior closes 7-18 months (ave 2 yrs)

sunken= dehydration

bulging = increased intracranial pressure

[image]

caput succedaneum - caused by vaccum extraction during delivery, babies look like cone heads

[image]

cephalohematoma - hemorrhage of blood between the skull and the periosteum

[image]

• A smooth philtrum — The divot or groove between the nose and upper lip flattens
• Thin vermilion — The upper lip thins
• Small palpebral fissures — Eye width decreases

turner's syndrome - 1:2500 girls, 1 X chromosome is missing or abnormal.

[image]

normal - s1, s2 splitting (s2 with inhale); s3

pathological ALWAYS - S4

physiologic - asx, SYSTOLIC, <3/6

pathologic - systolic >3/6 and DIASTOLIC

ASD - foramen ovale did not close

spontaneous closure in 90% (<3mm), surgery for larger defects

S1 - systole, closure of mitral valve (and tricuspid)

S2 - diastole, closure of aortic valve (and pulmonary valve

S3 - ventricular gallop.  ¨ken-tuc-ky¨ middle of diastole, oscillation of blood between walls of ventricles indicating increased blood volume in ventricles.  Listen w/ bell.  Later in life, could mean dilated CHF.

S4 - atrial gallop. ¨Ten-nes-see¨ just befort S1 at apex in LLD position holding breath.  Blood being forced into stiff/hypertrophic ventricle.

[image]

GRADES 1-6.  3/6 is loud.  4/6 has palpable thrill. 6/6 heard without stethoscope.

auscultation of newborn reveals holosystolic murmur.

complications?

Ventral Septal Defect-->can lead to pulm HTN and CHF (leading to failure to thrive aka FTT).

Spontaneous closure up to 50%.  Surgical repair for FTT and HF.

Machinery-like murmur in 2nd intercostal space, bounding peripheral pulses, and wide pulse pressure on newborn

Patent Ductus Arteriosus

L to R shunt between aorta and pulm artery.

Larger defect could cause left heart failure.

[image]

Patent Ductus Arteriosus

1) possible cause

2) is it normal?

3) tx

Patent Ductus Arteriosus

1) possible cause - maternal rubella

2) is it normal? yes, in full term newborns, dissapears in 12-24 hrs

3) tx - indomethacin for closure or surgery

a type of abdominal wall defect in which the intestines, liver, and occasionally other organs remain outside of the abdomen in a sac because of a defect in the development of the muscles of the abdominal wall.

The sac, which is formed from an outpouching of peritoneum, protrudes in the midline, through the umbilicus (navel).

omphalocele

[image]

normal mucoid discharge (even bloody); identify urethral and vaginal openings; clitoris size to exclude ambiguous genitalia

t/c hip dysplasia

Barlow Test is for diagnosis: push the ball of the hip rearward out of the socket.

Ortolani test is a maneuver to reduce a recently dislocated hip.

Primitive Reflexes

1) Moro

2) Rooting

3) Palmar

4) plantar/babinski

5) Tonic neck/fencer's position

1) Moro reflex - startle response.  Legs and head extend, arms jerk up w/ palms up and thumbs flexed.  Then, arms brought together and clenched into fists.  Gone by 2 months.

2) Rooting reflex - assists breastfeeding.  Head turns to anything that strokes cheek/mouth and then searched for object by moving head in decreasing arcs.  Gone by 4 months.

3) Palmar grasp - gone by 6 months.  Palm is stroked, fingers close.

4) plantar reflex (BABINSKI) - dorsiflexion of toes when foot stroked, normal response, should be gone by 2 yrs.  Sign of UMN lesion in adults.

5) Tonic neck reflex (FENCER'S POSITION) - head rotated to one arm and arm extends, while other arm flexes and fist clenched.  REverse happens when head is turned.

non cyanotic congenital heart defects:

1) systolic murmur in pulmonic area with wide split of S2

2) pansystolic murmur on LSB with thrill

3) continous diastolic + systolic murmur

non cyanotic congenital heart defects:

1)ASD: systolic murmur in pulmonic area with wide split of S2

2)VSD: pansystolic murmur on LSB with thrill

3)PDA: continous diastolic + systolic murmur

CNS tumor

gonadal tumor

congenital adrenal hyperplasia

constitutional (FHx of delayed puberty & short stature)

malnutrition

chronic disease

chromosomal

1) ABCs

2) Hx - choking, aspiration, apnea, poor ventilation, arrythmias

3) Labs - Na, BG, Mg, Ca

4) Give Meds: diazepam, lorazepam, fosphenytoin, coma induction

5) reassess vitals, mental status, irritability, PE

Lytes/glucose

CNS mass/bleed/abcess/trauma

bacterial/viral meningitis

encephalitis

shigella

todd's paralysis

ingestion

epilepsy

febrile seizure

BACTERIAL MENINGITIS

dx:

kernig's, brudzinski (NOT ACCURATE FOR KIDS < 1 YR!) paradoxical consolability - don´t want to be touched stiff neck

DO lumbar puncture (but not w/ incr ICP)

Neisseria meningitidis (meningococcus)

Streptococcus pneumoniae (pneumococcus)

<5y/o= H. influenzae type B (in non immunized).

tx and mortality for bacterial meningitis in neonates and older kids

supportive therapy

% with neuro damage complications

Neonates - cefotaxime, ampicillin covers listeria, 5-10% death.

Older kids - cefotaxime, vancomycin, 15-20% death.

Supportive therapies - BP, ICP, anti-epileptic meds

Neuro damage in 30% = delay and impaired hearing.

epidemiology of febrile seizures

1) % of kids

2) age range

3) duration of seizure

2-4% of kids

6 mos to 6 years

less than 15 minutes (ave less than 5 min)

roseola (HHV6) and AOM

**Note, often FHx of febrile seizures, no increased risk for epilepsy**

Not sleeping well, Hx of URI symptoms, not drinking well, not wanting to lie down, new fever, tugging at ear

dx, tx, complications

Dx - AOM

Tx - can wait 48 hours. amox, augmentin, 3rd generation cephalo for pseudomonas coverage.

other tx - Bilat myringotomy (tubes)

Complications: perf (self resolving), mastoiditis, meningitis, hearing impariment.

strep.

because....strep gets better in 3 days even w/o treatment and is accompanied by h/a, fever, abdominal pain.

EBV (infectious mononucleosis)

fever, sore throat, and posterior cervicle lymphadenopathy. Sometimes, a swollen spleen or liver involvement may develop

fever, abd pain, h/a, rash, palatal petechiae +/- URI sx and AOM

dx, testing, tx, complications

[image]

Strep Throat - GABHS.

dx - Rapid strep 95% effective.

Tx if high clinical suspician but tests negative.

tx- PCN, amox suspension for taste, clindamycin for reccurent strep

complication -  retro/parapharyngeal abcess, AGN, rheumatic fever.

sunken fontanelles and eyes, clammy skin, cap refill >3sec, impalpable pulse, parched mucosa.

these sx represent % of water loss in infant and child?

infant - 15%

child - 9%

(%hydrated/100) = (current wt/well weight)

eg: 10% dehydrated 11kg child

90/100=11/x

x=12.2

so...give 1.2 liters of IV fluid over 24 hrs

bolus 20ml/kg

Maintenance (ml/hr) =

4ml x 1st 10kilos

2ml x 2nd 10kilos

1ml x rest of kilos

IN ADDITION, give deficit over 24 hrs=

50% over 1st 8 hrs

50% over 2nd 16 hrs

characterized by some combination of apnea, color change, change in muscle tone, choking, or gagging.

whats your work up for this kid?

apparent life threatening event

Neuro - CT scan, EEG, pneumogram

Pulmonary - CXR, pulse ox, influenza

Cardiac - ECG, echo

GI - upper GI, pH probe

2.5% diagnosed in ER

50% neglect, 30% physical, 20% sexual

girls 8-12 yrs

RISKS: poor child-parent or parent-parent relationships, and a nonbiologically related male in house increase risk.

unintentional injury 50%

homicide 14%

suicide 12%

gonadotropin releasing hormone GnRH released from hypothalamus

stimulates release of FSH, LH from ant pituitary

stimulates gonads to produce estrogen/testosterone

Max growth for girls and boys

% of ht achieved during this time

girls 11.5-12: fat location changes

SMR3-4 breast development

SMR3 pubic hair development

boys 13-14 (longer): fat quantitiy increases, muscle mass doubles between 10-17.

