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