Pediatric Rounds Topics and Objectives

Pediatric Rounds Topics and Objectives Development Dysplasia Hip... 4... 4... 4... 5 Communicator... 5 Scholar... 5 Slipped Capital Femoral Epiphysis... 5... 5... 5... 6 Communicator... 6 Health Advocate... 6 Legg Calf Perthes Disease... 6... 6... 6... 7 Communicator... 7 Advocate... 7 Developmental/Congenital Caxa Vara... 7... 7... 7... 8 Communicator... 8 Knee Injuries in Adolescent... 8... 8... 8... 9 Scholar... 9 Osteochondritis Dissecans... 9 1

... 9... 9 Health Advocate... 9 Communicator... 9 Patellofemoral Disorders... 10... 10... 10 Health Advocate... 10... 10 Scholar... 10 Club Foot... 11... 11... 11... 11 Communicator... 11 Cavus Foot... 12... 12... 12... 12 Pes Planus... 12... 12... 12... 13 Miscellaneous Foot Conditions... 13... 13... 13 Lower Extremity Fractures... 13... 13... 13 Leg Length Discrepancy... 14... 14 2

... 14... 15 Communicator... 15 Metabolic Conditions... 15... 15... 15... 16 Scholar... 16 Angular Deformities... 16... 16... 16... 16 Child Abuse... 17... 17... 17... 17 Communicator... 17 Upper Extremity Fractures... 17... 17... 17 Scholar... 18 Idiopathic Scoliosis Juvenile, Adolescent... 18... 18... 18... 19 Communicator... 19 Congenital Scoliosis... 19... 19... 19... 19 Tumor Rounds... 19 3

... 19... 19... 20 Communicator:... 20 Scholar... 20 Didactic Lectures... 20 Rounds: Supervisors: Time Place Rm Pediatric Rounds Dr. Deane/Dr. Jackman 7:45-8:45 AM 2J619 Janeway Development Dysplasia Hip 4 1. Resident learns how to perform a newborn clinical history identifying risk factors for DDH and pertinent birth history and developmental milestones 2. Review physical exam tests including looking for a. Barlows, Ortolani, Galleazi b. ROM hip, leg length inequality, asymmetrical skin folds c. Completes a thorough newborn exam including feet, spine and neck exam 3. Review and understand appropriate radiological tests including a. Ultrasound hips with B and A angles b. Xray pelvis and documenting dysplasia vs subluxation vs dislocation c. Arthrogram hip looking for obstacles to reduction, dye pool d. Post reduction CT scan of hips 4. Develop an approach to treatment of DDH including a. Closed reduction and role of adductor tenotomy, arthrogram b. Open Reduction hip c. Hip spica casting

5. Develop an understanding of the role of longterm follow-up and the principles of the different types of pelvic osteotomies around the hip joint 1. Make residents aware of the multi-disciplinary approach to this problem and the need for consultation with various team members Communicator 1. Develop an approach to speaking with the family as a whole in a professional manner and explaining diagnosis, treatment and possible complications in an organized fashion 2. Develop an understanding that both a patient and their parents are involved and this situation is unique to pediatrics thereby addressing all three in the discussion when age appropriate Scholar 1. To provide up to date knowledge on current treatment and investigation tools including any references required. Slipped Capital Femoral Epiphysis 1. Develop an approach to taking a history form the patient including addressing risk factors for SCFE and any associated medical concerns 2. Review physical exam findings including examining the knee and hip for ROM, LLD 3. Develop an understanding of appropriate radiological tests including AP and lat pelvis looking for the signs of a SCFE and addressing the opposite side 4. Review the surgical technique for percutaneous pinning of the hip 5. Understands the role of longterm followup and the various complications that can arise including AVN, chondrolysis and slip progression 5

