Children's Orthopaedics Flashcards
Abnormal features in babies/young children usually correct…
with age.
When is deformity significant>
Only if it is likely to persist and cause physical or mental health problems later in life
Longitudinal growth of bones
Growth plate (physics) by ENDOCHONDRAL OSSIFICATION
Echondal ossification
Longitudinal growth of bones
Circumferential growth of bones
From periosteum by APPOSITIONAL GROWTH
Some physes contribute to growth more than others
40% of upper limb growth comes from the shoulder
70% of lower limb from the knee joint
Factors affecting the growth plate
Diet/nutrition
Sunshine, vitamins (Vit D & A)
Injury
Illness
Hormones (GH)
Short stature
Aged <3 growth much more variable.
Can cross centiles
Nutrition plays a big part
Look at parents’ height
Dysmorphic features –> increase chance underlying genetic or endocrine disorder
Low GH
Normal development landmarks
6-9 months - sits alone, crawls
8-12 months – stands
14-17 months walks
24 months jumps
1-6 months Loss of primitive reflexes – Moro, grasp , stepping, fencing
2months head control
9-12 months few words
14 months feeds self, uses spoon
18 months stacks 4 blocks, understands 200 words
3 years potty trained
HIGHLY VARIABLE
Genu varum
Born on a horse
Bow legged
Can vary with age.
Normal in age <2
Persisitng mild genu vacuum can run in families –> reassure
Genu valgum
Knock kneed
6° knock kneed on average.
Usually normal - peak at age 3 1/2
Chart and monitor
Refer if asymmetric, painful, severe (>2SD)
> 8cm intermalleolar distance at age 11 –> consider surgery
When can genu vacuum be pathological
If Unilateral (asymmetry >5°)
Severe >2SD/16° from mean
Short stature >2SD
Painful
Patholigical Genu Varum
Skeletal dysplasia
Rickets
Tumour (enchondroma)
Blounts disease
Trauma –> injury to physis
Blount’s disease
- sign on x ray
Growth arrest of medial tibial physis of unknown aetiology
Typical BEAK like protrusion on X ray
Genu valgum - pathological causes
Tumours - endochondroma, osteochondroma
Rickets
Neurofibromatosis
Idiopathic
Intoeing
Child walks with toes pointing in (pigeon-toed)
Often accentuated when running
May be related to femoral neck ante version, internal tibial torsion, metatarsus adducts or combo
Femoral neck anteversion
Femoral neck normally points anteriorly
XS anteversion –> increased Internal Rotation of hip
Tend to sit in W position
30-40° at birth, slowly unwinds and should be around 10-15° at maturity
Usually of no consequence.
Can predispose to patellofemoral problems
Internal tibial torsion
Usually seen in toddlers
Vast majority resolves by 6 yrs
Internal torsion causes the foot to adduct, and the patient tries to compensate by everting the foot, externally rotating at the hip, or both
Does bracing/orthotics help in internal tibial torsion?
Ineffective and not required
Metatarsus adductus
Common
Benign
Resolves
If not passively correctable - serial acting may help age 6-12 months.
causes the front half of the foot, or forefoot, to turn inward.
Intoeing - what to do
Define cause
Reassure - vast majority get better with time
Chart/photograph
Review
Discharge unless persisting and severe
Flat feet
Common
We are born with flat feet but most develop medial arch once walking as tibias posterior strengthens
Flat feet usually asymptomatic
Flat feet - flexible or fixed?
Fixed flat feet
On tip toes and form an arch = flexible
on tip toes an NO arch formed = fixed
Fixed feet may indicate an abnormality
???
Flexible may be related to generalised ligamentous laxity or tightness gastrocsoleus complex
Many resolve
Orthotics unhelpful unless there is pain
No proven consequence of persisting flat feet
Calf tightness assessment
Flat feet
Need to relax gastrocs by flexing knee.
Hyper mobility
More flexible
Beighton score 9/9.
Tarsal coalition can cause
Flat feet.
Rigid flat foot
May benefit from surgery if painful.
Curly toes
Common in younger children
Most 3rd or 4th toes
Vast majority resolve by 6 yrs old
Splinting or taping is INEFFECTIVE.
Rarely persisting cases can consider flexor tenotomy
Anterior knee pain
more common in females than males
Adolescent
Localised patellar tenderness
Stairs/squats pain
very very common
CHECK THE HIPS
Physiotherapy, most resolve
In anterior knee pain, what else should you check?
HIPS
Slipped femoral head?
