19 - Orthopaedics Flashcards

1
Q

What type of fractures occur in paediatrics and why?

A
  • Children have more cancellous bone than adults so more flexible but less strong
  • Children have growth plates
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2
Q

How are growth plate fractures classified?

A

Salter-Harris Classification

  • Type 1: Straight across
  • Type 2: Above
  • Type 3: BeLow
  • Type 4: Through
  • Type 5: CRush
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3
Q

What pain relief can be given for children?

A
  • Step 1: Paracetamol or ibuprofen
  • Step 2: Morphine

DO NOT give aspirin, tramadol or codeine in children

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4
Q

How may hip pain present in a child who cannot verbalise?

A
  • Limp
  • Refusal to use the affected leg
  • Refusal to weight bear
  • Inability to walk
  • Pain
  • Swollen or tender joint
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5
Q

What are some differentials for hip pain in children?

A
  • 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
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6
Q

What are some red flags for hip pain?

A
  • Under 3
  • Fever
  • Waking at night
  • Weight loss
  • Anorexia
  • Night sweats
  • Fatigue
  • Persistent pain
  • Stiffness in the morning
  • Swollen or red joint
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7
Q

When does a child with a limp need to be referred for an urgent assessment at the hospital?

A
  • 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
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8
Q

What investigations may be done for acute limp/hip pain in a child?

A
  • 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
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9
Q

What is transient synovitis?

A
  • 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
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10
Q

How does transient synovitis present and what investigations should you do for this?

A

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
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11
Q

How is transient synovitis managed?

A
  • 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
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12
Q

What is the prognosis with transient synovitis?

A
  • Symptoms improve in 24-48 hours and fully resolve within 1-2 weeks without any long term damage
  • May recur
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13
Q

What is the epidemiology of septic arthritis in children?

A
  • Most common in under 4’s
  • M>F

Emergency as mortality of 10%, join destruction

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14
Q

How does septic arthritis present?

A

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
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15
Q

What are the common organisms causing septic arthritis in children?

A
  • Staph aureus: most common
  • Neisseria gonorrhoea: Sexually active teenagers
  • Strep pyogenes
  • Haemophilus influenza
  • Escherichia coli
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16
Q

What investigations are done for suspected septic arthritis?

A
  • Joint Aspirate: MC+S
  • FBC, CRP, ESR
  • Blood cultures
  • ?X-ray
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17
Q

What diagnostic criteria is used to distinguish transient synovitis from septic arthritis?

A

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

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18
Q

How is septic arthritis managed in children?

A

Immediately refer to surgeons

  • Empirical IV antibiotics: take aspirates and cultures first, continue for 3-6 weeks
  • Surgical washout and drainage: if severe
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19
Q

What is Perthe’s disease and the pathophysiology of this?

A

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

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20
Q

What are some risk factors for Perthe’s disease?

A

Affects 1 in 9000

  • 4 times more common in boys
  • Caucasian
  • Passive smoking
  • Deprivation
  • Obesity
  • Prenatal factors (e.g. low birth weight)
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21
Q

How does Perthe’s disease present?

A

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

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22
Q

What are some differentials for Perthe’s disease?

A
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23
Q

How is Perthe’s disease diagnosed?

A

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

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24
Q

What are the different stages of Perthe’s?

A

Will see sclerosis and fragmentation on hip x-ray

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25
Q

What are the complications of Perthe’s disease?

A
  • Hip osteoarthritis
  • Early fusion of growth plate
  • Leg length discrepancy
  • Reduced function
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26
Q

How is Perthe’s disease managed?

A

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
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27
Q

What surgery is done for Perthe’s disease?

A

Osteotomy to realign the femoral head and change remodelling

28
Q

What is the prognosis with Perthe’s disease?

A
  • Most cases resolve with conservative measures
  • Risk of early onset osteoarthritis
  • Poor prognostic factors: age>8 at onset, female, obesity and stiffness on examination.
29
Q

What is slipped upper femoral epiphysis and the epidemiology of this?

A

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%
30
Q

How does SUFE present?

A
  • 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
  • Restricted internal rotation
31
Q

What movement is restricted in SUFE?