80-90% ht achieved

at age 21 or within 3 yrs of sex (no longer current guidelines)

OR if presenting with abd pain, STIs, menstrual irregularities, before starting OCP

Early, middle, late adolescence - ages and social characteristics

Early 10-13: concrete thoughts, unrealistic goals, more comfortable with same sex

Middle 14-16: emotions, mood swings, abstract thinking, self-centered, autonomy from parents

Late 17+: idealism (concrete concepts of right and wrong), less self-centered, realistic goals for future

age at

1) gender identity

2) sense of masculine/feminine

age at

1) gender identity at age 2

2) sense of masculine/feminine at age 5-6

criteria for anorexia inpatient tx - when to admit

1) body wt

2) HR

3) two clinical presentations

4) K+ level

5) wt loss

6) previous experience

7) current

adolescent suicide

1) highest rate

3) highest rate of unsuccessful suicides

adolescent suicide

1) highest rate - white males

3) highest rate of unsuccessful suicides - 3x higher in females

occurs between 2-4 wks after birth in 20% of newborns.  inflammatory papules/pustules on face.

dx

resolved when?

cause?

acne neonatorum

resolves by 6-12 months

Presumed to be due to hormonal withdrawal

1-2 mm white papules on face.  Epidermal cysts filled with keratin.  40% of newborns.  rupture spontaneously.

dx

if present in mouth, called what?

Milia

In mouth - Epstein Pearl (85% of newborns)

blue black macule over lumbosacral area.  Also on shoulders, back, butt.

[image]

dx

prevalence?

tx

Mongolian spots (can be mistaken for child abuse)

90% of native am, afr am, asain newborns

fades as child ages

red, rubbery nodules.  benign tumors of capillary endothelial cells, present by 2-4wks after birth.

dx

when does it go away

when is immediate tx needed, how to tx?

Hemangioma

90% gone by age 9

tx if obstruct vision, airway, cardiac decompensation

tx w/ prednisone 2-3mg/kg x 6-12 wks

2nd line: interferon if not responding.

[image]

50% of newborns get this within 1-2 days after birth. Splotchy, erythematous macules on trunk, face, extremities.

dx

may be associated with what?

when does it go away?

erythema toxicum

may be assoc w eosinophilia in blood

gone by day 7[image]

greasy yellow scale that affects primarly the scalp in infants (cradle cap)

dx

tx

seborrhea

tx: spontaneously resolve at 8-12months, DON'T USE keratolytic shampoos like nizorel.

USE low potency steroids.[image]

whitish plaques on erythematous base on buccal mucosa

dx, tx

Thrush - candida albicans

tx: nystatin susp QID

fluconazole PO

breastfeeders - treat mother's nipples topically

occlusion of the sebaceous follicle opening produces clinical lesions on face, upper chest, back.

neonatal and adolescent

complications

types of clinical manifestations

tx

acne vulgaris

neonatal - appears 2-4 wks, gone by 6 months

adoescent - appears 8-10 years

complication: cystic acne requires attn ASAP b/c of scarring.  can form sinus tracts

manifestations:

open comedone/black head - predominant lesion in early adolescent acne.  obstruction at follicular mouth

closed comedone/white head - obstruction beneath follicular opening.  precursors of inflammatory acne lesions

tx: benzoyl peroxide

PO/topical ABX

topical retin A

OCP

Accutane as last resort

exposed areas (face and extremities) or diaper area of infants.  begins as smal vesicles easily ruptures...erosions by covered by moist, honey-color crusts. occurs in warm climate months.  enhanced spread by crowding.

dx, etiology

tx

Impetigo - staph aureus or GABHS.  VERY CONTAGIOUS.

tx: PO ABX - cephalexin (KEFLEX) and cefaroxil (DURICEF)

topical BACTROBAN TID

HAND WASHING - stress this![image]

grouped vesicles on erythematous base on lips, cheeks, chin, or eyes. preceded by tingling sensation 85% of time in recurrent cases.

dx

1) types

2) incubation pd

herpes simplex virus I -

dx by Tzank smear (scrape with #15 blade, smear of glass slide, stain with Wright stain.  Positive if multinucleated giant cells indicates HSV or VZV.

1) types - primary, reccurrrent

2)  incubation pd - 2 to 12 days

herpetic whitlow

*seen in thumb suckers often* results from innoculation of HSV through cutaneous break.

acyclovir PO QID or topical

penciclovir q 2 hrs x 4 days

avoid precipitating factors

flesh, white, or yellow colored papules with central umbilication/indentation, diameter 1-15 mm on extremities, head, neck (type I) OR on genitals (type II)

dx and etiology

incubation

contagious?

tx

dx: molluscum contagiousum

(pox-virus induces benign epidermal cell proliferation)

incubation 2-7wks

contagious as long as active lesions present

tx: cantharidin or trichloroacetic acid 25% applied with wooden toothpick to central umbilication and then neutralize with alchohol.

