19 - Orthopaedics Flashcards
What type of fractures occur in paediatrics and why?
- Children have more cancellous bone than adults so more flexible but less strong
- Children have growth plates
How are growth plate fractures classified?
Salter-Harris Classification
- Type 1: Straight across
- Type 2: Above
- Type 3: BeLow
- Type 4: Through
- Type 5: CRush
What pain relief can be given for children?
- Step 1: Paracetamol or ibuprofen
- Step 2: Morphine
DO NOT give aspirin, tramadol or codeine in children
How may hip pain present in a child who cannot verbalise?
- Limp
- Refusal to use the affected leg
- Refusal to weight bear
- Inability to walk
- Pain
- Swollen or tender joint
What are some differentials for hip pain in children?
- Septic arthritis: ALWAYS THIS UNTIL PROVEN OTHERWISE
- Developmental dysplasia of the hip (DDH)
- Transient synovitis
- Perthes disease
- Slipped upper femoral epiphysis (SUFE)
- Juvenile idiopathic arthritis
- Malignancy
- Henoch SP
What are some red flags for hip pain?
- Under 3
- Fever
- Waking at night
- Weight loss
- Anorexia
- Night sweats
- Fatigue
- Persistent pain
- Stiffness in the morning
- Swollen or red joint
When does a child with a limp need to be referred for an urgent assessment at the hospital?
- Fever
- Any red flags
- Suspect NAI
- <3 as transient synovitis rare in this age, likely septic arthritis
- >9 with painful or restricted hip movements to exclude SUFE
- Severe pain
- Not able to weight bear
What investigations may be done for acute limp/hip pain in a child?
- CRP and ESR: for JIA and septic arthritis
- Xrays: look for fractures, SUFE and other boney pathology
- US: look for effusion
- Joint aspiration: to diagnose or exclude septic arthritis
- MRI: to diagnose osteomyelitis
What is transient synovitis?
- Inflammation in the synovial membrane of the hip joint (synovitis)
- Main cause of hip pain aged 3-10, diagnosis of exclusion
- Associated with a recent viral URTI
- Joint pain but otherwise well child, NO fever. If fever think septic arthritis
How does transient synovitis present and what investigations should you do for this?
Presentation
- History of URTI
- Low grade fever (if high think septic)
- Limp
- Refusal to weight bear
- Groin or hip pain
Ix
- FBC: look at WCC
- CRP
- US and X-ray: look for effusion
- Joint aspirate: if considering septic, send for MC+S
How is transient synovitis managed?
- Always need to rule out septic arthritis
- If aged 3-9 with limp <48 hours then manage in primary care but clear safety net advice to go to A+E immediately if there is temperature. Follow up at 48 hours and then 1 week
- Supportive: simple analgesia
What is the prognosis with transient synovitis?
- Symptoms improve in 24-48 hours and fully resolve within 1-2 weeks without any long term damage
- May recur
What is the epidemiology of septic arthritis in children?
- Most common in under 4’s
- M>F
Emergency as mortality of 10%, join destruction
How does septic arthritis present?
Usually single joint with rapid onset of:
- Hot, red, swollen and painful
- Refusing to weight bear
- Stiffness and reduced range of motion
- Systemically unwell e.g fever, lethargy and sepsis
What are the common organisms causing septic arthritis in children?
- Staph aureus: most common
- Neisseria gonorrhoea: Sexually active teenagers
- Strep pyogenes
- Haemophilus influenza
- Escherichia coli
What investigations are done for suspected septic arthritis?
- Joint Aspirate: MC+S
- FBC, CRP, ESR
- Blood cultures
- ?X-ray
What diagnostic criteria is used to distinguish transient synovitis from septic arthritis?
Kocher Criteria
- fever >38.5
- non-weight bearing
- raised ESR >40 or CRP>20
- raised WCC>12
If 3 or more do urgent blood culture and US guided joint aspirate
How is septic arthritis managed in children?
Immediately refer to surgeons
- Empirical IV antibiotics: take aspirates and cultures first, continue for 3-6 weeks
- Surgical washout and drainage: if severe
What is Perthe’s disease and the pathophysiology of this?
Idiopathic avascular necrosis of the femoral head (epiphysis)
Occurs in children aged 4 – 12 years, mostly between 5 – 8 years, and is more common in boys
Over time there is revascularisation or neovascularisation and healing of the femoral head. There is remodelling of the bone as it heals
What are some risk factors for Perthe’s disease?
Affects 1 in 9000
- 4 times more common in boys
- Caucasian
- Passive smoking
- Deprivation
- Obesity
- Prenatal factors (e.g. low birth weight)
How does Perthe’s disease present?