1. Understand the role of other medical services and who to consult when appropriate for medical conditions associated with a SCFE 2. Develop an understanding of the role of other health care professionals in the post op period Communicator 1. Discuss an approach to discussing diagnosis with child and the parents and answers questions appropriately including addressing risks of long term complication Health Advocate 1. Resident understanding of the determinants of health and inquires about them 2. Understand the role that residents play as physicians to speak to family/ patient about these determinants 3. Understand the tole for timely referral to the medical services ( EX endocrinology) as needed 4. Resident advocates for timely access to the OR Legg Calf Perthes Disease 1. Discuss the pathophysiology of this condition and its normal course 2. Develop an approach to accurate history taking and physical exam including gait assessment, ROM, muscle strength testing etc. 3. Discuss prognostic factors 4. Review radiological tests identifying hip at risk signs, migration index etc. 5. Discuss the role of additional diagnostic tests including MRI 6. Develop an approach to the principles of treatment and where non operative treatment is warranted vs operative 7. Discuss the surgical treatment for this including a femoral varus osteotomy +/- salter osteotomy+/- adductor tenotomy 6

1. Discuss the role of a multidisciplinary approach to this problem including the need to consult orthotics, physiotherapy where appropriate Communicator 1. To develop an approach to discussing the diagnosis in common terms with parents and the patient including the prognosis, and possible treatments required Advocate 1. Advocated for timely access to treatment 2. Identifies the determinants for health including risk for arthritis at early age and need to avoid obesity, maintaining active lifestyle and when older discussing possible occupation possibilities Developmental/Congenital Caxa Vara 1. Discuss the normal skeletal development including timing of bone formation and muscle formation 2. Develop an understanding of longitudinal bone growth including the principles of endochondral ossification and intramembranous bone formation 3. Review bone development prenatally on ultra sound and able to identify the absence of appendages ex. PFFD 4. Discuss the pathophysiology involved in coxa vara including congenital coxa vara and how it is different from developmental coxa vara 5. Review the radiological features 6. Discuss the principles of treatment including the risk factors for progression as well as when treatment should be initiated 7. Discuss the principles of trochanteric osteotomies 8. Discuss the pathophysiology of proximal femoral focal deficiency as well as congenitally short femur and its associated conditions 7

9. Discuss an approach to treatment priniciples of these conditions including the indications for limb reconstruction or amputation 10. Review the different types of amputations and prosthetics required if amputation is required 1. Discuss the role of a multidisciplinary approach to many of these problems including the need for pre-operative consultation with prosthetics prior to amputation Communicator 1. Review the need to explains to both the child and parents the different types of treatment options and the risks associated with each Knee Injuries in Adolescent 8 1. Review how to accurately perform acceptable history and physical on the patient to come up with a sound differential diagnosis and investigation plan for these injuries a. ACL deficient knee acute and chronic b. LCL/MCL/PCL/posterolateral corner injury c. Meniscal injury including discoid meniscus d. Iliotibial band syndrome 2. Review how to perform special tests where required for example : Lachman, Drawer and pivot shift test when looking at ligamentous disruption to the knee 3. Review pathophysiology of the ligamentous/tendinous structures around each joint and the function these structures serve 4. Develop an approach to interpretation of radiological tests including but not limited to plain radiographs, MRI, CT scan and US. 5. Review the role of non operative treatment and the services required with this 6. Review the role of surgical treatment, the complications associated with this and the post op rehabilitation required for a. ACL reconstruction ( hamstrings, patellar tendon, allograft)

b. PCL repair c. Meniscal repair/partial meniscectomy 1. Review the role of orthotists for bracing as well as different braces available 2. Review the role of physiotherapy and the need for consultation with them in the pre-op as well as post-op phase Scholar 1. Review up to date knowledge and review the various literature available on these issues Osteochondritis Dissecans 1. Discuss the pathoanatomy of OCD and the various classifications used to decide on treatment 2. Review pertinent history and physical examination findings 3. Discuss radiological findings and role of additional tests including MRI interpretation 4. Discuss a treatment plan including role of non-operative treatment 5. Discuss arthroscopic findings of OCD and surgical treatment required Health Advocate 1. Discuss the determinants of health including obesity, activity restriction and prognostic factors Communicator 1. Discuss the role of communicating with both the parents and the child the role of non-operative treatment including activity restriction in a way that the family understands why this may be required 9