OR cryotherpy is best.

[image]

verrucae

common - verruca vulgaris - papule with irreg, scaly border.

flat - verruca plana - multiple, flat-topped, broad, skin colored papules, affinity to face and extremities

plantar - verruca plantaris - papule is pushed into the skin

venereal - condyloma acuminata - multiple confluent papules w/ irregular surface on genital mucosa or adjacent skin

cryotherapy, salicyclic acid, retin A cream, podophyllum, surgery

80% recurrence

well demarcated lesion with central clearing, scaling, +/- erythema, alopecia, broken hairs

dx

tx

complication

tinea capitis

tx: griseofulvin PO up to 6months with fatty foods

topical nizoral, selsun blue as adjunct

complication: kerion, a boggy nodule with pustules

well demarcated lesion with papular boder and central clearing, scaling, erythema, contagious, self contamination.

also called ringworm

topical antifungals 90% effective - lotrimin, nizoral (ketoconazole) x 4 wks

other: cotton, airing, no underwear during sleep

thick, s/f, exaggerated, scaling, cracked erythematous skin w/ macerated moist pruritic skin btwn toes

athletes foot

dx

tx

tinea pedis

tx: topical antifungal or antifungal/steroid combos

betamethasone .05%, clotrimazole 1% BID x 12 wks

multiple oval macules (hypo/hyperpigmented) with fine scales on neck, chest, upper back, shoulders, non-contagious yeast found on all humans

dx

tx

tinea versicolor - pityrosporum ovale

tx: topical azoles or selenium sulfide BID x 4 wks

diaper rash - beefy red papules or plaques on skin in the folds of infants with satellite lesions

1) dx

2) often follows what?

3) labs

4) tx

1) candida albican

2) ABX use

3) KOH prep = budding yeast hyphae

4) tx: topical antifungals QID x 5 days, educate about hygeine, air out

GABHS mediated rash - fine macules and papules on neck and spreading down to trunk and extremities, NO PALMS AND SOLES. 1-2mm papular elevations giving sandpaper quality

1) dx

2) ages

3) appears how long after infection

4) associated s/s

5) labs

6) tx

1) dx: scarlatina, scarlet fever.

2) ages - 2 to 10 years

3) appears how long after infection: 1-2 days

4) strawberry tongue, generalized lymphadenopathy, desquamation

5) labs: throat culture positive

6) PCN, ampicillin, amox

PCN allergy= use erythromycin

prodromal s/s followed by maculopapular erythematous rash on forehead and face, spreading down to neck, body, extremities, KOPLIK'S SPOTS( small red lesions with blue-white centers on oral mucosa and conjuctiva)

1) dx

2) type of virus

3) transmission

4) contagiousness

5) tx

1) dx: measles (rubeola)

2) type of virus: RNA

3) transmission: transfer of nasopharyngeal secretions

4) contagiousness: 5 days after exposure to 4-5 days after rash gone

5) tx: supportive, monitor for 2º infections, encourage vaccination (NO RELATION BTWN AUTISM AND VACCINE)

Prodromal s/s plus anorexia, paiinful enlargement of salivary glands under ears/jaw on one or both sides of face (parotitis)

1) causative agent

2) time of year

3) ages

4) transmission and incubation

5) contagiousness

6) complications

7) tx

1) MUMPS - RNA virus

2) time of year - spring

3) ages - 10 to 19 years

4) transmission and incubation - respiratory, incubation 14-25 days

5) contagiousness - 3 days prior to gland swelling, 4-6 days after.  less than measles or varicella.

6) complications: orchitis, oophoritis, meningitis, encephalitis

7) tx - supportive, prevent transmission

fever, lymphadenopathy, maculopapular rash progresses from head to foot, lasts 3 days, itchy.  Rash more prominent after hot shower.

1) dx

2) time of year

3) transmission

4) incubation

5) contagiousness

6) tx

7) complications

1) dx - RUBELLA (third dz, german measles)

RNA virus

2) time of year - winter/spring

3) transmission - respiratory

4) incubation - 14 days

5) contagiousness - 7 days before, 5-7 days after rash appears

6) tx - supportive

7) complications - arthralgias, encephalitis, hemorragic disorder uncommon

malaise, fever, generalized pruritic rash of macules papules vesicles and crusted lesions.

