Bone and joint infections of children

Question 1

How might a child with flat foot present?

Answer 1

Feet will be visibly flat - arches have not developed

ankles appear to turn inwards - weight bearing through inside of sole

Question 2

How is flat foot treated?

Answer 2

Orthotics (insoles etc) or surgery

Question 3

What might toe walking be a sign of?

Answer 3

Cerebral palsy
Duchenne MD
Other nervous system problems

Question 4

How is toe walking in otherwise healthy children treated?

Answer 4

• casting foot and ankle for about 6 weeks to help stretch calf muscle
• physiotherapy
• surgery to release tight calf muscles

Question 5

How does clubfoot present?

Answer 5

Also called talipes equinovarus
fixed varus and equinus deformity
- internal rotation of foot and contraction of achilles tendon

Question 6

What are the risk factors for clubfoot?

Answer 6

breech presentation 
connective tissue disorder (ehlers danlos)
oligohydramnios 
edward's syndrome (trisomy 18)
family history

Question 7

How is clubfoot treated?

Answer 7

Ponseti method - its like invisalign for your ankles –> stretching the ligaments/tendons/joints capsules and setting in a cast after each stretching
gradually reaching the correct alignment

Question 8

What are the risk factors for congenital hip dysplasia?

Answer 8

female 
breech presentation 
1st born 
family history 
oligohydramnios 

(associated with scoliosis and clubfoot)

Question 9

How is congenital hip dysplasia diagnosed?

Answer 9

Ortolani: relocating subluxed hip 
Barlow: dislocating hip 
Galeazzi: later diagnosis + limb length discrepancy 
Ultrasound 
Radiography

Question 10

Explain Graf grading of congenital hip dysplasia.

Answer 10

Use US to measure the alpha angle 
- this is the angle between the hip joint inclination and the iliac margin 
normal angle will be >60
Grade I: >60
Grade II a,b: 50-59
Grade IIc: 43-49
Grade IIIa,b, IV: <43

Question 11

How can radiographs be used to diagnose congenital hip dysplasia?

Answer 11

Limited use until femoral ossifies around 4-6 months
Look at the angle between Hilgenreiner’s line and acetabular index line, should not be >34 degrees
Also use Perkin’s line - femora head should be in the lower median quadrant

Question 12

How is congenital hip dysplasia treated?

Answer 12

Usually corrects spontaneously within 2-8 weeks
<6 months: closed reduction + immobilisation with Pavlik harness (6 weeks full time + 6 weeks part-time)
>6 months: closed reduction with spica cast
>18 months: open reduction

Question 13

What is Perthe’s disease and what is the epidemiology?

Answer 13

Self-limiting avascular necrosis to the femoral head
1:1000
4:1 males
usually unilateral

Question 14

What are the different stages of Perthe’s disease?

Answer 14

1. Necrosis: portion of femoral head dies and shapes changes causing pain, stiffness and inflammation –> up to 1 year
2. Fragmentation: dead cells absorbed + replaced by new bone cells. Varying femoral head shapes –> 1-3 years
3. Reossification: femoral head continues to grow with new bone cells –> 1-3 years
4. Remodelling: New bone cells are gradually replaced by normal bone cells and remodelling continues –> 1-3+ years

Question 15

How is Perthe’s disease treated in young children and older children?

Answer 15

<5 years/mild cases:

• observation
• physiotherapy
• bed rest
• plaster cast or braces
• abduction to keep femoral head in acetabulum

Older children:
- surgery –> osteotomy

Question 16

What is SUFE? What are the potential causes?

Answer 16

SUFE = Slipped Under Femoral Epiphysis

Due to obesity, hypothyroidism, deficiency or increased androgens, trauma

Question 17

What are the different types of SUFE?

Answer 17

Pre-slip: wide epiphyseal line, no slippage
Acute: slippage sudden
Acute-on-chronic: slipping occurs acutely on existing chronic slip
Chronic: steady progressive slippage (more common)

Question 18

What is klein’s line? What is its association with SUFE?

Answer 18

Virtual line that can be drawn on an x-ray of an adolescents hip parallel to the upper edge of the femoral neck
if the line does not intersect the outermost part of the femoral head then a diagnosis of SUFE can be made

Question 19

How is SUFE treated? What complication can arise in unilateral fixation?

Answer 19

Rest
Analgesia
Surgery (closure of growth plate via screws, may be followed by corrective osteotomy)

Unilateral fixation of SUFE can lead to contralateral slip

Question 20

What is Blount’s disease?

Answer 20

Growth problem of the distal tibia (medial compartment)
Causes tibia varus
Medial part of proximal tibia fails to develop = angulation –> this is an irreversible pathological change

Question 21

How is Blount’s disease treated?

Answer 21

Conservative: braces
Surgical: if early onset of brace fails
- can perform osteotomy and gradual distraction

Question 22

What is Osgood-Schlatter’s? What are the potential causes? How does it present?

Answer 22

Osteochondrosis –> disturbance of endochondral ossification
Self-limiting –> symptoms disappear ~1 year after onset

Cause: repeated traction from the patellar ligament on the tibial tuberosity
- avulsion fractures to parts of the tibial tuberosity

presents with pain the point of insertion of patellar ligaments

Question 23

How is Osgood-Schlatter’s treated?

Answer 23

rest
avoidance of activities causing pain
NSAIDs
strapping + brace to support knee