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BRS Phase 1b > Children's Orthopaedics > Flashcards

Children's Orthopaedics Flashcards

1
Q

How many bones does a Child’s skeleton have?

A

A child’s skeleton has 270 bones and is a system that is in continuous change

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2
Q

What are the physics?

A

The physis (growth plates) are the areas from which long bone growth occurs post-natally

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3
Q

How do flat bones develop?

A

Intramembranous

Mesenchymal cells»bone

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4
Q

How do long bones develop?

A

Endochondral

Mesenchymal»cartilage»bone

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5
Q

Describe Intramembraneous Ossification

A

4 key stages

In intramembranousossification, a group of mesenchymal cells in the central ossification centres differentiate first into preosteoblasts and then intoosteoblasts.

These cells synthesize and secreteosteoidand the osteoblasts further differentiate into osteoclasts

These cells then collectively create the immature woven trabecular matrix and immature periosteium.

Angiogenesis occurs and Blood vessels incorporated between the woven bonetrabeculaewill form the future bone marrow.

Later, the woven bone is remodeled and is progressively replaced by mature lamellar bone.

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6
Q

What happens during Endochondrial Ossification?

A

At both the primary and secondary ossification centres

Primary Ossification Centres
Sites of pre-natal bone growth through endochondral ossification from the central part of the bone

Secondary Ossification Centres:
Occurs post-natal after the primary ossification centre and long bones often have several (the physis)

TISSUE that will become bone is firstly formed from cartilage.

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7
Q

What happens during Primary endochondral ossification?

A

a) Mesenchymal Differentiation at the primary centre
b) The cartilage model of the future bony skeleton forms
c) Capillaries penetrate cartilage.
Calcification at the primary ossification centre – spongy bone forms
Perichondrium transforms into periosteum
d) Cartilage and chondrocytes continue to grow at ends of the bone
e) Secondary ossification centres develop with its own blood vessel and calcification at the proximal and distal end – calcification of the matrix
f) Cartilage remains at epiphyseal (growth) plate and at joint surface as articular cartilage.

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8
Q

Where does primary endochondral ossification take place?

A

The first site of ossification occurs in the primary center of ossification, which is in the middle ofdiaphysis of the bone - prenatal

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9
Q

What happens in secondary endochondral ossification?

A

Long bone lengthening

Happens at the physis (physeal plate)
Zone of elongation in long bone
Contains cartilage
Epiphyseal side – hyaline cartilage active and dividing to form hyaline cartilage matrix
Diaphyseal side – Cartilage calcifies and dies and then replaced by bone

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10
Q

How do children bones differ in elasticity?

A

Children’s bone can bend – more elastic than adult

Increased density of haversian canals

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11
Q

What does increased elasticity lead to

A

Plastic deformity
– bends before breaks

Buckle fracture
– Tarus like the column

Greenstick
– like the tree
One cortex fractures but does not break the other side

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12
Q

What happened at the Physis?

A

Growth occurs at varying rates at varying sites
Growth stops as the physis closes
Gradual Physeal closure, Puberty, Menarche, Parental height
Complete at
Girls 15-16
Boys 18-19

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13
Q

What do Physical injuries lead to?

A

Growth arrest

Can lead to deformity

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14
Q

What is speed and remodelling dependent on?

A

The speed of healing and remodeling potential is dependent on the location and the age of the patient

Younger child heals more quickly

Physis at the knee grows more
Physis at extreme of upper limb grows more

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15
Q

What are some common Children’s congenital conditions?

A

Developmental Dysplasia of the Hip
Club Foot
Achondroplasia
Osteogenesis Imperfecta

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16
Q

What happens in Developmental Dysplasia of the Hip?

A

Group of disorder of the neonatal hip where the head of the femur is unstable or incongruous in relation to the acetabulum.
A ‘Packaging Disorder’
The normal development relies on the concentric reduction and balanced forces through the hip

Spectrum with dysplasia – subluxation – dislocation

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17
Q

What are the risk factors for Developmental Dysplasia of the Hip?

A

Dysplasia 2: 100
Dislocation 2:1000

Risk Factors
Female 6:1
First born
Breech
FH
Oligohydramnios
Native American/Laplanders – swaddling of hip
Rare in African American/Asian
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18
Q

What are the examinations for Developmental Dysplasia of the Hip?

A

Usually picked up on baby check – screening in UK
RoM of hip
Usually limitation in hip abduction
Leg length (Galeazzi)
In those 3 months or older Barlow and Ortalani are non-sensitive

19
Q

What are the investigations for Developmental Dysplasia of the Hip?

A

Ultrasound – birth to 4 months
After 4 months X-ray
If prior to 6 weeks needs to be age adjusted
Measures the acetabular dysplasia and the position of hip

20
Q

What is the treatment for Developmental dysplasia of the hip?

A

Reducible hip and <6 months
Pavlik harness 92% effective

Failed Pavlik Harness or 6-18 months
Secondary changes- capsule + soft tissue
MUA + Closed reduction and Spica

21
Q

What is Clubfoot?

A 
Congenital Talipes Equinovirus
Congenital deformity of the foot 
1:1000
Highest in Hawaiians
M2:1F
50% are bilateral

Genetic
Approx. 5% likely of siblings
Familial in 25%
PITX1 gene

22
Q

What is CAVE in clubfoot?