1) dx

2) incubation

3) contagiousness

4) transmission

5) tx

6) complications

1) dx - Varicella (VZV) HHV3.  Chicken pox then zoster.

2) incubation - 14 days

3) contagiousness - 2 days before rash through 5 days, or until lesions have crusts

4) transmission - resp, direct contact, inhalation vesicular fluid

5) tx - supportive, vaccinate

6) complications - 2º infection of skin, peumonia, reyes, meningitis/encephalitis

Erythema infectiousum, fifths disease

caused by parvovirus B19

tx= supportive.  careful during pregnancy.

roseola infantum - HHV6,7

transmitted during respiratory secretions

tx supportive

nits 1cm from scalp, firmly attached to hair shaft.  Nocturnal pruritis

dx, tx

Pediculosis Capitis (head lice)

whites>>>non whites

tx: permethrin (ELIMITE; NIX)

massage into scalp, set 10 min, rinse, fine tooth comb, repeat in 7 days.

CLEAN EVERYTHING.

intesne pruritis, worse at night.  Papules on abdomen, dorsa of hands/feet, elbows, periaxillary skin and interdigital webs.  2º impetigo may be seen, as well as S-shaped burrows.

dx, tx

scabies - 8 legs, live 40 days on human, 2 days off human.

Close personal contact to contract.

tx: permethrin (ELIMITE) - apply from neck to toes (include head <2y/o), leave overnight. 

Store bedding/clothing for 3 days.

Handwashing.

asthma, allergic rhinitis, atopic dermatitis (eczema)

runs in families

infants: extensor surfaces, cheeks, face, trunk

children: flexor surfaces of arms and legs

inflammation in the s/f dermis and epidermis characterized by disruption of the skin surface.  heriditary

1) dx

2) clinical appearance

3) tx

4) begins at what age, how many have manifestations during adolescence

1) atopic dermatitis (eczema)

2) dry skin, thickened from scratching

3) get rid of aggravators, topical steroids, wet dressings, antihistamines.

4) begins 1-4 months, few continue into adolescence

contact dermatitis

1) majority of cases (80%)

2) tx

1) majority of cases (80%) - irritant contact dermatitis (acids, solvents, soaps) vs allergic (plants, ABX, latex, cosmetics, metals)

2) tx: antihistamines, topical corticosteroids, oral prednisone.

well circumscribes, erythematous pruitic plaques/wheals may be migratory.

dx

1) types

2)tx

3) complication

dx - urticaria

1) types: acute (allergic), chronic (idiopathic, autoimmune)

2)tx:PO:  antihistamines, short term corticosteroids

3) complication:  immediate attn - angioedema, respiratory stridor/wheezing

oval lesions composed of tiny papules with fine scale, may be itchy.

herald patch (single, papular, erythematous lesion enlarging over 1-2 days)

[image][image]

christmas tree distribution

1) dx

2) age group

3) tx

pityriasis rosea

2) teens/ young adults

3) suuportive.  oral antihistamines PRN.  rash may last 6 wks, no therapy will shorten eruption.

Pervasive Developmental Disorders (PDD)

unofficially - autistic sprectum disorders (ASD)

Autism

1) appears when

2) what type of disorder

1) appears by 3 years

2) neurologic disorder and developmental disability - impairments in social interactions, communication, imaginative play

Autism

Asperger's

PDD NOS

Rett's Syndrome

Childhood Disintegrative Disorder

6+ items total, including...

2+: social impairment

-no multiple nonverbal behaviors (eye contact)

-bad peer relationships

-no sponatenous seeking of enjoyment

-no social/emotional reciprocity

1+: communication impairment:

-language delay or none

-inability in sustaining conversation

-repetitive use of language

-lack of varied play

1+: repetitive and stereotyped patterns:

-inflexible and adherent to specific routines

-repetitive movement

-preoccupation with parts of objects

ADDITIONAL CRITERIA prior to age 3, delayed in following areas:

1) social interaction

2) language in social communication

3) symbolic/imaginative play

Autism

1) epidemioloy

2) impairments evident by

3) % mental retardation

4) % without useful communication skills

5) % with seizure disorders

1) 5/10,000, 4:1 males

2) impairments evident by age 3

3) 75% mental retardation

4) 50% without useful communication skills

5) 33% with seizure disorders

• no significant delay in language
• no significant delay in cognitive development, self-help skills, adaptive behavior, curiosity

• NORMAL intelligence
• ALL INCOMPASSING interest, which may be developmentally typical or atypical
  