2. Able to answer questions by the family with regards to prognosis and timing of surgery if required Patellofemoral Disorders 1. Discuss the pertinent details to address in the history and physical 2. Review physical exam finding including special tests ( apprehension sign, J sign, patella compression test, Quads strength ) 3. Review radiological investigations including an understanding the role of special tests like MRI and CT scan 4. Develop a treatment approach recognizing the significant role for non operative treatment and what this consists of ( rehab for ROM, weight bearing, strength building etc) 5. Understand the role of operative treatment including the need for urgent surgical intervention vs non urgent 6. Review the various surgical procedures including soft tissue procedures ( lateral release, MPFL reconstruction, VMO advancement) as well as bone procedure ( tibial tuberosity transfers) and the indications for both 7. Recognize the unique situation of the pediatric population and the surgical limitations caused by this Health Advocate 1. Discuss the determinants of health including healthy BMO, quadriceps strength and activity modification in special circumstances and advocate to the patient for this 2. Discuss the role of timely access to radiological investigation in the case of osteochondral fractures and timely access to the OR 1. Discuss the strong role of non operative intervention for this disorder including the need for physiotherapy, orthotics for brace fitting etc\ Scholar 10

1. Discuss up to date knowledge including recent literature including the role of any new surgical procedures Club Foot 1. Demonstrates how to perform an adequate history and physical on a newborn child including a pertinent MSK exam 2. Review the pathophysiology of clubfeet and the theories linked to its etiology 3. Review the clinical manifestations of clubfoot including cavus, adductus, varus and equinus of the heel as well as internal tibial torsion foot/leg size asymmetry 4. Discussion of associated syndromes 5. Review the role of non operative treatment and the various types including the Ponseti technique as well as some knowledge of the French method 6. Review the steps involved in the Ponseti method and the role of tendo Achilles lengthening, boots and bars etc 7. Review surgical treatment including incision and structures to be released 8. Review the principles of treatment for a recurrent or under corrected clubfoot including principles of osteotomies, soft tissue release and arthrodesis in skeletally mature patients 1. Review the multidisciplinary approach to treatment including the role of cast technicians, physiotherapy and social supports for the family to cover travel costs, boots and bars costs etc. Communicator 1. Review effective communication with the family and the patient involved so they have informed knowledge of the treatment principles 11

Cavus Foot 1. Review pertinent facts on history taking including presenting complaint and history of progression, developmental history, family history 2. Review underlying conditions associated with cavus deformity 3. Review physical exam findings including cavus, hindfoot varus, skin abnormalities, neuro exam and spine exam 4. Review the role of the Coleman Block test in determining treatment 5. Review the pathological factors for cavus foot to guide as an approach to treatment 6. Discuss an approach to treatment including non operative options 7. Review the various surgical techniques and the indications for each 1. Review the various medical conditions assoc with cavus feet and the need for medical consultation 2. Review the role of orthotics and the need for consultation with the orthotist Pes Planus 12 1. Develop an approach for taking an accurate history 2. Review pertinent physical exam findings including differentiating between flexible and non flexible flatfoot 3. Review the indications for radiological investigation and an approach to interpretation 4. Understand the pathology of tarsal coalition and the various types 5. Identify tarsal coalitions on MRI and CT scans 6. Develop a treatment approach for flexible flat feet including the role for orthotics and the various types available

