Children's fractures and disorders Flashcards
What is osteogenesis imperfect (Brittle bone disease)
Genetic disorder causing fragile bones and low trauma fractures
What genetic defect causes osteogenesis imperfecta
Defect of maturation and organization of type 1 collagen of bone
Why is type 1 collagen important
Because it accounts for most of the organic composition of bone
Inheritance pattern of osteogenesis imperfect a
Autosomal dominant
Autosomal recessive
Symptoms of autosomal dominant osteogenesis imperfecta
Multiple fragility fractures
Short stature
Blue sclerae
Dentinogenesis imperfecta (discoloured, translucent, weak teeth)
Loss of hearing
Easy bruising
Ligament laxity
Scoliosis
Symptoms of autosomal recessive osteogenesis imperfecta
Fatal in perinatal period
Spinal deformity
Investigations for osteogenesis imperfecta
Xray
What would xray show for osteogenesis imperfecta
Thin cortical layer
Osteopenic - loss of bone mineral
Mild cases may have normal xray with history of low energy fractures
Management for osteogenesis imperfecta
Fracture fixation - splints, surgery
Surgery to correct deformities
IV bisphosphonates
What is developmental dysplasia of the hip
Dislocation of femoral head during perinatal period causing the joint to be dislocated easily and develop abnormally
Risk factors for developmental dysplasia of the hip (5Fs)
Female
Firstborn
Family history
Fanny first (breech presentation)
Fluid - oligohydraminos
What is oligohydramino
Amniotic fluid volume less than expected for gestational age
Which hip is more commonly involved in DDOH
Left hip
Signs of DDOH
Asymmetry of legs
Loss of knee height
Less abduction in flexion
Positive Barlow’s test
Positive Ortolani’s test
Timing of presentation of DDOH
During neonatal baby checks - right after birth / 6-8 weeks during GP check
When the child starts to walk
<4 years old
Investigations for DDOH
US
Barlow’s test
Ortolani’s test
Xray only in 4-6 months old
Describe Barlow’s test
- infant supine
- Flex and adduct the hips while applying posterior force
Positive = palpable dislocated hip
Describe Ortolani’s test
- Infant supine
- Flex and abduct the hips while applying an anterior force
Positive = palpable and audible clunk as hip is reduced
Difference between Barlow’s and Ortolani’s test
Barlow’s is Bad = joint is dislocated
ORTolani - Orthopaedic doctors relocate joints = joint is reduced
Management of early DDOH
Pavlik harness 23-24hrs a day
Management of late DDOH
Closed / open reduction spica cast
What is transient synovitis
Inflammation of synovial lining of the hip joint
Transient synovitis most commonly affects
2-10 years old
Boys
Transient synovitis is often preceded by
Viral URTI
Symptoms of transient synovitis
Pain
Limp
Reluctant to weight bear
Reduced ROM
Low fever
Symptoms are generally milder than septic arthritis
Investigations for transient synovitis
Same day referral
Bloods - CRP, WCC
Xray
Joint aspiration if uncertainty between transient synovitis and septic arthritis
MRI
Management for transient synovitis
NSAID
Usually resolves within a few weeks
What is Perthe’s disease
avascular necrosis of femoral head in children
Perthe’s disease most commonly affects
4-9 years old
Boys
esp short stature / very active
Pathophysiology of Perthe’s disease
- The femoral head transiently loses its blood supply
- Causes necrosis and abnormal growth
- Remodelling occurs but the congruence of the joint is determined by age of onset and amount of collapse
- Older kids = more likely to be incongruent joint
- Incongruent joint causes early onset arthritis
Symptoms of Perthe’s disease
Intermittent hip pain
Referred knee/groin pain exacerbated by internal hip rotation
Limp
Signs of Perthe’s disease
Loss of internal rotation of the hip
Then progresses into loss of abduction
Then progresses into Trendelenburg’s gait
Pain in transient synovitis may be similar to Perthe’s disease. What is the key difference?
Pain in transient synovitis resolves within 2 weeks whereas pain in Perthe’s can persist for >4 weeks.
