Children's Orthopaedics Flashcards
What is the difference between an adult and children’s skeleton?
Child’s has 270 bones - in continuous change
Physis (growth plates)
Elasticity
Speed of healing
Remodelling
What are the two pathways of bone development?
Intramembraneous
Endochondral
What are the main features of intramembraneous ossification?
Mesenchymal cells –> bone
Flat bones
What are the main features of endochondral ossification?
Mesenchymal –> cartilage –> bone
Long bones
What are the stage of intramembraneous ossification?
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.
What are the stages of primary endochondral ossification?
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.
What are primary ossification centres?
Sites of pre-natal bone growth through endochondral ossification from the central part of the bone
What are secondary ossification centres?
Occurs post-natal after the primary ossification centre and long bones often have several (the physis)
What is the role of the physis?
responsible for the further growth of bones ‘Secondary ossification sites’.
What happens if the physis are faulty?
Any congenital malfunction to this area or acquired insult – weather it is traumatic/infective or otherwise will therefore have a subsequent impact on growth of the child
What are the main features of children’s bone being more elastic?
Children’s bone can bend – more elastic than adult
Increased density of haversian canals
Why are there more Haversian canals in children’s bones?
More metabolically active as they are growing
Need more metabolites
What are the different injuries seen in children?
Plastic deformity
– bends before breaks
Buckle fracture
– Tarus like the roman column
Greenstick
– like the tree
One cortex fractures but does not break the other side
When does growth stop?
When the physis close
What influences when growth stops?
Puberty, Menarche, Parental height
When does growth stop typically?
Complete at
Girls 15-16
Boys 18-19
What are the features of remodelling in children’s bone?
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
What are common children’s congenital conditions?
Developement dysplasia of the hip
Club foot
Achondroplasia
Osteogenesis Imperfecta
What is DDH?
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’
Occurs in utero and depends on how they sit in the womb
What does normal development of the hip result in?
The normal development relies on the concentric reduction and balanced forces through the hip
What are the different ways DDH presents?
Spectrum with
- dysplasia
– subluxation
– dislocation
What are risk factors of DDH?
Female 6:1 First born Breech FH Oligohydramnios Native American/Laplanders – swaddling of hip Rare in African American/
When is DDH usually picked up?
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
What investigations should be done for DDH?
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
How is DDH treated?
Reducible hip and <6 months
Pavlik harness 92% effective
Holds femoral head in the acetabulum
Failed Pavlik Harness or 6-18 months
Secondary changes- capsule + soft tissue
MUA + Closed reduction and Spica
What is the aim of DDH treatment?
No prevent morbidity in infancy
but to allow for as normal hip development as possible to avoid problems in later life
What is congential talipes equinovarus?
Congenital deformity of the foot 1:1000 Highest in Hawaiians M2:1F 50% are bilateral
What is the genetic aspect of club foot?
Approx. 5% likely of siblings
Familial in 25%
PITX1 gene
What are the presentations of club foot?
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
What is the treatment of club foot?
Ponseti Method
Gold standard
- First a series of casts to correct deformity
- Many require operative treatment
Soft tissue releases - Foot orthosis brace
- Some will require further operative intervention to correct final deformity.
What is achondroplasia?
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
What results in achondroplasia?
Rhizomelic dwarfism Humerus shorter than forearm Femur shorter than tibia Normal trunk Adult height of approx. 125cm
Normal cognitive development
Significant spinal issues
What are the bone effects of OI?
Fragility fractures
Short stature
Scoliosis
What are the non-orthopaedic manifestations of OI?
Heart
Blue Sclera
Dentinogenesis imperfecta – brown soft teeth
Wormian skull - abnormal fusion of cranial sutures
Hypermetabolism
How do we describe fractures?
Pain
Pattern
Anatomy
Intra/Extra-articular
Displacement
What is used to classify fractures when it involves the physis?
Salter-Harris
What is the pattern of fracture representative of?
How the energy was dissipated through the bones
What does anatomy refer to?
Where in the bone
For example, long bones are split into thirds (proximal, middle, distal)
What is meant by intra/extra articular?
Intra - primary bone healing
Extra - secondary bone healing
What are different terms describing displacement?
Displaced
Angualted
Shortened
Rotated
What displacement is not tolerated very well?
Rotated
What does the slater harris classifcation?
Classifies physial injuries
What are the 5 types in the Salter-Harris classification?
SALT
- Physeal Separation
- Fracture traverses physis and exits metaphysis (Above)
- Fracture traverses physis and exits epiphysis (Lower)
- Fracture passes Through epiphysis, physis, metaphysis
- Crush injury to physis
Risk of growth arrest increases from 1 -5
Type 2 injuries most common
What are the main features of growth arrest?
Injuries to the physis can cause growth arrest
The location and timing is key
How much potential growth is left?
How much of the physis is affected?
What are the outcomes that depend on how much of the physis is affected?
Whole physis – limb length discrepancy
Partial – angulation as the non affected side keeps growing
What is the aim of treatment of growth arrest?
Aim is to correct the deformity
Minimise angular deformity
Minimise limb length difference
How can limb length be corrected?
Shorten the long side
OR
Lengthen the short side
How can angular deformity be corrected?
Stop the growth of the unaffected side
OR
Reform the bone (osteotomy)
What are the four R’s of fracture management?
Resuscitate
Reduce
Restrict
Rehabilitate
What is closed reduction?
Reducing a fracture without making an incision
Such as traction and manipulation in A&E
What is open reduction?
Making an incision
The realignment of the fracture under direct visualisation
What is common in paediatric fractures for reduction?
Closed
e.g. gallows traction
What is Gallows traction?
Skin traction applied to the femur
Holding the skin, the long bones of the lower limb can be reduced
What is the purpose of restricting a fracture?
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!
What are external holding methods?
Plaster
Splints
What are internal holding methods?
Plates
Screws
Intramedullary devices
What are the features to consider with fixation in children?
Operative intervention may be required
Consider the ongoing growth at the physis
Metalwork may need to be removed in the future
What are the main features of paediatric rehabilitation?
Children generally rehabilitate very quickly
Play is a great rehabilitator
Stiffness not as major issue as in adults
Use it, Move it and Strengthen!
What can cause a limp in child?
Septic arthritis
Transient synovitis
Perthes
SUFE
Why is septic arthritis important to always consider in a limping child?
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
What is Kocher’s classification?
Kocher’s classification can help score probability of septic arthritis
Non weight bearing
ESR >40
WBC >12,000
Temperature >38
What is key in the history when considering septic arthritis?
Duration
Other recent illness
Associated joint pain
What is transient synovitis?
diagnosis once septic arthritis has been excluded
Is a inflamed joint in response to a systemic illness
Supportive treatment with antibiotics is the treatment
What is Perthes disease?
Idiopathic necrosis of the proximal femoral epiphysis
Who is Perthes disease seen in?
Usually in those 4-8 years old
Male 4:1 Female
What need to be done first with Perthes?
Septic arthritis needs to be excluded first
What is the treatment for Perthes?
Treatment is usually supportive in the first instance
What is SUFE?
Slipped upper femoral epiphysis
The proximal epiphysis slips in relation to the metaphysis
In who does SUFE normally occur?
Usually obese adolescent male
12-13 years old during rapid growth
Associated with hypothyroidism/hypopituitrism
What need to be done first with SUFE?
Septic arthritis needs to be excluded first
What is treatment of SUFE?
Treatment is operative fixation with screw to prevent further slip and minimise long term growth problems