Slow onset of:
- Pain in the hip or groin
- Limp (Antalgic then Trendelenburg)
- Restricted hip movements
- Referred pain to the knee
No history of trauma. If pain triggered by minor trauma, think SUFE
What are some differentials for Perthe’s disease?
How is Perthe’s disease diagnosed?
AP and Frog-Leg Lateral Pelvic X-ray: first line, can be normal
MRI or Te Bone scan: if no x-ray changes, can show very early changes
What are the different stages of Perthe’s?
Will see sclerosis and fragmentation on hip x-ray
What are the complications of Perthe’s disease?
- Hip osteoarthritis
- Early fusion of growth plate
- Leg length discrepancy
- Reduced function
How is Perthe’s disease managed?
Aim is to reduce pain and avoid irreversible damage to femoral head
- Symptomatic relief by restricting weight bearing and casting/bracing
- Physiotherapy
- Regular x-rays to review healing
- Surgery if older or later disease
What surgery is done for Perthe’s disease?
Osteotomy to realign the femoral head and change remodelling
What is the prognosis with Perthe’s disease?
- Most cases resolve with conservative measures
- Risk of early onset osteoarthritis
- Poor prognostic factors: age>8 at onset, female, obesity and stiffness on examination.
What is slipped upper femoral epiphysis and the epidemiology of this?
Head of the femur is displaced along the growth plate, usually postern-inferiorly (down and back)
- More common in boys
- Typically 8-15 years
- More common in obese children
- Bilateral in 20%
How does SUFE present?
- Usually adolescent, obese male undergoing a growth spurt
- History of minor trauma that triggers onset of symptoms
- Suspect if pain disproportionate to severity of trauma
What movement is restricted in SUFE?
- Internal rotation
- Hip, groin, medial thigh or knee pain
What are some risk factors and complications of SUFE?
Risk Factors
- Onset of puberty
- Obesity
- Endocrine disorders: hypothyroidism, panhypopituitarism, renal osteodystrophy, and growth hormone deficiency
- Male
- Afro-Caribbean
- Previous radiotherapy
Complications
- OA
- AVN
How is SUFE diagnosed?
- AP and lateral (typically frog-leg) pelvic X-ray: diagnostic
- Other tests to exclude differentials: FBC, CRP, Te Bone scan, CT, MRI
How is SUFE managed?
Internal Fixation Surgery
Unstable SUFE
- Surgical repair
- Prophylactic fixation of contralateral hip
Stable SUFE
- In-situ screw fixation
- Prophylactic fixation of contralateral hip
- Open reduction and internal fixation
- Bone graft epiphysiodesis
What is the epidemiology and risk factors of osteomyelitis in children?
- Usually in boys under 10 with a risk factor predisposing them
- Usually S.Aureus
How does osteomyelitis present in children?
- Refusing to use limb or weight bear
- Pain
- Swelling
- Tenderness
- Afebrile or low grade fever
If high fever OM has likely spread to joint and causing septic arthritis
What investigations are done for suspected osteomyelitis?
- FBC and CRP: raised WCC and CRP
- X-Ray: initial but can be normal
- MRI: best way to diagnose OM
- Blood culture: establish causative organism. A bone marrow aspiration or bone biopsy may be necessary
How is OM in children managed?
- IV flucloxacillin: for 6 weeks
- Surgical washout and debridement: if severe
What is the most common primary bone malignancy in children and the epidemiology of this?
Osteosarcoma
- Aged 10-20 years
- Usually femur, tibia or humerus
- Associated with retinoblastoma
How does osteosarcoma present?
- Persistent bone pain
- Worse at night and may wake child up
- Bone swelling
- Palpable mass
When does a child need an urgent referral for suspected osteosarcoma and what is done at the appointment?
Very urgent direct access xray within 48 hours for children presenting with unexplained bone pain or swelling
If the xray suggests a possible sarcoma they need very urgent specialist assessment within 48 hours.
What does osteosarcoma look like on x-ray and what are some further tests done for diagnosis?
Xray: poorly defined lesion in the bone, with destruction of the normal bone and a “fluffy” appearance. “Sunburst” appearance
Bone Profile: Raised ALP
Imaging: CT, MRI, Bone scan, PET, bone biopsy
How is osteosarcoma managed?
- Surgical resection: usually limb amputation
- Adjuvant chemotherapy
- MDT
Complications: pathological bone fractures and metastasis
What is talipes?
- Fixed abnormal ankle position that presents at birth, clubfoot
- Talipes equinovarus or Talipes calcaneovalgus
How is talipes treated?