7. Develop a treatment approach for tarsal coalitions including non operative options first ( cast, orthotics) then the surgical options and indications 1. Review the role of the orthotist and the indications for consultation 2. Review the role of physiotherapy and the need for consultation in the case of contractures around the ankle Miscellaneous Foot Conditions 1. Develop an approach to accurate history taking for the conditions below a. Severs Disease b. Plantar fasciitis c. Kohlers Disease d. Jones fractures 2. Review pertinent physical exam findings 3. Review the role of radiological tests and their interpretation 4. Discuss the role of treatment including both non-operative as well as operative Lower Extremity Fractures 1. Review how to assess a multiple trauma patient including ATLS protocol and the role of the orthopedic surgeon during a trauma situation 2. Review the principle of immobilizations in the acute setting including the application of appropriate splints, casting including the Thomas splint 13

3. Review appropriate radiologic tests that are ordered for lower extremity injuries including CT scans for peri-articular fractures and MRI for knee injuries and how to interpret them 4. Review the management principles in the acute phase and definitive treatment for the following fractures a. Hip fractures b. Femur fractures including supracondylar c. Tibial spine fractures d. Tibial tuberosity fractures e. Knee dislocations f. Proximal tibial fractures g. Mid-shaft tibial fractures h. Tillaux fractures i. Tri-plane fractures j. Ankle fractures k. Subtalar fracture/dislocations l. LisFranc injuries m. Jones fracture 5. Review the surgical techniques of open reductions vs percutaneous, flexible nailing femur and tibia, role of arthroscopy for knee injuries 6. Review the complications unique to each injury in the short and long term including neurovascular injuries, compartment syndrome and growth arrests Leg Length Discrepancy 14 1. Review common causes of leg length inequality including idiopathic, hemihypertrophy and the various syndromes associated with this 2. Review physical examination findings including gait abnormalities 3. Describe how to properly evaluate leg length including true leg length versus apparent leg length

4. Review proper radiological tests for quantifying leg length differences 5. Develop an approach to management including the role for equalization procedures and amputation. 6. Discuss the indications for shortening procedures vs lengthening 7. Discuss the principles for leg lengthening procedures, including rate, extent and associated complications 1. Discuss the multidisciplinary approach to leg lengthening and the critical role of therapists, nursing and home support 2. Review the role of the prosthetist, psychologist both for the pediatric patient and family Communicator 1. Review the role of informed consent and what this entails, the differences between a pediatric patient vs an adolescent 2. Discuss the value of open communication as well as the role of multiple opinions/consultations in this decision-making process Metabolic Conditions 1. Review Ca/PO4 homeostasis and its role in bone turnover 2. Review the various roles of VIT D, PTH and calcitonin and their metabolism 3. Develop an approach to the common metabolic disorders including rickets and its various types 4. Review the treatment of rickets including the need for medical consultation 5. Review the common conditions associated with altered bone turnover including an approach to diagnosis and treatment a. Osteogenesis imperfecta b. Osteoporosis c. Renal bone dystrophy d. Osteo 15

6. Review the role of surgical management for these conditions including correction of deformities and fracture management 1. Review the role of the internist with several of these conditions and the need for medical consultation 2. Review the role of genetics and the need for collaboration with this specialty for the purpose of diagnosis and genetic counselling Scholar 1. Review common literature on these conditions including current medical treatment, prophylactic surgery Angular Deformities 1. Review accurate history and physical examination findings including gait, stature, deformity detection 2. Review the proper radiological investigations and how to properly measure anatomical axis as well as mechanical axis for the lower extremity 3. Review how to determine the level of deformity and the center of rotation 4. Develop an approach for planning corrective surgery including the proper bone level and the types of osteotomies available 5. Review soft tissue balancing where needed 6. Develop a post operative approach for these patients including the need for extensive rehabilitation 7. Review the complications of deformity correcting including neurovascular injury, compartment syndrome etc 1. Review the multidisciplinary approach to deformity correction including the need for therapy, orthotics as well as psychological support 16

