Bones & Joints: paediatrics Flashcards
When does the head control milestone usually begin and be complete?
- 1 month
- 3 months
When does the sit milestone usually begin and be complete?
- 6 months
- 9 months
When does the stand milestone usually begin and be complete?
- 9 months
- 12 months
When does the walk milestone usually begin and be complete?
- 12 months
- 20 months
What are the deformities children may have?
Angular plane/ coronal: -Bow legs -Knock knees Rotational plane: -In/out toeing =Femoral Torsion =Tibial Torsion =In the Foot
What are the names for bow legs and knock knees?
Genu varum= bow legs
Genu valgum= knock knees
What is the normal change in coronal alignment in growth?
Natural bowed legs when born until walking
Walking= straight
2-3 years knock kneed appearance
When does the normal gait pattern develop?
7 years
Alignment 6/7 degrees of valgus
Adulthood
How might apparent bow/ knock knees be misleading?
- Apparent bowleg occurs when child stands with hips and knees flexed (external rotation)
- Child lies down and extends hips and knees, legs are straight
How does pathological forms of genu varum/ valgum present?
-Asymmetric
-Resistant to normal change
(rickets)
-Short stature
-Varus > 11 degrees (Blount’s)
-Trauma/ systemic
What are the treatments for coronal deformities?
- Used to be observational, growth, osteotomy (reshape and plate)
- Now Eight Plate guides growth, gentle
How does Eight Plates work?
Titanium plates, stiff, same stiffness as bone so bend with growth
-Apply to one side of growth plate to slow down on one side, correction in deformity as other side grows
How does in/ out toeing in the rotational plane present?
-Clumsy
-Tripping/ limping
-“deformed”
-From femur, tibia, foot
(how leg rotates in length= foot position)
What are the angles considered in-toeing and out-toeing?
Out-toeing= above 15 degrees
In-toeing below 0 degrees
What is femoral anteversion?
-30 degrees
The angle of axis through the condyles
Fit into pelvis, turn hip in, guide to how much hip will internally rotate
How do we measure femoral anteversion?
Lie on front to estimate anteversion, leg/knee at 90%, internal hip rotation until feel prominent greater trochanter
What are the pathological forms of the rotational plane?
- Excessive femoral anteversion
- External tibial torsion
What is the normal range of foot progression angle?
Max: +15
Ideal: +5
Min: -10 (+15/-15)
What is the normal range of thigh-foot angle?
Max: +20-+30
Ideal: -3- +15
Min:-30 to-5
(+15/-15)
What is the normal range of external hip rotation?
Max: 90 to 55
Ideal: 65 to 38
Min: 45 to 25
(+15/-15)
What is the normal range of internal hip rotation?
Max: 60 to 55
Ideal: 40 to 43
Min: 15 to 20
(+15/-15)
What is persistent in toeing?
- Baby= natural 50 degree anteversion, changes when walking (15 by 7)
- Persistent femoral anteversion
- Internal tibial torsion
- Many resolve with growth/ remain asymptomatic
What is miserable malignment?
Combination of PFA and ext tib torsion can result in patellar instability
-Symptomatic/ knees
What is the pathological form of out toeing?
Femoral Retroversion
- present from birth
- Osteotomy
What are pathological problems in the foot?
Metatarsus Adductus
-Medial curve of foot
-Resolves completely with growth
Club foot (CTEV)
-Underdeveloped parts of world badly managed
-Corrective surgery if not treated in childhood
-Many casts gradually correct deformity (first cast unlocks foot into dorsal flexion), cut Achilles
Flat foot (planovalgus)
-Tip toes
-Symptomatic only treatment= insoles
-Subtalar implant (medial weight bearing)
Describe limping
- Common presentation in paediatric orthopaedics
- Often atraumatic
- 180/100,000
What is the normal gait in children in early walking?
Short stride length Fast cadence (number of steps per min) Low velocity Widened base of support -Until 30-36 months= poor balance and abductor strength so cannot maintain single leg stance -Mature gait age 7
What causes a limp?
- Pain
- Mechanical problem
- Neuromuscular problem
Describe the age distribution of limping
0-3= DDH (development dysplasia in hip) 3-6= Transient Synovitis 10-15= SUFE
4-8= Perthes’
0-15= Tumours and Septic Arthritis= neuromuscular
What are the pain characteristics of a history of limping?
- Acute= trauma, infection
- Constant= malignancy, chronic infection
- Morning pain/ pain after inactivity= inflammatory joint disorders
- Night pain= malignancy, osteoid osteoma, benign growing pains
What do we examine in limping?
- Gait
- Spine
- Asymmetry
- Deformity
- Swelling
- Tenderness
- Examine all joints
- Rotational profile
What is Transient Synovitis?
Irritable hip
Non-specific, short-term inflammatory synovitis with synovial effusion of the hip joint
-Aspirate
What is the clinical presentation of Transient Synovitis?
- Painful hip/ thigh/ knee
- Often associated with viral infection= immune response
- Synovial fluid effusion
- Hip held in flexion, lateral rotation and abduction
- Exclusion of other conditions
What are the investigations for Transient Synovitis?
(Excluding Sepsis)
- Full blood count
- ESR, CRP
- X rays- AP and frog lateral
- Ultrasound
- MRI, bone scan, etc
What is Developmental Dysplasia (DDH)?
- 1-5/1000 births
- Hereditary influence
- Breach after 32 weeks or Caesarean
- 1st Born
- Oligohydramnios
- Female: male= 5:1
What do we see on examination in DDH?
-Barlow’s= leg in flexion, push down on knee (brutal) until clunk
-Ortolani= abduction until clunk (out hips) back into joint
DISLOCATED HIPS
-Skin crease asymmetry
-Leg length discrepancy
-Reduced abduction (cant do frog position)
How do we treat DDH?
Pelvic harness treatment Halter, Stirrups Anterior (Flexor) Stirrup-strap Posterior (Abduction) Stirrup-strap -Allows hip to sit down into position -3 months -Can need surgery
What is Perthes Disease?
- Avascular osteonecrosis of femoral epiphysis caused by poorly understood non-genetic factors
- Boys> girls 4:1
- 4-8 years in majority
- Lower social class= increased risk
What are the principles of Perthes Treatment?
- Prevention of stiffness
- Contain femoral head in acetabulum
- Surgical treatment required in certain circumstances
- Outcome depends on how well femoral head remodels
- Varus osteotomy
What is Slipped Upper Femoral Epiphysis (SUFE)?
- Males (3:1) 13-16 years
- In females younger, not after menarche
- Bilateral in 42%
- Obese or tall and slender
- Rapid growth
- 7% risk of a 2nd family member involved
What are the clinical features of SUFE?
- Acute/ chronic/ Acute on Chronic
- Pain groin, thigh, knee
- Limp
- Antalgic gait
- Externally rotated and adducted limb
What are the red flags of examination?
- Neonate with painful paralysed looking arm or leg= septic arthritis/ infection
- Asymmetry of spin or limbs= scoliosis/ DDH
- School age child with limp= Perthes disease
- Knee pain in adolescent= SUFE or tumour
- Back pain= discitis
Describe infection
- Cellulitis
- Osteomyelitis
- Septic arthritis
- Usually requires emergent referral for investigation +/- aspiration
Describe Discitis
- Presentation can be subtle
- MRI usually required
- Epidural abscess is surgical emergency
What should raise suspicion of non accidental injury?
- Pre-existing disability
- Vague history from parents
- Injury inconsistent with history
- Delay in presentation
- Multiple bruises of varying age
- Multiple fractures
- Burns
