Bone and Joint Problems of Children Flashcards
What do these conditions usually present with?
Limp (i.e. lower limb)
Are these conditions generally more common in males or females? Why?
Males - linked to development and growth, along with the presence of epiphyseal growth plates. Particularly the growth spurt in puberty putting strain on the growth plate (this is woven bone, so it is a weak spot that can collapse if you put pressure on it).
Most babies are born with flatfeet and develop arches as they grow - if the arches never fully develop, what is this called?
Flat foot
The parents of babies with flat feet often first notice what about their child?
“Weak ankles” noticed when they first start walking - the ankles appear to turn inward
How is flat foot treated?
Orthotics
Surgery (to shave tarsal bones to be the right shape)
Physiotherapy (to exercise dorsiflexors)
What is most flat foot caused by?
Muscle imbalance
Toe walking is common among toddlers as they learn to walk, i.e. it is…?
It generally disappears by what age?
Idiopathic (habitual)
Age 2
Persistent toe walking in older kids might be linked to other conditions, such as…? (3)
Cerebral palsy
Duchenne (muscular dystrophy)
Nervous system problems
Persistent toe walking in otherwise healthy children may require treatment - how is it treated?
Castingthe foot and ankle for about 6 weeks to help stretch calf muscles.
Surgery to release tight calf muscles (i.e. lengthen Achilles’ tendon)
Talipes equinovarus - what is this?
Club foot - fixed varus and equinus deformity
What is club foot due to?
Calf underdevelopment (dorsiflexors are too strong, plantar flexors are not working as well)
What is the epidemiology of club foot?
1:1000
50% bilateral
M:F ration = 2:1
What is club foot associated with? (5)
Breech presentation
Connective tissue disorders e.g. Ehlers Danlos
Oligohydramnios
Genetic syndromes (Edward’s Syndrome – trisomy 18)
Family history
What happens in Ehlers Danlos?
Collagen in tendons and ligaments is too stretchy, gets disorganised during development
Why does oligohydramnios cause club foot?
Causes constraint injury, infant can’t move around in the amniotic cavity, leading to the feet being pushed up against the wall of the uterus. Can’t kick/develop muscles during intrauterine growth.
How is club foot treated?
Ponseti method – manipulative technique to correct clubfoot without invasive surgery
How successful is the Ponseti method?
Painless / fast / successful in almost 100% of cases
When does congenital hip dysplasia present?
Present at birth
Is congenital hip dysplasia more common in boys or girls?
What other risk factors are there?
Girls
Breech delivery, genetics
How many children per 1000 have CDH?
1.5 per 1000
What other skeletal disorders is CDH associated with?
Clubfoot
Scoliosis
What is seen on the neonate with CDH?
Asymmetric creases around the hip joint – double crease
Shortened leg
Leg externally rotated
How is CDH diagnosed (tests)? (3)
Barlow test – push down with legs together from abduction to adduction
Ortolani test – opposite of Barlow (limited abduction)
Galeazzi sign – extra creases seen, and leg length discrepancy
What can be seen on the x-ray for CDH?
Femoral head goes posteriorly and moves the gluteal muscles (so they become more vertical)
The alpha angle (angle between the iliac margin and joint inclination) is less than 60 degrees
Why are radiographs of limited use in CDH?
Because the femoral head isn’t ossified until 4-6 months)
What lines are used on x-rays to diagnose CDH?
Hilgenreiner’s line (plus acetabular index line) – look at angle
Perkin’s line (from lateral superior border of the acetabulum down) – femoral head should be medial to the line
How is CDH treated?
Maintain reduction of femoral head in true acetabulum
Subluxation often corrects spontaneously
How is CDH treated in newborns up to 6 months?
Closed reduction and immobilization in Pavlik harness
Hip flexed and abducted while still allowing movement
In harness for at least 6 weeks full-time and 6 weeks part-time
80-95% success
If hip not reduced in 3 weeks then alternative needed (e.g. closed reduction with hip spica)
What is a danger of Pavlik harnesses?
