Children's Orthopaedics Flashcards
How many standard deviations are considered within normal limits
2
How does angular profile vary between newborns and children aged 4-6 years
Newborns = Genu valgus
1.5 - 2 years = Normal angular profile
2 - 2.5 years = Genu varum
4-6 years = Normal angular profile
Give examples of abnormal features in toddlers which correct themselves with age
Overlapping toes
Internally rotated feet
Flat feet
If a deformity is asymmetrical/unilateral, it is less likely to be pathological. TRUE/FALSE?
FALSE
a deformity is more likely to be pathological if it is only present on one side
e.g. Blouts disease
Describe the two ways in which bones can grow during development
Longitudinal/vertically from the growth plate (epiphysis) by enchondral ossification
Circumferential (bone gets wider)
from the periosteum by appositional growth
When do humans begin to lose bone mass, and do males or females lose it quicker?
Post-menopause OR after age of 50
Men start with a higher bone mass BUT both genders lose it at the same rate
Give an example of a dangerous recreational activity for young children which can damage their epiphyseal growth plate
Trampolining
damages blood vessels and growing bone in this region
How many children have a short stature as a result of a pathological condition?
1 in 5 children
remember to check parents height
What factors can affect the growth plate?
Diet / Nutrition Sunshine, Vitamins (Vit D & A) Injury Illness Hormones (GH)
When a child is growing, they are more likely to fracture the shaft of a bone. TRUE/FALSE
FALSE
more likely to fracture developing growth plates
At what age do children develop each of their integral physical movements (crawling, walking, jumping etc)?
6-9 months - Sits alone, crawls 8-12 months – stands 14-17 months walks 24 months jumps 3 years manages stairs alone
At what age do children develop the ability to move their head, speak, feed themself and become potty trained?
1-6 months Loss of primitive reflexes – grasp , stepping
2 months 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
Why should you be concious to not over-review children with undetermined conditions?
Overtreatment and over-investigation = fear of doctors, feelings of stigmatisation and psychologic distress
both experienced by parent and child
Persisting mild genu varum can run in families. TRUE/FALSE?
TRUE => reassure families that this is normal
When may genu varum be considered abnormal?
- unilateral (asymmetry >5°)
- severe >2SD/16° from mean
- short stature >2SD
- Painful
What pathological conditions can cause genu varum?
Skeletal Dysplasia Rickets – deficiency vitamin D Tumour e.g. enchondroma Blounts disease Trauma => physeal injury
What is Blount’s disease?
The outside of the growth plate continues to grow whilst the inside slows down
=> causing an angular deformity
typical Beak-like protrusion on xray
What surgical intervention can be undertaken on a child with Blount’s disease?
Debridement of growth plate to get rid of dead material and encourage further growth
When does Genu Valgum usually peak?
3½
When should a child with Genu Valgum be referred or considered for surgery?
Refer if asymmetric, painful, severe (>2SD)
> 8cm intermalleolar distance at age 11
=> consider surgery
How is intoeing often tested clinically in children
Often accentuated when running
What 3 deformities can cause intoeing?
femoral neck anteversion
Internal Tibial Torsion
metatarsus adductus
or combination
How do children with femoral neck anteversion usually like to sit?
In the W position
Describe the pathogenesis of femoral neck anteversion
Femoral neck usually sits at 40 degrees anteriorly
when you get older this regresses to 10-15 degrees
some children have a condition where the femoral neck does not regress as quickly
At what age are children usually affected by internal tibial torsion?
Usually seen in toddlers (1-3 yrs)
vast majority resolve by 6 yrs
What treatment is used for internal tibial torsion
Bracing & orthotics = ineffective and not required
Surgery very rare for severe cases!
Is metatarsus adductus usually a serious presentation?
No it is Common and Benign and usually Resolves
If not passively correctable then serial casting may help age 6-12 months
How common is flat feet in adults?
1 in 5 adults have this condition
Are babies born with flat or arched feet?
FLAT => develop medial arch once walking as tibialis posterior strengthens
What can cause flexible flat feet?
generalised ligamentous laxity
tightness gastrocsoleus complex
What test is used if there is suspicion of a tight gastrocsoleous complex in flat feet?
Calf tightness assessment
=> need to relax gastrocs by flexing knee
What scoring system is used to test hypermobility?
Beighton Score 9/9
What can cause rigid flat foot?
underlying bony connection known as tarsal coalition
May benefit from surgery if painful
What toes are most affected by curling and when does this condition usually resolve?
Most 3rd or 4th toes
Vast majority resolve by 6 years
What age group and gender are most likely to develop anterior knee pain
Females>males
Adolescent
What other symptoms often occur with anterior knee pain
Localised patellar tenderness
pain on walking up Stairs/ doing squats
What should be analysed in the radiology of a patient with anterior knee pain?
ALWAYS THE HIP
can be a result of arthritis or fracture
What are the main congenital conditions which present in a paediatric orthopaedic clinic?
