Bone and Joint Problems of Children Flashcards
1
Q
name the common musculoskeletal problems of childhood
A
Flat foot
Club foot
Toe walking
CDH
Perthe’s
SUFE
Blount’s disease
Osgood-Schlatter disease
2
Q
how do people with childhood musculoskeletal problems present
A
- usually present with a limp in the lower limb
3
Q
who usually gets musculoskeletal problems of childhood
A
- usually boys except for CDH which effects girls more
4
Q
what is childhood musculoskeletal problems linked to
A
Linked to development
Growth
Presence of epiphyseal growth plates
5
Q
are babies born with flat feet
A
Most babies are born with flatfeet and develop arches as they grow and start to walk
- In some the arch never fully develops - either because the muscles are hypotonic
6
Q
what does a parent described that children having when they are born with flat feet
A
Parents often first notice their child has what they describe as “weak ankles”
7
Q
why in some babies do they have flat feet
A
- In some the arch never fully develops
- either because the muscles are hypotonic
- or a bony problem in the shape of the tarsal bones are not the right shape then the arch does not developed
8
Q
what do the ankles look like in flat foot
A
Ankles appear to turn inward
- Weight on inside of sole
9
Q
What is the treatment of flat foot
A
Orthotics
Surgery
10
Q
who is toe walking normal in
A
Toe walking is common among toddlers as they learn to walk
- Idiopathic (habitual)
11
Q
when does toe walking become a problem
A
- muscle imbalance in conditions such as cerebral palsy that can make dorsiflexors hypotonic compared to the plantar flexors
12
Q
when does normal toe walking tend to disappear
A
by the age of 2
13
Q
what conditions is toe walking in older children linked to
A
- cerebral palsy
- DMD (duchenne muscular dystrophy)
- nervous system problems
14
Q
how do you treat toe walking in healthy children
A
Castingthe foot and ankle for about 6 weeks to help stretch calf muscles
Physiotherapy
Surgery to release tight calf muscles
15
Q
describe the epidemiology of club foot
A
1:1000
50% bilateral
M:F ration = 2:1
16
Q
name the other name for club foot
A
Talipes equinovarus
17
Q
what can club foot develop from
A
- underdevelopment of the calf muscles
- in utero need to move your legs around to stretch them out to move and develop the joints and the muscles, if there is any constraint in utero this can lead to everything being constricting
18
Q
describe club foot
A
Fixed varus and equinus deformity,
19
Q
what is club foot associated with
A
- Breech presentation
- Connective tissue disorders (Ehlers Danlos)
- Oligohydramnios
- Genetic syndromes (Edward’s Syndrome – trisomy 18)
- Family history
20
Q
what is treatment for club foot
A
Ponseti method – manipulative technique to correct clubfoot without invasive surgery - repetitive plasting over weeks, so you can reshape into a normal condition
- after this fixed plaster class requires abduction of the foot brace thus keeping the position of the ankle and foot in the normal positive
- in this full time for 24 hours a day for 12 weeks and then every night up to the age of 4
21
Q
describe the benefits of the ponseti method
A
- Painless
- fast
- successful in almost 100% of cases
22
Q
what is congenital hip dysplasia
A
- this is a dysplasia
- present at birth
- same position as an adult posterior hip dislocation
23
Q
what are the risk factors of congenital hip dysplasia
A
- Females - everything is looser, and the pelvis is wider
- Breech delivery
- Family history
- Oligohydramnios
- 1st born
24
Q
what are other skeletal disorders with congenial hip dysplasia
A
Clubfoot
Scoliosis
25
when does congenial hip dysplasia spontaneous resolve
60-80% resolve spontaneously within 2-8 weeks
26
How do you diagnose congenital hip dysplasia
Barlow test
Ortolani test
Galeazzi sign
27
what is the Barlow test
- adduct and push downward to try and dislocate the hip
28
what is the ortolani test
- abduct hips and try to relocate hip
| - fingers push femur forwards into acetabulum
29
what is the gaelazzi sign
- flex the hip and knee and look to see if the knee is shortened or lower which tells you that the leg length is shortened
30
why are x rays not great in children
- ultrasound is easier to see what is going on and they move as well so you can see the hip dislocate
- due to the epiphyseal growth plate
31
what would you see in childhood hip dysplasia in an ultrasound
- head of the femur is out of the acetabulum and pushes the gluteal muscles in a more vertical position
- can then monitor the position o the gluteal muscles with treatment
32
describe the grading of childhood dysplasia of the hip from the ultrasound
Grade I >60o
Grade IIa,b 50-59o
Grade IIc 43-49o
Grade IIIa,b, IV <43o
33
when can radiographs be used for childhood hip dysplasia
Limited use until femoral head ossifies
| - 4-6 months
34
describe how a radiography can be used for childhood hip dysplasia
Hilgenreiner’s line (plus acetabular index line) - goes through the epiphyseal growth plate in the pelvis on both sides
acetabular index line - superior lateral across the ilium part of the acetabulum and it intersects and you measure the angle
Perkins line
- better visualised cue
- goes from the Superior lateral aspect of the acetabulum and vertical line straight Dom from there
- looking for where the femoral head is in relation to that line
- in a normal hip it should be medial to that line
- in CHD it is lateral to that line
35
what is the treatment for CHD
- want to wait two to 8 weeks to see if it will resolve
- Closed reduction and immobilization in Pavlik harness
- keep the 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
- can use the ultrasound to see if the hip is relocating
- If hip not reduced in 3 weeks then alternative needed
36
what are the potential long term problems with congenial hip dysplasia
Avascular necrosis