• personal space
• motor clumsiness
• loud noises, clothing, food texture sensitivity
• volume, intonation, inflection, rhythm of speech off
• can´t understand others feelings, interpret social cues
• formal style of speaking, literal interpretation of language
• innapropriate social responses
• no give and take of conversations

Screening: CHAT (toddlers), PDDST

Diagnostic Rating Scales

Gilliam, CHildhood, Gilliam Asperger's

controversal - chelation, omega-3

• stimulants for hyperactivity - poorly tolerated
• SSRI for repetitive behavior - fluoxetine
• SGA for aggression - risperidone

• Ind Edu Program (IED) for school age kids
• Speech, OT, PT therapy
• ABA - applied behavoral analysis to improve social skills and verbalization/communication

Major depressive disorder (MDD)

1. definition and substitute definition for children

Criteria for MDD= 2+ weeks of 4+ sx:

Epidemiology of MDD in 

1. Children

2. Adolescents

3. Lifetime prevelence

4. what % go untreated

5. what % will have MDD in adulthood

6.  what is the male to female ratio of MDD in children and adolescents

1. 2-4% Children

2. 8% Adolescents

3. 15% Lifetime prevelence

4. 50-75% go untreated

5. 70% will have MDD in adulthood

6.the male to female ratio of MDD in children is 1:1 and adolescents is 1:2

MDD comorbidities

1. Psych-90%

2. Medical

1. Anxiety;ODD, CD;Substance use; ADHD;Learning disabilities and developmental disorders

1. —Irritable, low frustration tolerance, —Failure to thrive, —School refusal, phobias, Somatic complaints, Social withdrawal, Little verbalization of depression  

2. —Hypersomnia, Delusions, —High risk activities

FDA approved; fluoxetine (Prozac) MDD (>8yo), OCD (>7yo). Taper to d/c.

escitalopram (Lexapro) MDD (>12yo) . Taper to d/c.

CBT may mitigate risk of self harm in initial stages of SSRI treatment. 

combination of lateral head tilt and rotation deformity of cervical spine.

what is this? describe etiologies when seen in infancy and childhood

torticollis

infancy - congenital muscular

childhood - traumatic rotatory subluxation, Grisel's Syndrome (atlantoaxial rotary subluxation in association w/ pharyngeal infection), neoplasia of brain or C-spine

dx by CT scan if trauma is possible etiology

congenital muscular torticollis characterized by...

associated findings...

studies...

tx...

contracted sternocleidomastoid muscle (theory: compartement syndrome)

associated hip dysplasia (20%), cranial/facial asymmetry

studies: C-spine, hip U/S, CT if traumatic etiology

tx: stretch! (only if other etiologies ruled out)

surgery: >1yr, cosmetic, limited ROM

scoliosis

1) definition

2) etiologies

3) 7º on scoliometer = ? on XRAY

1) lateral curvature of spine >10º.  DESCRIPTIVE, NOT DIAGNOSIS

2) etiologies: idopathic (70% adolescents), neuromuscular, congenital, spinal cord issues/neoplasms

3) 20º

poor posture, hips stick out, uneven shoulders

skin lesions, differing leg lengths, pain, paresthesias, bowel/bladder sx, L-sided curve

whats your PE?

scoliosis

PE:

skin, symmetry, gait

 Adams forward bend test - no shirt, lean forward...if prominence, get XRAY-->PA/Lat

XRAY may show:

Cobb Angle - a measurement used for evaluation of curves in scoliosis on an AP radiographic projection of the spine  

Risser Sign - how far the patient's iliac apophysis  has progressed from the anterior superior iliac spine.

scoliosis tx

when to observe, brace, surgery

<25º - observe

25-50 - brace

>50º - surgery

Congenital failure of segmentation of tarsal bones.

what % bilat?

most common areas?

Tarsal coalition.

50% bilat.

talocalcaneal and calcaneonavicular.

FYI: review of tarsal bones.

