Bone and joint problems of childhood Flashcards
Common musculoskeletal problems of childhood are due to improper development of which structure? [1]
Epiphyseal growth plate
Which age do each of the following occur at?
CDH [1]
Perthe’s []1
SUFE [1]
CDH: at birth: babies or neonates
Perthe’s: 5-8 yrs
SUFE: 13-16 yrs
Name two pathologies in which toe walking commonly persists? [1]
Explain why this occurs [1]
Cerebral palsy; Duchenne Muscular Dystrophy
Imbalance of plantar flexors; causes pull foot into plantar flexion
State three treatment options for toe walking [3]
- Surgical procedures can be done to release the tight calf muscles by tendon lengthening of the achilles
- Cast the foot and ankle for 6 weeks to help stretch the calf muscles out. Foot brace does the same
- Physiotherapy
Describe shape of babies feet and how this changes with age [2]
How can this process be pathological? [1]
Flat foot: fat pad present for energy reserves. As they grow this dissapears
In some children the arch never fully develops: presents as weak ankles and turn inwards
Flat feet aka? [1]
Pes planus
Treatment of pes planus? [2]
Orthotics
Surgery
Persistent toe walking in older children might be linked to other conditions. What are they? [3]
Cerebral palsy: (hypertonia of plantar flexors)
Duchenne Muscular Dystrophy (early stages causes hypertrophy in calf muscles)
Nervous system problems
Toe walking can shorten which muscle? [1]
Achilles muscle
Toe walking is a normal that is generally disappears after how many years? [1]
2
How can you treat persistant toe walking? [3]
Castingthe foot and ankle for about 6 weeks to help stretch calf muscles
Physiotherapy
Surgery to release tight calf muscles: cerebral palsy
Club foot aka? [1]
Talipes equinovarus
Describe characteristics of Talipes equinovarus [2]
Fixed varus and equinus deformity due to calf underdevelopment
Can be bilateral or unilateral
Name 5 causes of Talipes equinovarus
Breech presentation
Connective tissue disorders (Ehlers Danlos)
Oligohydramnios
Genetic syndromes (Edward’s Syndrome – trisomy 18)
Family history
Describe the treatment of Talipes equinovarus [2]
Ponseti method – manipulative technique to correct clubfoot without invasive surgery
Wear in night everyday
Places the foot in abduction / valgum: as the skeleton continues to grow don’t have the deformity come back
Describe pathophsiology of Congenital hip dysplasia [1]
Hip dislocated during birth [1]
Describe risk factors for congenital hip dysplasia [5]
Females:
* relaxin produced
Breech delivery
Family history
Oligohydramnios
1st born
Descibe the presentation of CDH [3]
Double crease
leg turned into external rotation
asymmetric gluteal folds
State three tests used to diagnose CDH [3]
Barlow test
Ortolani test
Galeazzi sign
Describe the mechanism of the following
Barlow test
Ortolani test
Barlow test: adduct and push downward to try and dislocate the hip
Ortolani test: abduct hips to try and reolcated hi[; fingers push femur forwards into acetabulum
Both tests are used together
Describe what a Galeazzi sign is
The test is performed with infant supine, hips flexed to 45 and knees flexed to 90 with feet flat on examining surface. Examiner looks for symmetry in the level of the knees. An inequality in the height of the knees is a positive Galeazzi sign and usually is caused by hip dislocation or congenital femoral shortening.
Describe ultrasound imaging results for CHD [4]
Ultrasound
A = gluteal muscle
B = ilium
C = acetabulum
D = femoral head
Explain how you can interpret ultrasound to determine CHD level [4]
Ultrasound interpretation of CHD can also be done by interpretation of the alpha-angle, which is an angle formed by the acetabular roof to the vertical cortex of the ilium and thus reflects the depth of the bony acetabular roof.
The normal value is greater than or equal to 60 degrees. Less than 60 degrees suggests dysplasia of the acetabulum
- Grade 1 > 60 degrees
- Grade IIa,b 50-59 degrees
- Grade IIc 43-49 degrees
- Grasde IIIa, b, IV < 43 degrees
What is this line called? [1]
Hilgenreiner’s line:
line drawn horizontally through the inferior aspect of both triradiate cartilages
How is Hilgenreiner’s line used in CHD diagnosis? [1]
It should be horizontal but is mainly used as a reference for Perkin’s line and measurement of the acetabular angle.