- head of the femur is attached to the acetabulum via the ligamentum trees which as the obturator branch supplying the femoral head, this ligament of the femur can be damaged and disrupt the blood flow leading to avascular necrosis
femoral nerve palsies
- compressed the femoral nerve up against the inguinal ligament in the harness
- therefore they wont be able to extend the hip or move as well
- can't extend the knee as well
- this is normally a compression so over a few weeks then femoral nerve will work again
- but it can leave a little weakness
37
what should you use to treat CHD if the pavlik harness does not work
Closed reduction with hip spica
= If Pavlik not working or in children older than 6 months
= 12 weeks
Open reduction
- If not resolved by 18 months
- Femoral osteotomies with or without pelvic osteotomies
- cutes the neck and put it in the acetabulum
38
what happens if CHD is left untreated
- head of the femur hors a new acetabulum on the back of the ileum
- leg length shortened as the acetabulum has moved up
- not hyaline cartilage but fibrocartilage therefore osteoarthritis can develop
39
What is perthes disease
- Self limiting avascular necrosis of the femoral head
-
- usually unilateral but in about 1/6th of cases it can be bilateral
40
describe the epidemiology of Perthes disease
1:1000
presents Usually between 4-8 years with a limp
4:1 male to female ratio
41
describe blood to the head and neck fo the femur
neck
- medial and lateral circumflex
head
- majority from the acetabulum branch of obturator artery (only in children)
once the epiphyseal growth plate has closed they more or less have the same blood supply
42
what are the stages of perthes disease
phase 1 = Necrosis
phase 2 = fragementation
phase 3 = reossification
phase 4 = remodelling
43
describe what happens in the stages of perthes disease
phase 1 = Necrosis
- A portion of femoral head dies.
- Shape of femoral head changes, causing pain, stiffness and inflammation.
- last up to a year
phase 2 = fragementation
- Dead cells absorbed and replaced by new bone cells. - As new bone forms it produces varying femoral head shapes.
- 1-3 years
phase 3 = reossification
- Femoral head continues to grow with new bone cells
- 1-3 years
phase 4 = remodelling
- New bone cells are gradually replaced by normal bone cells and remodeling continues
- 1-3 years or more
44
in older children Perthes disease is ...
has a worse outcome
45
What is the treatment for perthes disease in
- children under the age of 5
- older children
If child young (under 5) or in mild cases
- Observation
- physiotherapy
- Bed rest
- Plaster casts or braces
- Abduction to keep femoral head in acetabulum
For older children
- Surgery = Osteotomy - length the femoral head to reduce leg length discrepancy
46
describe the epideiomology of slipped upper femoral epiphysis (SUFE)
- 30-60:100,000
Stabilises around 3.6 months in girls 4.5 months in boys
3:1 boys to girls
47
What does SUFE stand for
Slipped upper femoral epiphysis
48
in SUFE what hip is more common
- Left hip more common than right
| - Bilateral in 20-40%
49
What age does SUFE occur
10-17 years
Age of incidence
- 13 years old for boys and is more severe
- 11.5 years for girls and less severe
- Stabilises around 3.6 months in girls 4.5 months in boys
50
what happens in SUFE
- epiphysis stays in place but it is the neck and shaft of the femur that is moving
51
how do SUFE patients present
- shortened
- externally rotated at the foot
- reduced movement
- limited internal rotation of the left hip
52
what are the risk factors of SUFE patients
Obesity
Hypothyroidism
Deficiency or increased androgens
Trauma
- SUFE = obese, underdeveloped sexual characteristics
53
what are the different 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 slow progressive slippage (most common)
54
How do you treat SUFE
Rest
Analgesia
Surgery
- Closure of epiphyseal growth plate (screws)
- Followed by corrective osteotomy if required
55
what happens if you only close one epiphyseal growth plate in SUFE
= put stress on the non closed epiphyseal growth plate
| - therefore have to close both of them to stop the stress
56
What is blounts disease
Growth problem of distal tibia (medial compartment)
Causes tibia varus
- squashing the proximal tibia epiphyseal growth plate with weight and compresses it therefore it does not grow
- irreversible pathogenic changes
57
what is the cause of blounts disease
Cause is unknown, thought to be due from effects of weight on epiphyseal growth plate.
58
what fails to grow in blounts disease
Medial part of proximal tibia, fails to develop normally, causing angulation
59
what are the age groups for Blounts disease
Infantile 1-3 years
Juvenile 4-10 years
Adolescent 10 years +
60
what is the treatment of blounts disease
Conservative
- Brace
Surgical
- Early onset
- When brace fails
- Osteotomy
- Gradual distraction
61
What is osgood-schlatters
osteochondrosis
Disturbance of endochondral ossification
- quadriceps and tibial tuberosity match up just below the epiphyseal growth plate
- children involved in lots of sports extend the knee and pull of the bit of woven bone and you end up with a lump at the tibial tuberosity
62
what is the most common knee pain in children
osgood-schlatters
| - 10-15 years
63
how do you treat osgood-schlatters
Symptoms disappear about 1 year after onset
| - if you stop doing sporting activities and pulling on it
64
What is the most likely cause of osgood-schlatters
Repeated traction from the patellar ligament on the tibial tuberosity
Avulsion fractures to parts of the tibial tuberosity
65
where do you get pain in osgood-schlatters
Pain at the point of insertion of the patellar ligaments
66
what is the treatment of osgood-schlatters
Rest
Avoidance of activities that cause pain
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Strapping and brace to support knee