A
  • Internal rotation
  • Hip, groin, medial thigh or knee pain
32
Q

What are some risk factors and complications of SUFE?

A

Risk Factors

  • Onset of puberty
  • Obesity
  • Endocrine disorders: hypothyroidism, panhypopituitarism, renal osteodystrophy, and growth hormone deficiency
  • Male
  • Afro-Caribbean
  • Previous radiotherapy

Complications

  • OA
  • AVN
33
Q

How is SUFE diagnosed?

A
  • AP and lateral (typically frog-leg) pelvic X-ray: diagnostic
  • Other tests to exclude differentials: FBC, CRP, Te Bone scan, CT, MRI
34
Q

How is SUFE managed?

A

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
35
Q

What is the epidemiology and risk factors of osteomyelitis in children?

A
  • Usually in boys under 10 with a risk factor predisposing them
  • Usually S.Aureus
36
Q

How does osteomyelitis present in children?

A
  • 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

37
Q

What investigations are done for suspected osteomyelitis?

A
  • 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
38
Q

How is OM in children managed?

A
  • IV flucloxacillin: for 6 weeks
  • Surgical washout and debridement: if severe
39
Q

What is the most common primary bone malignancy in children and the epidemiology of this? (age, location, association)

A

Osteosarcoma

  • Aged 10-20 years
  • Usually femur, tibia or humerus
  • Associated with retinoblastoma
40
Q

How does osteosarcoma present?

A
  • Persistent bone pain
  • Worse at night and may wake child up
  • Bone swelling
  • Palpable mass
41
Q

When does a child need an urgent referral for suspected osteosarcoma and what is done at the appointment?

A

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.

42
Q

What does osteosarcoma look like on x-ray and what are some further tests done for diagnosis?

A

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

43
Q

How is osteosarcoma managed?

A
  • Surgical resection: usually limb amputation
  • Adjuvant chemotherapy
  • MDT

Complications: pathological bone fractures and metastasis

44
Q

What is talipes?

A
  • Fixed abnormal ankle position that presents at birth, clubfoot
  • Talipes equinovarus or Talipes calcaneovalgus
45
Q

How is talipes treated?

A

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

46
Q

What is developmental dysplasia of the hip and some risk factors for this?

A
  • 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
47
Q

What tests are done to screen for DDH in the NIPE?

A

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

48
Q

After screening how is DDH diagnosed?

A

US Hips: if child has risk factors or positive screening

Xrays: if >4.5 months old this is first line not US

49
Q

How is DDH managed?

A
  • 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
50
Q

How may rickets present in children?

A
51
Q

What investigations are done for rickets and what may they show?

A

Vit D affects how much calcium and phosphorus is absorbed

52
Q

How is rickets treated?

A

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

53
Q

What is achondroplasia and the pathophysiology of this?

A

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
54
Q

What are the clinical features of achondroplasia?

A
  • 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

55
Q

What are some comorbidities with achondroplasia?

A
  • Recurrent otitis media, due to cranial abnormalities
  • Kyphoscoliosis
  • Spinal stenosis
  • OSA
  • Obesity
  • Foramen magnum stenosis can lead to cervical cord compression and hydrocephalus
56
Q

What is the management and prognosis of achondroplasia?

A
  • No cure
  • MDT
  • Leg lengthening surgery: osteotomy and create gap but can cause chronic pain so rarely done
57
Q

What is Osgood Schlatter’s disease and the pathophysiology of this?

A

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

58
Q

How does Osgood-Schlatter’s disease present?

A

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
59
Q

How is Osgood-Schlatter’s managed and what is the prognosis with this?

A

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

60
Q

What is osteogenesis imperfecta and the pathophysiology of this?

A

Brittle bone disease where there is issues in collagen metabolism so bone fragility and fractures

Autosomal dominant

61
Q

How does osteogenesis imperfect present??

A

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
62
Q

How is osteogenesis imperfecta managed?

A

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
63
Q

What is the first question you should ask a child/parent presenting to ED with a limp?

A

Any trauma?

64
Q
A
65
Q

What are the common missed diagnoses when a child presents with hip pain?

A
66
Q

What is Klein’s line?

A

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
67
Q

What age does adult gait develop?

A

7 to 8 years old