Children's Orthopaedics

Question 1

What causes increased incidence in developmental dysplasia of the Hip (DDH)?

Answer 1

First born
Oligohydramnios (deficiency in amniotic fluid)
Breech presentation
Family history
Other lower limb deformities

Question 2

What are some clinical features of DDH?

Answer 2

Ortolani’s sign- palpable sensation of the femoral head slipping into the acetabulum.

Barlow’s sign- can passively dislocate hip when in a reduced position

Piston Motion sign

Question 3

How is DDH managed?

Answer 3

Pavlik Harness for 0-6months
IL felt brace
Surgical closed reduction of the hip
SPICA cast

Question 4

What is Legg-Calve-Perthes Disease?

Answer 4

Avascular necrosis of the proximal femoral head resulting from compromise to the tenuous blood supply to this area. Usually occurs in children aged 4-10years.
Can be insidious onset or after hip trauma.

Question 5

What are some features of Legg-Calve-Perthes Disease/

Answer 5

M>F
Short stature
Limp
Knee pain on exercise
Stiff hip joint
Systemically well

Question 6

What are the phases of Legg-calves-perthes disease?

Answer 6

Avascular necrosis
Fragmentation - revascularisation (pain)
Reossification - bony healing
Residual deformity

Question 7

What is the treatment for Legg-calve-perthes disease?

Answer 7

Maintain hip motion
Analgesia
Restrict painful activties
Supervised neglect
Containment - consider osteotomy in selected groups of older children.

Question 8

What is slipped capital femoral epiphysis (SCFE)?

Answer 8

Hip condition that occurs in pre teens and teens who are still growing. Ball at head of femur slips of the neck of the bone in a backwards direction.

Question 9

How is SCFE detected?q

Answer 9

Pain in hip or knee
Externally rotated posture and gait
Reduced internal rotation especially in flexion.
Plain x-rays best seen on lateral view.

Question 10

What is the pathology of SCFE?

Answer 10

Displacement through hypertrophic zone

Metaphysis moves anterior and proximal

Question 11

What is the treatment for SCFE?

Answer 11

Surgery to prevent the femoral head slipping any further. May use in situ fixation or open reduction.

Question 12

What are the different types of SCFE?

Answer 12

Unstable - Patient cannot walk or bear weight even with crutches. Severe slip that requires urgent treatment.

Stable - Patient can bear weight and walk with or without crutches. Most common.

Question 13

What are some complications of SCFE?

Answer 13

Avascular necrosis
Chondrolysis
Deformity
Early osteoarthritis

Question 14

What is the Trethowan sigh?

Answer 14

If an anteroposterior view of the hip joint is taken then a line drawn along the superior surface of the neck should pass through the femoral head. If the line remains superior to the femoral head then this is termed Trethowan’s sign.
Positive in SCFE.

Question 15

What is a common differential diagnosis for a limping child?

Answer 15

Transient (toxic) synovitis
Osteomyelitis
Septic Arthritis
Infective myositis

Question 16

What is a limp?

Answer 16

An abnormal gait commonly due to pain, weakness or deformity. Shorter stance phase on the affect limb.

Question 17

What anatomical regions cause limp in a child?

Answer 17

Hip
Thigh
Knee
Leg
Foot

Question 18

What initial investigations would you do for child limp?

Answer 18

Temperature
x-ray
USS
Bloods - WCC, CRP, ESR< CK, Cultures

Question 19

How does septic arthritis present?

Answer 19

Limping
Pseudoparalysis
Swollen red joint (usually knee or hip)
Refusal to move joint
Pain
Temperature

Question 20

What are some routes of entry for septic arthritis?

Answer 20

Haematogenous route
Dissemination from osteomyelitis
Spread from adjacent soft tissue infection
Diagnostic or therapeutic measures
Penetrating damage by puncture or trauma.

Question 21

What would the findings of investigations be for septic arthritis?

Answer 21

Raised WCC >12,000/mm3
ESR>50mm/hr
Blood cultures positive in 30-50% cases
Cannot weight bear
Pyrexia

Question 22

What is the Kocher criteria?

Answer 22

Prediction rules for septic arthritis, the more positives of the following the greater the likelihood of septic arthritis. 
Pyrexia
Cannot weight bear
WBC >12000/ml
ESR>40mm/hr

Question 23

What is the treatment for Septic Arthritis?

Answer 23

Antibiotics (usually staph Aureus) IV 2 weeks, 6weeks total.
Aspiration
Arthroscopy
Arthotomy

Question 24

What is the pathogenesis of acute haematogenous osteomyelitis?

Answer 24

Vascular anatomy - vascular loops and terminal branches.

Cellular anatomy - inhibited phagocytosis (low pO2)

Trauma

Question 25

What are the symptoms of Osteomyelitis?

Answer 25

Pain
Localised signs and symptoms
Fever
Reduced ROM
Reduced weight bearing.

Question 26

What are the indications for surgery in osteomyelitis?

Answer 26

Aspiration for culture
Drainage of subperiosteal abscess
Drainage of joint sepsis
Debridement of dead tissue
Failure to improve 
Biopsy in equivocal cases.

Question 27

What are the features of Transient Synovitis?

Answer 27

Diagnosis of exclusion.
Limping but with touch of weight bearing. 
Slightly unwell
History if viral infection e.g. URTI/ear
Apyrexial
Allows joint to be examined
Low CRP, Normal WCC
May have joint infusion
Not that unwell

Question 28

What are the features that raise concern of neoplasm (cancer)?

Answer 28

Night pain
Often incidental trauma
Stops doing sport/going out
Sweat and fatigue
Abnormal blood results - low Hb, atypical blood film, atypical platelets.