Raise suspicion if pain persist >4 weeks
Most cases of Perthe’s disease are unilateral / bilateral
Unilateral
10% bilateral
Investigations for Perthe’s disease
Xray - may be normal at first so should be repeated if suspicion persists
MRI
What can be shown on xray for Perthe’s disease
Sclerosis
Fragmentation of epiphysis
Management for Perthe’s disease
For less than 50% involvement of femoral head
- rest
- avoid physical activity
- traction
For more than 50% involvement of femoral head
- plaster cast
- osteotomy
When is osteotomy indicated in Perthe’s disease
If femoral head partially dislocates due to femoral head becoming flatter, wider, aspherical (incongruent)
What is slipped upper femoral epiphysis
Weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis
In which direction does the femoral head epiphysis slip in relation to the femoral neck in SUFE
Inferiorly
Risk factors for SUFE
Adolescents 8-18
Overweight
Male
Hypothyroidism
Hypogonadism
Afro-Carribean / Hispanic ethnicity
Symptoms of SUFE
Hip pain
Limp
Referred pain to knee; Can present as JUST knee pain
Antalgic gait
Trendelenburg’s gait
Difference between antalgic gait and Trendelenburg’s gait
Antalgic gait is due to pain whereas Trendelenburg’s gait is due to weakness in gluteus medius/minimus
Hip does not dip to one side in antalgic gait
Signs of SUFE
Antalgic gait
Loss of internal rotation of hip
Investigations for SUFE
Xray - AP and Lateral
Frog leg xray - provides visualisation of femoral head
Management for SUFE
Internal fixation
Complications of SUFE
AVN
Deformity
Chondrolysis
What is femoroacetabular impingement syndrome
Bones of the hip joint are not shaped properly during childhood which causes them to rub against one and another
When does femoroacetabular impingement syndrome usually present
20-45 years olds as groin pain
Types of femoroacetabular impingement syndrome
CAM
Pincer
Mixed
What is CAM type femoroacetabular impingement
Femoral head is not completely round so it cannot rotate smoothly inside the acetabulum
CAM type femoroacetabular impingement is associated with
Previous SUFE
What is Pincer type femoroacetabular impingement
Extra bone extends over the normal rim of acetabulum, can crush acetabular labrum
CAM type femoroacetabular impingement is more commonly seen in males / females
Males
Pincer type femoroacetabular impingement is more commonly seen in males / females
Females
femoroacetabular impingement syndrome can result in
Damage to labrum
Damage to cartilage
OA
Symptoms of femoroacetabular impingement syndrome
Pain in groin during flexion and rotation of hip
Difficulty sitting
Signs of femoroacetabular impingement syndrome
Positive C sign
Positive FADIR test (flexion/adduction/internal rotation)
What is C sign
When patients indicate the location of pain by gripping the lateral hip just above the greater trochanter
Investigations for femoroacetabular impingement syndrome
Xray
CT
MRI - visualize labrum damage
Management for femoroacetabular impingement syndrome
Observation in asymptomatic patinets
Arthroscopic / open surgery for CAM
Osteotomy for Pincer
Arthroplasty / THR for older patients with secondary OA
What is skeletal dysplasia
Short stature (dwarfism) due to genetic error causing abnormal development of bone and connective tissue
Most common type of skeletal dysplasia
Achondroplasia
What does achondroplasia cause
Disproportionately short limbs
Prominent forehead
Wide nose
Lax joints
Bowing of legs
Does achondroplasia disturb mental development
No
Inheritance pattern of achondroplasia
Mostly sporadic
Can be autosomal dominant
What can other types of skeletal dysplasia cause
Learning difficulties
Spine deformity
Haemangiomas
Spinal cord compression
Atlanto-axial subluxation
Examples of connective tissue disorders
Familial joint laxity
Marfan’s syndrome
Ehlers-Danlos syndrome
Down syndrome
What causes the genetic connective tissue disorders
Due to genetic disorders of type 1 collagen synthesis
Connective tissue disorders cause
Joint hyper mobility
Osteogenesis imperfecta is also caused by disorder of type 1 collagen. What is the difference between it and connective tissue disorders
Connective tissue disorders affects soft tissues more than bone whereas osteogenesis imperfecta affects type 1 collagen of bone
Inheritance pattern of familial joint laxity
Autosomal dominant
Signs of familial joint laxity
“double jointed”
Able to perform tricks such as voluntary dislocation of shoulder
Frequent ankle sprains
Recurrent dislocations of joints
Inheritance pattern of Marfan’s syndrome
Autosomal dominant
Sporadic
Signs of Marfan’s syndrome
Disproportionately long limbs
High arched palate
Tall stature
Pectus excavatum
Aortic problems - aortic dissection / aneurysm
Mitral valve prolapse
What is Ehlers-Danlos syndrome
Abnormal elastin and collagen formation
Signs of Ehlers-Danlos syndrome
Joint hyper mobility
Highly elastic skin
Easy bruising
Scoliosis
Disorders causing joint hyper mobility all causes
Frequent soft tissue injuries - ankle sprains
Recurrent dislocations
What is Duchenne muscular dystrophy
Genetic disorder leading to progressive muscle wasting
Inheritance pattern of Duchenne muscular dystrophy
X linked recessive
Duchenne muscular dystrophy only affects
Males
Cause of Duchenne muscular dystrophy
Defect in dystrophin gene. Dystrophin is required to maintain the integrity of muscle cells
Signs of Duchenne muscular dystrophy
Progressive muscle weakness
Unable to walk by the age of 10
Progressive cardiac and resp failure
Death at 20
Investigations for Duchenne muscular dystrophy
Raised CK
Muscle biopsy
Difference between the bones of children and adults
In children:
Presence of growth plate
Thicker periosteum
More elastic
Can remodel themselves and correct angulation
Why do children’s fractures heal more easily than adults
Thicker periosteum
Growth plates
How does thicker periosteum allow better healing of the bone
Often stays intact in fractures -> can stabilise fracture
Rich supply of osteoblasts
When should we consider children’s bones as adult bones
12-14 ; once they hit puberty
Because after they hit puberty, there is less chance of remodeling / correcting angulation by themselves
What is special about children’s fractures? Why does this occur?