A

CAVE deformity due to muscle contracture
Cavus –high arch: tight intrinsic, FHL, FDL
Adductus of foot: Tight tib post and ant
Varus: Tight tendoachillies, tib post, tib ant
Equinous: tight tendoachilles

23
Q

What is the treatment for clubfoot?

A

Ponseti Method
Gold standard

  1. First a series of casts to correct deformity
  2. Many require operative treatment
    Soft tissue releases
  3. Foot orthosis brace
  4. Some will require further operative intervention to correct final deformity.
24
Q

What is Achondroplasia?

A

The most common skeletal dysplasia
Autosomal Dominant
G380 mutation ofFGFR3
inhibition of chondrocyte proliferation in theproliferative zoneof thephysis
results in defect in endochondral bone formation

25
Q

What happens in Rhizomelic dwarfism?

A

Humerus shorter than forearm
Femur shorter than tibia
Normal trunk
Adult height of approx. 125cm

Normal cognitive development
Significant spinal issues

26
Q

What is Osteogenesis Imperfecta

A

Brittle bone disease

Hereditary – autosomal dominant or recessive
Decreased Type I Collagen due to:
Decreased secretion
Production of abnormal collagen

Insufficient osteoid production

27
Q

What are the effects of Osteogenesis Imperfecta?

A 
Bones 
Fragility fractures
Short stature
Scoliosis 
Non-orthopaedic manifestations
Heart
Blue Sclera
Dentinogenesis imperfecta – brown soft teeth
Wormian skull
Hypermetabolism
28
Q

How do you classify paediatric fractures?

A

Pattern
Anatomy
Intra/extracellular
Displacement

29
Q

What is Salter-Harris classification?

A

Classification of physeal injuries (SALT)

  1. Physeal Separation
  2. Fracture traverses physis and exits metaphysis (Above)
  3. Fracture traverses physis and exits epiphysis (Lower)
  4. Fracture passes Through epiphysis, physis, metaphysis
  5. Crush injury to physis

Risk of growth arrest increases from 1 -5

Type 2 injuries most common

30
Q

What happens in growth. arrest?

A

Injuries to the physis can cause growth arrest

The location and timing is key

Whole physis – limb length discrepancy

Partial – angulation as the non affected side keeps growing

31
Q

What are the aims of treatment of growth arrest ?

A

Aim is to correct the deformity
Minimise angular deformity
Minimise limb length difference

32
Q

What are the 4 R’s of fracture management?

A

Resuscitate
Reduce
Restrict
Rehabilitate

33
Q

What do you do in reduce

A

Correct the deformity and displacement

Reduce secondary injury to soft tissue / NV structures

34
Q

What would you do in closed reduction?

A

Reducing a fracture without making an incision

Such as traction and manipulation in A&E

35
Q

What would you do in open reduction?

A

Making an incision

The realignment of the fracture under direct visualisation

36
Q

Give an example of a closed reduction?

A

Gallows traction

Holding the skin, the long bones of the lower limb can be reduced

Closed reduction to correct deformity

37
Q

What would you do to Restrict?

A

Maintain the fracture reduction
Provides the stability for the fracture to heal
Children rarely have issues with bone not healing
Can have issues with too much healing!

But remember the child’s quicker fracture healing times and remodeling potential

38
Q

What is used for restriction?

A

Plasters and splints commonly used in paediatric fracture

Remodeling and huge healing potential means that operative internal fixation often can be avoidedOperative intervention may be required

Consider the ongoing growth at the physis
Metalwork may need to be removed in the future
Internal - plate + screws, intra-medullary device.

39
Q

What do you do to Rehabilitate?

A

Children generally rehabilitate very quickly

Play is a great rehabilitator

Stiffness not as major issue as in adults

Use it, Move it and Strengthen!

40
Q

What happens in septic arthritis?

A

Septic arthritis in a child is a orthopaedic emergency!

Can cause irreversible long term problems in the joint
Therefore needs surgical washout of the joint to clear the infection

41
Q

What is the diagnosis once septic arthritis has been excluded?

A

Transient synovitis is a diagnosis once septic arthritis has been excluded
Is a inflamed joint in response to a systemic illness
Supportive treatment with antibiotics is the treatmentThe history is key
Duration
Other recent illness
Associated joint pain

42
Q

What helps score the probability of septic arthritis?

A 
Kocher’s classification can help score probability
Non weight bearing
ESR >40
WBC >12,000
Temperature >38
43
Q

What is Perthes Disease?

A

Idiopathic necrosis of the proximal femoral epiphysis

Usually in those 4-8 years old
Male 4:1 Female

Septic arthritis needs to be excluded first

Treatment is usually supportive in the first instance

44
Q

What is SUFE?

A

Slipped upper femoral epiphysis

The proximal epiphysis slips in relation to the metaphysis

Usually obese adolescent male
12-13 years old during rapid growth
Associated with hypothyroidism/hypopituitrism

Septic arthritis needs to be excluded first

Treatment is operative fixation with screw to prevent further slip and minimise long term growth problems

BRS Phase 1b (80 decks)

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