- Clubfoot (CTEV)
- Rocker bottom foot (CVT)
- Neurofibromatosis
- Skeletal dysplasia
What neuromuscular conditions are commonly seen in patients presenting to a paediatric orthopaedic clinic?
- Cerebral palsy
- Tip toe walking
- Duchenne muscular dystrophy
- High arch (cavus) foot
What are the main features of clubfoot?
– C cavus
– A adductus
– V varus
– E equinus (ballerina feet - constantly pointed, cant bring foot to anterior leg)
What is the clinical term for Clubfoot?
Congenital talipes equinovarus (CTEV)
What gender usually gets Clubfoot and how many of these cases are bilateral?
2:1 boys
50% cases are bilateral
What causes Clubfoot?
Most = Idiopathic
OR
Assoc. with conditions such as:
- Myelomeningocoele (spina bifida)
- Diastrophic dwarfism
- Tibial hemimelia (short/absent tibia)
What is Postural Talipes and how do you differentiate it from Clubfoot?
- tightness in muscles around ankle
- due to position of baby in womb
- not caused by problems with bones in foot and
- will not cause any problems with walking
- diagnosed by examining the baby’s feet
- Pt can dorsiflex their foot to neutral or further in postural talipes NOT clubfoot
How is Clubfoot treated?
Ponseti Method
Casting for 4-6 weeks
+/- achilles tenotomy to allow ankle to straighten
(achilles tendon heals undamaged due to childrens ability to heal)
What is “Rocker Bottom” Feet?
• Irreducible dislocation of talus on navicular
What is the clinical term for Rocker Bottom Feet?
Congenital Vertical Talus (CVT)
What are the signs of Rocker Bottom Feet?
– Round plantar surface
– Equinus hindfoot
What other conditions can predispose to Rocker Bottom Feet?
Myelomeningocoele (Spina Bifida) Arthrogryposis (curved joints) Spinal muscular atrophy Neurofibromatosis Trisomies
Where does neurofibromatosis commonly affect?
–Extremities
–Spine (scoliosis) >10%
–Skin (neurofibromas)
What Type of Neurofibromatosis is most common?
NF1 => Type 1
Neurofibromatosis is an Autosomal Dominant condition. TRUE/FALSE?
TRUE
NF1 gene mutation (neurofibromin) found on Chromosome 17
What is the diagnostic criteria for neurofibromatosis?
2/7 of the following: • >6 café au lait spots • ≥2 neurofibromas / plexiform neurofibroma • Freckling axilla / inguinal region • Optic glioma • ≥2 Lisch nodules • Cortical thinning / pseudoarthrosis • First degree relative affected
What is skeletal dysplasia?
abnormal development of cartilage and bone
What clinical signs are apparent in skeletal dysplasia?
–Shortening of involved bone
–Short stature (usually) <2SD from normal
Can be Proportionate / disproportionate
=> e.g. trunk much longer than legs
What is the genetic mutation involved in achondroplasia?
Fibroblast growth factor receptor 3 (FGFR3)
- Autosomal dominant
- 80% spontaneous mutations
What features are usually seen in achondroplasia
– Normal trunk / short limbs – Frontal bossing – Genu varum – Normal intelligence – Motor delay
What is cerebral palsy?
Non-progressive neuromuscular disorder:
• Injury to immature brain (<2 years)
– Prematurity
– Perinatal (infection / anoxic (birth) injuries / meningitis)
What are the common features of cerebral palsy?
– Upper Motor Neurone disease > muscle weakness / spasticity
– Early: abnormal muscle forces > dynamic deformity
– Late: contractures / fixed deformity / dislocation
What is the “clasp knife spasticity” concept?
Testing muscles shows tightness then sudden relaxation
How are Cerebral Palsy conditions classified?
classified by how much patient is able to walk
What methods are used to treat Cerebral palsy?
MEDICINES:
- Benzodiazepines
- Baclofen
SURGERY:
- identifies over-firing nerves and cuts them
- non-reversible
BOTOX:
- injected to relax muscles
What X-Linked neuromuscular condition presents with progressive muscle weakness?
Duchenne Muscular Dystrophy (DMD)
What is the pathophysiology of DMD?
– Absence dystrophin protein
– replacement of muscle with fibrofatty tissue
When do patients with DMD usually present?
2-5 years of age
Describe the age progression of DMD
2-5 = diagnosis 10 = need walking assistance 15 = wheelchair 20 = Pts often pass away
What features are present in Duchenne Muscular Dystrophy?
– Muscle weakness (prox > distal)
– Clumsy walking
– Positive Gowers sign (walks hands up knees to get up)
– Scoliosis
What is Cavus feet?
Pes cavus (high arched foot) • Elevated longitudinal arch & varus hindfoot
What causes Cavus Feet?
– Idiopathic / familial
– 2/3 due to neurological disorder:
- polio,
- cerebral palsy
- myelomeningocoele (spina bifida)
- Spinal Cord Injury
– Charcot Marie Tooth
- peripheral nerve disease
What is the management for Cavus Foot?
Management:
– conservative
Surgery:
– Soft tissue surgery
– Bony (osteotomies)