Bones bend or bow rather than snap and splinter
Because bones are soft and the periosteum is thick
Growth plates is the weakest part of the bone so it is prone to injury
What classification is used for fractures at growth plate
Salter Harris
Most common type of growth plate fracture
Salter Harris II
What is salter Harris I fracture
Pure growth plate separation
Prognosis of salter Harris I fracture
best prognosis, unlikely to complicate into growth arrest
What is salter Harris II fracture
Small metaphysical fragment attached
Prognosis of salter Harris II fracture
Good, unlikely to complicate into growth arrest
Salter Harris II fracture commonly occurs at
Distal radial physis
What are salter Harris III and IV fractures
fracture spitting the growth plate + Intraarticular fractures
Prognosis of salter Harris III and IV fractures
Greater potential for growth disturbances
What is salter Harris V fracture
Compression injury to growth plate causing growth arrest
When can salter Harris V fracture be seen
CANNOT be seen on xray
Only seen when angular deformity has occurred
What are the common children’s distal radius fractures
Buckle fractures
Greenstick fractures
Salter Harris II fractures
What is a buckle fracture
When the bone is pressed to the point of bulging out of space
Management of buckle fracture
Splint 3-4 weeks
What is greenstick fracture
Partial thickness fracture - only cortex and periosteum disrupted on one side but undisrupted on the other
What are the common forearm fractures in children
Monteggia
Galeazzi
Both bones of forearm
Management of monteggia and galeazzi fractures in children
Reduction + fixation with plates and screws
Usually for children’s fractures reduction and rigid fixation is not needed since they heal well. Why is it used in monteggia and galeazzi fractures ?
Because there is high rate of re-dislocation of radial head / distal radio-ulnar joint if only manipulation and casting is used
Injury mechanism of supracondylar fracture
Fall on outstretched hand
management of supracondylar fracture in children
If undisplaced - splint
If displaced - closed reduction + wires
Which structures may be damaged by a severely displaced supracondylar fractures in children
Brachialis muscle
Median nerve
Brachial artery
Managment of severe displaced supracondylar fracture with damage to brachialis
Open reduction
Sign of median nerve damage at elbow
cannot make OK sign
hand of benediction - no flexion at 1-3rd fingers
Why does median nerve damage cause hand of benediction sign
Because median nerve innervates all anterior compartment muscles except MEDIAL half of flexor digitorum and flexor carpi ulnaris
This means that the little and ring fingers will still be able to flex.
Sign of median nerve damage at wrist
Parasthesiae at palmar thumb, index, middle and half of ring fingers
thumb weakness
muscle wasting of thenar eminence
What would indicate an emergency surgery for supracondylar fractures
Absent radial pulse
Nerve injury
Injury mechanism of femoral shaft fracture in children
Fall onto flexed knee
Bending/rotational force
Femoral shaft fractures in children less than 2 can indicate
NAI
Management of femoral shaft fracture in children less than 2
inform senior if suspect NAI
Admit child for safeguarding, ensure other children at home are also safe
Manage fracture
- Gallows traction
- Hip spica cast
Management of femoral shaft fracture in children 2-6
Thomas splint / hip spica cast
Management of femoral shaft fracture in children above 6
Flexible IM nail in 6-12
Adult IM nail in above 12
What should you suspect when you see a femoral shaft fracture in a child
NAI
Malignant bone tumours
What fracture does “toddler’s fracture” describe
Undisplaced spiral tibial shaft fracture - common in toddlers
Management of toddler’s fracture
Cast
flexible IM nail / plates and screws / external fixation of severe
