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Year 2 MSK > Children's Orthopaedics > Flashcards

Children's Orthopaedics Flashcards

1
Q

What is the difference between an adult and children’s skeleton?

A

Child’s has 270 bones - in continuous change

Physis (growth plates)

Elasticity

Speed of healing

Remodelling

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2
Q

What are the two pathways of bone development?

A

Intramembraneous

Endochondral

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3
Q

What are the main features of intramembraneous ossification?

A

Mesenchymal cells –> bone

Flat bones

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4
Q

What are the main features of endochondral ossification?

A

Mesenchymal –> cartilage –> bone

Long bones

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5
Q

What are the stage of intramembraneous ossification?

A

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 are the stages of 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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7
Q

What are primary ossification centres?

A

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

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8
Q

What are secondary ossification centres?

A

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

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9
Q

What is the role of the physis?

A

responsible for the further growth of bones ‘Secondary ossification sites’.

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10
Q

What happens if the physis are faulty?

A

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

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11
Q

What are the main features of children’s bone being more elastic?

A

Children’s bone can bend – more elastic than adult

Increased density of haversian canals

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12
Q

Why are there more Haversian canals in children’s bones?

A

More metabolically active as they are growing

Need more metabolites

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13
Q

What are the different injuries seen in children?

A

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

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14
Q

When does growth stop?

A

When the physis close

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15
Q

What influences when growth stops?

A

Puberty, Menarche, Parental height

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16
Q

When does growth stop typically?

A

Complete at
Girls 15-16
Boys 18-19

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17
Q

What are the features of remodelling in children’s bone?

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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18
Q

What are common children’s congenital conditions?

A

Developement dysplasia of the hip

Club foot

Achondroplasia

Osteogenesis Imperfecta

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19
Q

What is DDH?

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’

Occurs in utero and depends on how they sit in the womb

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20
Q

What does normal development of the hip result in?

A

The normal development relies on the concentric reduction and balanced forces through the hip

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21
Q

What are the different ways DDH presents?

A

Spectrum with
- dysplasia
– subluxation
– dislocation

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22
Q

What are risk factors of DDH?

A 
Female 6:1
First born
Breech
FH
Oligohydramnios
Native American/Laplanders – swaddling of hip
Rare in African American/
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23
Q

When is DDH usually picked up?

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

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24
Q

What investigations should be done for DDH?

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

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25
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
26
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
27
What is congential talipes equinovarus?
``` Congenital deformity of the foot 1:1000 Highest in Hawaiians M2:1F 50% are bilateral ```
28
What is the genetic aspect of club foot?
Approx. 5% likely of siblings Familial in 25% PITX1 gene
29
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
30
What is the treatment of club foot?
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.
31
What is achondroplasia?
The most common skeletal dysplasia Autosomal Dominant G380 mutation of FGFR3 inhibition of chondrocyte proliferation in the proliferative zone of the physis results in defect in endochondral bone formation
32
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
33
What are the bone effects of OI?
Fragility fractures Short stature Scoliosis
34
What are the non-orthopaedic manifestations of OI?
Heart Blue Sclera Dentinogenesis imperfecta – brown soft teeth Wormian skull - abnormal fusion of cranial sutures Hypermetabolism
35
How do we describe fractures?
Pain Pattern Anatomy Intra/Extra-articular Displacement
36
What is used to classify fractures when it involves the physis?
Salter-Harris
37
What is the pattern of fracture representative of?
How the energy was dissipated through the bones
38
What does anatomy refer to?
Where in the bone For example, long bones are split into thirds (proximal, middle, distal)
39
What is meant by intra/extra articular?
Intra - primary bone healing Extra - secondary bone healing
40
What are different terms describing displacement?
Displaced Angualted Shortened Rotated
41
What displacement is not tolerated very well?
Rotated
42
What does the slater harris classifcation?
Classifies physial injuries
43
What are the 5 types in the Salter-Harris classification?
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
44
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?
45
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
46
What is the aim of treatment of growth arrest?
Aim is to correct the deformity Minimise angular deformity Minimise limb length difference
47
How can limb length be corrected?
Shorten the long side OR Lengthen the short side
48
How can angular deformity be corrected?
Stop the growth of the unaffected side OR Reform the bone (osteotomy)
49
What are the four R's of fracture management?
Resuscitate Reduce Restrict Rehabilitate
50
What is closed reduction?
Reducing a fracture without making an incision | Such as traction and manipulation in A&E
51
What is open reduction?
Making an incision | The realignment of the fracture under direct visualisation
52
What is common in paediatric fractures for reduction?
Closed e.g. gallows traction
53
What is Gallows traction?
Skin traction applied to the femur Holding the skin, the long bones of the lower limb can be reduced
54
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!
55
What are external holding methods?
Plaster | Splints
56
What are internal holding methods?
Plates Screws Intramedullary devices
57
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
58
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!
59
What can cause a limp in child?
Septic arthritis Transient synovitis Perthes SUFE
60
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
61
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
62
What is key in the history when considering septic arthritis?
Duration Other recent illness Associated joint pain
63
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
64
What is Perthes disease?
Idiopathic necrosis of the proximal femoral epiphysis
65
Who is Perthes disease seen in?
Usually in those 4-8 years old | Male 4:1 Female
66
What need to be done first with Perthes?
Septic arthritis needs to be excluded first
67
What is the treatment for Perthes?
Treatment is usually supportive in the first instance
68
What is SUFE?
Slipped upper femoral epiphysis The proximal epiphysis slips in relation to the metaphysis
69
In who does SUFE normally occur?
Usually obese adolescent male 12-13 years old during rapid growth Associated with hypothyroidism/hypopituitrism
70
What need to be done first with SUFE?
Septic arthritis needs to be excluded first
71
What is treatment of SUFE?
Treatment is operative fixation with screw to prevent further slip and minimise long term growth problems

Year 2 MSK (9 decks)

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