Describe the points that Perkins line is found [1]
How is it used for assessment for CHD? (affected v unaffected)
Top of the acetabulum going down: ID where the femoral head is
Affected side will be more lateral to the side
Unaffected side: femoral head more medial
Explain how you treat CHD? [1]
What does this treatment have a risk for? [1]
Pavlik harness: closed reduction and immobilization causing hip flexed and abducted (while still allowing movement)
Avascular necrosis is a risk
Which treatment do you give for CHD treatment if pavlik harness does not work:
Initially [1]
If ^ treatment doesn’t work after 18months? [1]
Closed reduction with hip spica
If not resolved in 18 months: Open reduction: femoral osteotomies with or without pelvic osteotomies
In cases of unilateral developmental dysplasia of the hip, leg length discrepancy can be defined as the difference between the distances between which two places?
In cases of unilateral developmental dysplasia of the hip, leg length discrepancy can be defined as the difference between the distances from the inter-teardrop line and the greater trochanter tip
Consequences of not treating CDH? [2]
Head of femur will form a new acetabulum on the back of pelvis: creating a leg length discrepancy due to the moving of the femur further onto the back of the ilium.
The acetabulum also forms of fibrocartilage rather than hyaline, further affecting the joint properties.
Describe the pathophysiology of Perthes disease (Legg-Calve-Perthes disease) [3]
Idiopathic
Self limiting avascular necrosis of the femoral head
Dual blood supply to femoral head. Secondary ossification centre suffers blood loss and causes avascular necrosis.
If left untreated, the femoral neck grows and over time there is revascularisation or neovascularisation and healing of the femoral head.
Describe imaging of a Ptx with Perthes disease
Femoral head looks fragmented
Describe and explain the 4 different stages of Perthes disease
Describe prognosis of Perthes disease [1]
Most cases: go away without treatment
If develop at later age (8-11) have much less time for the femoral head to remodel and for the blood supply to re-establish
x-rays of perthes disease
Describe treatment of Perthe’s disease:
Children less than 5 [1]
Children older than 5 [1]
Less than 5:
* self limiting; treat with observation, physiotherapy and bed rest with plaster casts
Older than 5:
* Osteotomy surgery is the best option to realign the femoral head in the acetabulum and prevent avascular necrosis.
Slipped upper femoral epiphysis (SUFE) is more common in [left / right] hip
left
Describe the movement of the joint that occurs in SUFE [2]
Epiphysis actually stays in place it’s the neck and shaft of the femur that moves
Epiphysis moves posteriorly and medially
State what type of Salter-Harris fracture SUFE is [1]
Type 1
State 4 causes of SUFE [4]
Obesity
Hypothyroidism
Deficiency or increased androgens
* Adolescent growth spurt
Trauma
* SUFE = obese, underdeveloped sexual characteristics with sudden growth spurt
State 4 different presentations of SUFE [4]
Pre-slip: wide epiphyseal line, no slippage
Acute: slippage is sudden
Acute on chronic: slippage occurs acutely on existing chronic slip
Chronic; steady progressive slip (most common)
When looking at x-ray think of ice cream slipping off the cone
Where in the epiphyseal growth plate does a fracture occur in SUFE? [1]
How does this change the structure of the epiphyseal growth plate? [1]
Fracture occurs at hypertrophic zone
Changes to the epiphyseal plate zones hypertrophic zone is 80% of the plate (normal hypertrophic zone is 15-30% of the plate width)
Where is Klines line? [1]
How can you use this to diagnose SUFE? [1]
Klein’s line is drawn along superior border of femoral neck should cross at least a portion of the femoral head. When SUFE the femoral head drops below this line.
Perthes disease can lead to which MSK disease? [1]
Osteoarthritis [1]
Describe the pathophysiology of Osgood-Schlatters disease
Inflammation at the tibial tuberosity where the patella ligament inserts.
The patella tendon inserts into the tibial tuberosity. In patients with Osgood-Schlatter disease, multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of the bone.
This leads to growth of the tibial tuberosity, causing a visible lump below the knee. Initially, this lump is tender due to inflammation.
Lead to heterotopic ossification at site of tibial tubercle
As the bone heals and inflammation settles, the lump becomes hard and non-tender.
Consequences of not treating CDH? [2]
Head of femur will form a new acetabulum on the back of pelvis: creating a leg length discrepancy due to the moving of the femur further onto the back of the ilium.
The acetabulum also forms of fibrocartilage rather than hyaline, further affecting the joint properties.
Blount’s disease is a growth problem of which part of which bone? [2]
What deformity does this create? [1]
medial compartment of the distal tibia
Causes: irreversible tibia varus
State 3 risk factors for Blount’s disease [3]
State 2 methods of treating Blount’s disease [2]
Risk factors:
* obesity
* walking too early
* genetic factors
Treatment
* brace,
* surgery if brace fails (osteotomy with gradual distraction)