[image]

[image]

s - Slipped

A - Above

L - Lower

T - through

R - Rammed

Fall onto outstretched hand.  Severe pain and can´t move elbow

dx and tx and complications

posterior elbow dislocation

[image]

Reduce then check stability and neurovascular status and get another radiograph to confirm reduction

[image]

complications: most common is intra-articular entrapment of medial epicondyle

annular ligament displacement after forceful longitundinal tractions (UE in slight flexion, pronation, internal rotation)

1) dx

2) common ages

3) tx

1) dx - nursemaids elbow

2) common ages - up to 6 yrs

3) tx - XRAY, no fracture...attempt reduction by supination, hyperflexion, and pressure over lateral aspect of arm.[image]

kids twists knee while running, gets hemarthrosis, and limps away

1) dx

2) PE

3) imaging

4) tx

1) ACL tear

2) Lachman and anterior drawer sign.  Also test varus-valgus stress for collateral ligament tears[image][image]

Lachman                      Ant Drawer

3)MRI

4) tx - reconstruction via hamstring graft, bone-patellar-bone graft

defect of pars interarticularis, L5 -S1 most common

1) dx

2) whats it called if there is anterior slippage of L5 on S1 in pediatric pt

3) sign on oblique xray

4) tx for #1 and #2

1) spondylolysis

2) sponylolisthesis - grade 5 (100% slippage)

3) scotty dog

[image]

4) tx for spondylolysis: restricted activity, PT, brace for comfort, not much progression

tx for spondylolisthesis: grades 3+ and neuro findings and deformity...do surgery

-degenerative disease of the hip joint

-growth/loss of bone mass leads to collapse of the hip joint and to deformity of the ball of the femur and the surface of the hip socket.

-characterized by idiopathic avascular osteonecrosis of the capital femoral epiphysis

1)dx

2) sex

3) ages, ave age

4) unilat or bilat

5) complications

6) 3 s/s

7) tx

Legg-Calve-Perthes Syndrome (LCP)

2) sex: male>females

3) ages, ave age: 2-12 (ave 7yr)

4) unilat usually

5) osteoarthritis (DJD) in adulthood

6) 3 s/s: painful limp, limited ROM, weakness

7) tx: maintain ROM, limit progression, surgery

displacement of the proximal femoral epiphysis from the metaphysis

1) dx

2) salter harris type

3) sex

4) age

5) unilat or bilat

6) risk factor

7) etiologies

8) presentation

9) labs

10) images

11) complications

12) tx

Slipped Capital Femoral Epiphysis (SCFE)

2) salter harris type I

3) male>female

4) age 12

5)  bilat 30-60%

6) risk factor: obesity

7) etiologies: idiopathic, hormonal during growth spurts b/c of weakness (thyroif, gonad, GHT), renal osteodystrophy, radiation therapy

8) presentation: limp, thigh/groin pain, knee pain 30% (obturator n.), decr hip int rotation, pain hip ROM

9) labs: thyroid, BUN/CR

10) XRAY

11) complication: AVN if undiagnosed, osteoarthritis

12) tx: surgery to prevent any additional slipping of the femoral head until the growth plate closes. If the head is allowed to slip farther, hip motion could be limited. treatment begins within 24 to 48 hours.

slipped capital femoral epiphysis

salter harris type I of proximal femoral epiphysis.

Slipped capital femoral epiphysis (SCFE) is the most common hip abnormality presenting in adolescence and is a primary cause of early osteoarthritis.

0-6mos:  asymmetric thigh folds, positive galleazzi, ortolani, and barlow

6mos-walking:asymmetric thigh folds, galleazzi, asymmetric abduction

barlow  and ortolani maneuvers

for what age group and for what?

FOR 0-6 MONTHS.

Barlow = back

Ortolani = abduct

POsitive tests = clunk felt and heard =

developmental dysplasia of the hip (DDH)

[image]

Child of walking age presents w/ leg length discrepency, painless limp, hyperlordoses, asymmetric abduction

1) dx

2) risk factors

3) etiologies

4) diagnostic tests (less than and greater than 6 months)

5) tx and complications (<6 months, <2yrs, >2yrs)

Developmental Dysplasia of the hip (DDH)

2) risk factors: beech birth (10x), female (4x), fam hx (4x)

3) etiologies:

hormonal (maternal relaxin), dysplasia gene (hyperlaxity, acetabular growth), mechanical, extra-articular (iliopsoas contracture, excess capsular tissue)

4) diagnostic tests:

<6month: U/S

>6 months: AP and frog leg lateral

5) tx:

<6months: PAVLIK HARNESS 90% effective (100º flex, 50º abduct) x 3month, do U/S in 3 wks.  Complication incl femoral n palsy, AVN

6mos-2yrs or failed PAVLIK: closed reducted in OR, cast  3-4 months. Complications: AVN, redisclocation, subluxation