Ponseti Method: non-surgical, done straight after birth. Casting then achilles tenotomy then brace
The foot is manipulated towards a normal position and a cast is applied to hold it in position. After treatment with the cast is finished a brace is used to hold the feet in the correct position when not walking until the child is around 4 years old. This brace is sometimes referred to as “boots and bars”.
Positional Talipes: resting position of the ankle is in plantar flexion and supination, however it is not fixed in this position. Just need physio input
What is developmental dysplasia of the hip and some risk factors for this?
- Instability in the hips and a tendency for subluxation or dislocation
- Can persist into adulthood and cause weakness, recurrent subluxation or dislocation, an abnormal gait and early degenerative changes
- Picked up during the newborn examinations or later when the child presents with hip asymmetry, reduced range of movement in the hip or a limp
What tests are done to screen for DDH in the NIPE?
When examining, look for symmetry in the hips, leg length, skin folds and hip movements
- Ortolani test
- Barlow test
Need US if clicking or clunking. Clunking more likely to be DDH
After screening how is DDH diagnosed?
US Hips: if child has risk factors or positive screening
Xrays: if >4.5 months old this is first line not US
How is DDH managed?
- Usually spontaneously stabilise by 3-8 weeks
- If persisting and <6months use Pavlik Harness for 6-8 weeks
- If >6 months need surgery and hip spica cast
How may rickets present in children?
What investigations are done for rickets and what may they show?
Vit D affects how much calcium and phosphorus is absorbed
How is rickets treated?
Prevention: Vit D supplements if breast feeding, fortified formula, supplements for young children
Children with vitamin D deficiency: Vit D and Calcium supplements. The dose for children between 6 months and 12 years is 6,000 IU per day for 8 – 12 weeks
What is achondroplasia and the pathophysiology of this?
Most common cause of disproportionate short stature
- FGFR3 mutation on chromosome 4 causing abnormal function of epiphyseal growth plates
- Autosomal dominant but homozygous is fatal so all patients have one normal and one abnormal
What are the clinical features of achondroplasia?
- Short limbs
- Normal spine length
- Short digits
- Bow legs
- Disproportionate skull
- Foramen magnum stenosis
Different areas of the skull grow by different methods, some of which are affected more than others. This leads to a disproportionate skull
What are some comorbidities with achondroplasia?
- Recurrent otitis media, due to cranial abnormalities
- Kyphoscoliosis
- Spinal stenosis
- OSA
- Obesity
- Foramen magnum stenosis can lead to cervical cord compression and hydrocephalus
What is the management and prognosis of achondroplasia?
- No cure
- MDT
- Leg lengthening surgery: osteotomy and create gap but can cause chronic pain so rarely done
What is Osgood Schlatter’s disease and the pathophysiology of this?
Inflammation at the tibial tuberosity where the patella ligament inserts due to repeated avulsion of the apophysis. Tibial tuberosity is at growth plate so repeated stress causes bone growth and a lump to form
Common cause of anterior knee pain in children aged 10-15, usually males. Usually unilateral
How does Osgood-Schlatter’s disease present?
Gradual onset of symptoms
- Visible or palpable hard and tender lump at the tibial tuberosity
- Pain in the anterior knee
- Pain exacerbated by physical activity, kneeling and on extension
How is Osgood-Schlatter’s managed and what is the prognosis with this?
Mx
- Reduction in activity
- ICE
- NSAIDs
- Physio
Prognosis
Symptoms will fully resolve over time. The patient is usually left with a hard boney lump on their knee
What is osteogenesis imperfecta and the pathophysiology of this?
Brittle bone disease where there is issues in collagen metabolism so bone fragility and fractures
Autosomal dominant
How does osteogenesis imperfect present??
Eye, hearing, dental and bone issues
- Recurrent inappropriate fractures
- Hypermobility
- Blue / grey sclera
- Short stature
- Deafness from early adulthood
- Dental problems, particularly with formation of teeth
- Bone deformities, such as bowed legs and scoliosis
- Joint and bone pain
How is osteogenesis imperfecta managed?
Often clinical diagnosis as genetic testing is expensive. Can get x-rays to diagnose fractures and bone deformities
- Bisphosphates to increase bone density
- Vitamin D supplementation to prevent deficiency
- MDT
What is the first question you should ask a child/parent presenting to ED with a limp?
Any trauma?
What are the common missed diagnoses when a child presents with hip pain?
What is Klein’s line?
On hip x-ray to diagnose SUFE
- Klein’s line drawn along superior border of femoral neck and should intersect with growth plate
- Failure to do so suggests early SUFE
- Lateral X-ray better at picking this up as most slips posteroinferior
What age does adult gait develop?
7 to 8 years old