Avascular necrosis and femoral nerve palsies due to compression
If Pavlik harness does not work or in children older than 6 months, how is CDH treated?
Open reduction
Femoral osteotomies with or without pelvic osteotomies
Perthes’/Legg-Calve-Perthes disease - what is it and how common is it?
When does it usually occur?
Self limiting avascular necrosis of the femoral head
1:1000
Usually between 4-8 years
Is Perthes’ more common in males or females?
4:1 male to female ratio
Is Perthes’ usually unilateral or bilateral?
Usually unilateral (6:1)
What are the stages of Perthes’ disease?
Necrosis - a portion of femoral head dies. Shape of femoral head changes, causing pain, stiffness and inflammation. UP TO ONE YEAR.
Fragmentation - dead cells absorbed and replaced by new bone cells. As new bone forms it produces varying femoral head shapes. 1-3 YEARS.
Reossification - femoral head continues to grow with new bone cells. 1-3 YEARS.
Remodelling - New bone cells are gradually replaced by normal bone cells and remodeling continues. 1-3 YEARS.
What artery is affected in Perthes’ disease?
Acetabular branch of obturator (artery to head of femur)
How is Perthes’ treated?
If child young (under 5) or in mild cases observation and physiotherapy - bed rest
Plaster casts or braces - abduction to keep femoral head in acetabulum
Surgery - osteotomy
How common is slipped upper femoral epiphysis (SUFE)?
Which side is most common?
Is it usually unilateral or bilateral?
30-60:100,000
Left hip
Unilateral (60-80%)
What is the age of incidence of SUFE for boys and girls? When does it stabilise?
13 years old for boys - stabilises in 4.5 months
11.5 years for girls and less severe - stabilises in 3.6 months
Is SUFE more common in boys or girls?
3:1 boys to girls
What is it that is slipping in SUFE?
Epiphysis actually stays in place, it’s the neck and shaft that displaces (moves relative to where epiphysis is).
What is the aetiology of SUFE?
Obesity
Hypothyroidism
Deficiency or increased androgens
Trauma
What are the types of SUFE?
Pre-slip – wide epiphyseal line, no slippage
Acute – slippage sudden
Acute-on-chronic – slippage occurs acutely on existing chronic slip
Chronic – steady progressive slippage (most common)
How is SUFE diagnosed?
Radiographs using Klein’s line - line 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.
LIMITED INTERNAL ROTATION
How is SUFE treated?
Rest
Analgesia
Surgery - closure of epihyseal growth plate (screws), corrective osteotomy
What is the potential problem of unilateral fixation for SUFE?
Contralateral slips
What is Blount’s disease?
What causes it?
Growth problem of distal tibia (medial compartment) -
fails to develop normally causing angulation/tibia varus
Cause is unknown, thought to be due from effects of weight on epiphyseal growth plate.
What is associated with Blount’s disease? (3)
Increased incidence with obesity
Walking early
Genetic factors
How is Blount’s disease treated?
Conservative - brace, physiotherapy
Surgical (for early onset or when brace fails) - osteotomy, gradual distraction
What is Osgood-Schlatters?
How long does it last?
Osteochondrosis - a self-limiting disturbance of endochondral ossification
Symptoms disappear about 1 year after onset, but there may be residual knee pain when kneeling
What is the most common cause of knee pain in children between 10-15 years?
Osgood-Schlatters
What is the most likely cause of Osgood-Schlatters?
Repeated traction from the patellar ligament on the tibial tuberosity (quadriceps insert onto tibial tuberosity and pull it, this is close to growth plate, causing growth plate to move and bone growth anteriorly at insertion point and pain)
Avulsion fractures to parts of the tibial tuberosity
This causes bone growth anteriorly at insertion point.
How is Osgood-Schlatters treated?
Conservative treatment - rest, avoidance of activities that cause pain, NSAIDs