>2yrs or failed closed reduction: open reduction

3 types of rotational deformities that form this....[image]

tx

femoral anteversion

internal tibial torsion

metatarsus adductus

tx: observe

correlation of JRA with adult RA

none

altered pain free kinematics, stiffness w/ activity, fatigue, joint warmth, muscle atrophy, joint contracture, growth disturbance (hyperemic physis= increased bld flow)

Systemic signs: fever, rash, hepatosplenomegaly, lymphedema, uveitis

XRAY shows joint widening early in the process, late stage joint narrowing, periosteal rxn, osteoporosis

1) dx

2) labs that support dx

3)tx

4) what % have good prognosis

JRA - dx is mostly clinical

labs: CBC shows anemia, leukocytosis, ESR, CRP, ANA

tx: preserve strength/ROM, prevent deformity, control pain, extre-skeletal management,

NSAIDS; steroid

70-85% good prognosis (not to adulthood)

radiograph shows parallelsim of talus and calcaneus

(here's a review of anatomy)

[image]

Congenital Clubfoot - Congential Talipes Equinovarus

[image]

2/1000

Boys>girls

50% bilat

Loder classification for Slipped capital femoral epiphysis

FYI:

[image]

UNSTABLE SCFE: unstable to walk, 50% get AVN

STABLE SCFE: able to walk, good prognosis

AVN of the hip

[image]

1) 3 traumatic etiologies

2) management

etiologies:

unstable SCFE

hip fx

hip dislocation

management:

reconstruction, fusion, replacement

1) radiograph

2) gross realignment

3) NEUROVASCULAR exam

4) send to specialist for reduction

5) closed reduction and cast 95% effective (open reduction for plates and screws)

IV ABX 24-48 hrs beginning immediately:

cephalosporin + aminoglycoside for contamination + PCN for farm injury

tetanus

irrigation/debridement non-viable tissue

stabilize/immobilize

wound closure/bone coverage

1)PE:

Neurovascular exam:

-pulse

-cap refill

-Ankle Brachial Index (ABI)

-sensory and motor

2) Fracture reduction in OR, then wait 10-15 minutes for spasm to resolve

3) open site, inspect popliteal a., do on table arteriogram and vascular repair

kid falls on her head during chearleading, she has burning in all extremities and inability to move extremities.

dx and management

CERVICAL CORD NEURAPRAXIA

1) ABCs and spine stabilization to ER

2) Neuro exam

3) imaging C-spine & full spine MRI

****exam is normal usually 10 minutes after trauma, all imaging is normal. The mechanism is thought to be due to brief compression of the spinal cord resulting in transient interruption of the spinal pathways.***

Torg ratio <0.80

torg ratio= diameter of cervical canal : to width of cervical body

**athletes with cervical cord neurapraxia (CCN) have torgue ratio      < 0.80**

normal MRI and exam

no previous CCN

Depression Scale For Children (CES-DC)

 Depression Scale For Children (CES-DC)

 screening tool

higher the score, more depressed.

scale 0-60

score >15 = suggestive of depression

2 y/o presents with barking cough and respiratory distress, worsening at night and improving in the morning. kid had recent URI.  PE reveals inspiratory stridor

+/- rales, diminished breath sounds (atelectasis), fever (50%)

1) dx and age group

2) etiology

3) pathophysiology

4) studies

5) tx

1) dx= CROUP: 6mos-3yrs

2) etiology: parainfluenza virus type I, other: RSV, influenza A&B, adenovirus, enterovirus, rhinovirus, measles, M. pneumoniae

3) pathophysiology - acute inflammation of upper and lower respiratory tracts.  Atelectasis if bronchioles become obstructed.

4) studies - AP neck/chest xray show subepiglottic narrowing, but dx is usually clinical

5) tx is supportive. 

lasts 3-4 days, resolves spontaneously. 

HYDRATE 

antipyretics.

cool humidified air

PO dexamethasone (corticosteroids)

racemic epinephrine

3 y/o presents with sudden onset of sore throat and high fever.  ASsociated dysphagia, drooling, inspiritary stridor.  Pt is sitting, leaning forward, w/ hyperextended neck and mouth open.

1) dx

2) age group

3) etiology

4) management

5) tx

EPIGLOTTITIS

-2 to 5 years

-H. Influenza type B in unvaccinated kids

- ADMIT ASAP, neck XRAY, flexible fibroscopic laryngoscopy

-NASOTRACHEAL tube to secure airway, IV ABX

**prevent w/ vaccine**