Child Abuse 1. Review the common child abuse patterns including how to take an accurate history to ensure injury compatible with mechanism as well as a developmental and social history 2. Describe physical examination findings including a thorough investigation of physical abuse findings, as well as how to identify failure to thrive in infants 3. Review common xray findings in child abuse including specific fracture patterns ( corner fractures, humeral physeal separation) 4. Review the indications for further radiological investigations including skeletal survey, CT scan head etc 5. Review the federal laws whereby all suspected child abuse is by law mandatory to report 6. Review orthopedic management of common orthopedic injuries 7. Review other differential diagnosis specifically osteogenesis imperfecta 1. Review the role of additional health care providers including social work, child protection, RCMP etc 2. Review the many aspects of abuse including mental, emotional abuse and the need to consult with psychology etc. Communicator 1. Review how to communicate with a child in need to allow protection and discussing the various options available to the child 2. Review how to approach a family when child abuse is suspected. Upper Extremity Fractures 17 1. Review growth of upper extremity including development of physis and the various ossification centers

2. Review common injury mechanisms and patterns for a. Proximal humeral fractures b. Humeral fractures c. Supracondylar fractures d. Lateral condyle fractures e. Medial condyle and epicondyle fractures f. Elbow dislocations g. Monteggia fracture/dislocation h. Radial head fractures i. Forearm fractures j. Distal radius fractures 3. Review pertinent physical examination findings with these injuries including neurovascular compromise 4. Describe how to interpret radiographs of the elbow and the rest of the extremity 5. Review acceptable guidelines for treatment including the need for reduction, proper immobilization or surgical treatment 6. Review common surgical techniques used 7. Describe common complications in the acute and chronic period and how to treat including neurolovascular injury Scholar 1. Review up to date guidelines for surgical treatment and the common surgical techniques Idiopathic Scoliosis Juvenile, Adolescent 18 1. Review accurate history taking for the condition including developmental history, family and social history 2. Review the risk factors for progression 3. Review physical examination findings and Risser staging 4. Describe appropriate radiological investigations and their interpretation 5. Review indications for non surgical treatment including follow up, bracing and timing 6. Review surgical indications 7. Describe pro-operative planning

1. Review the need for pre-operative consultation with medicine, ICU etc. Communicator 1. Review the role of the orthopedic surgeon to effectively communicate with both the patient and the family discussing role of surgery as well as complications so that the family can make an informed consent Congenital Scoliosis 1. Review the pathology of congenital scoliosis including failure of segmentation and failure of formation 2. Review pertinent radiological findings 3. Review the indications for surgery and the appropriate timing for this 1. Review the multidisciplinary approach that is needed with these children as often there are medical or other congenital anomalies associated Tumor Rounds 1. To develop an approach to the patient with a "hole" in the bone. 2. To develop skill in the interpretation of radiographic imaging pertinent to bone tumors. 3. To develop develop skills to discern benign, benign aggressive and malignant bone tumors. 19

4. To develop an approach to investigation both systemically and locally for bone tumors. 5. To develop treatment approaches for the benign, benign aggressive and malignant bone tumors. 6. To understand the treatment algorithm for Ewings and osteogenic sarcoma. 7. To begin to understand limb salvage techniques for the oncology patient. 1. To understand that the treatment of the MSK oncology patient is multidisciplinary and will require potential input from Radiology, Medical oncology, Radiation oncology, Surgery, Physiotherapy, Occupational therapy, Prosthetics, Industry, Nursing. Communicator: 1. To understand the unique communication issues with the MSK oncology patient 2. Heath advocate: To understand that family counselling can play a large role in certain oncologic conditions in oncology. 3. Manager and Leader: The orthopaedic surgeon will sometimes be called on to manage and coordinate large groups of people in the coordination of care for the complex oncology patient and at times significant decisions will be required regarding cost of care perceived benefit analysis. Scholar 1. To understand that the literature is constantly changing in the oncology sphere and requires frequent reassessment. Didactic Lectures 20 1. Pediatric Scoliosis 2. Assessment and Management of Club Foot Deformity 3. An Approach to Cerebral Palsy 4. General Approach to Pediatric Trauma 5. Growth Plate Physiology and Response to Injury