Children's Orthopaedics Flashcards by Meley Gdey

briefly outline bone development in children

intramembranous (mesenchymal cells > bone, for flat bones)

endochondral (mesenchymal > cartilage > bone, for long bones)

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outline intramembranous ossification

condensation of mesenchymal cells > differentiate into osteoblasts > forms ossification centre > secreted osteoid trap osteoblasts > osteocytes > trabecular matrix + periosteum form > compact bone develops superficial to cancellous bone > blood vessels condense into red bone marrow

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bones that undergo intramembranous ossification

clavicle

cranium

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primary ossification centre

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

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secondary ossification centres

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

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outline endochondral ossification (pre natal bone growth through primary ossification centre)

mesenchymal differentiation at POC > cartilage model forms > capillaries penetrate cartilage > calcification at POC (forms spongy bone) > perichondrium transforms to periosteum > cartilage and chondrocytes continue to grow at ends > SOC develop

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outline endochondral ossification (post bone growth through secondary ossification centre)

long bone lengthening at physis, zone of elongation in long bone, contains cartilage
epiphyseal side (hyaline cartilage diving to form hyaline cartilage matrix)
diaphyseal side (cartilage calcifies, dies, replaced by bone

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children’s skeleton differs from adult skeleton in terms of?

elasticity
physis
speed of healing
remodelling

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what causes the increased elasticity in children’s bones?

increased density of Haversian canals

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what pathologies can occur due to increased elasticity of the bone?

plastic deformity (bend before break)
Buckle fracture (Tarus like the column)
Greenstick (one cortex fractures but doesn't break the other side)

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when does growth stop?

as the physis closes

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bone growth is complete at what age in girls and boys?

girls 15-16

boys 18-19

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physeal injuries are categorised by?

Salter-Harris

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physeal injuries can lead to?

growth arrest

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growth arrest can lead to?

deformity

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the speed of healing and remodelling potential is dependent on?

location

age of the patient (younger children heal faster)

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which physis grows more?

at the knee

extreme of upper limb

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common children’s orthopaedic congenital conditions

developmental dysplasia of the hip
club foot
achondroplasia
osteogenesis imperfecta

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what is developmental dysplasia of the hip?

group of disorder of the neonatal hip where the head of the femur is unstable or incongruous in relation to the acetabulum

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spectrum of developmental dysplasia of the hip

dysplasia
subluxation
dislocation

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risk factors for developmental dysplasia of the hip

female 6:1
first born
breech
family history
oligohydramnios
Native American/Laplanders - swaddling of hip
Rare in African American/Asian

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examination for developmental dysplasia of the hip

usually picked up on the baby check - screening in UK (RoM of hip - leg length, limitation in hip abducation) 3 months or older Barlow and Ortalani are non-sensitive

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investigation for development dysplasia of the hip

ultrasound 0-4 months (measures the acetabular dysplasia and the position of hip)
x-ray 4 months+

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treatment for development dysplasia of the hip

reducible hip + <6 months > Pavlik harness

failed Pavlik harness or 6-18 months, secondary changes - capsule + soft tissue > MUA + closed reduction + spica

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what is congenital talipes equinovarus?

congenital deformity of the foot

more likely for males or females to have congenital talipes equinovarus?

males to females | 2:1

what % of congenital talipes equinovarus is bilateral?

50%

what is CAVE deformity?

Cavus Adductus of foot Varus Equinous

cavus

high arch: tight intrinsic, FHL, FDL

adductus of foot

tight tib posterior and anterior

varus

tight tendoachilles, tib post, tib ant

equinous

tight tendoachilles

what gene causes congenital talipes equinovarus?

PITX1 gene

treatment for congenital talipes equinovarus

ponseti method: series of casts > many require operative treatment > foot orthosis brace > some require further operative intervention to correct final deformity

describe the genotype behind achondroplasia

autosomal dominant G380 mutation of FGFR3 inhibition of chondrocyte proliferation in the proliferative zone of the physis results in defect in endochondral bone formation

describe the phenotype of 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 causes osteogenesis imperfecta?

hereditary (autosomal dominant/recessive) decreased type I collagen: decreased secretion/production of abnormal collagen insufficient osteoid production

effects of osteogenesis imperfecta on bones

fragility fractures short stature scoliosis

non-orthopaedic manifestations of osteogenesis imperfecta

``` heart blue sclera dentinogenesis imperfecta – brown soft teeth Wormian skull hypermetabolism ```

classification of paediatric fractures

``` pattern anatomy intra/extra-articular displacement (acronym PAID) ```

pattern of paediatric fractures

``` transverse oblique spiral comminuted avulsion ```

anatomy of paediatric fractures

proximal, middle, distal 1/3 of the bone | diaphysis, metaphysis, epiphysis

intra/extra-articular of paediatric fractures

intra > primary bone healing by direct union, no callus formation extra > secondary? healing by callus

displacement of paediatric fractures

displaced angulated shortened rotated

what type of injuries are classified by salter-harris?

physeal

salter-harris classification

I physeal separation II Fracture traverses physis and exits metaphysis (Above) III Fracture traverses physis and exits epiphysis (Lower) IV Fracture passes Through epiphysis, physis, metaphysis V Crush injury to physis

how does risk of growth arrest change from type I to type V salter harris fractures?

increases

what salter-harris fracture type is most common?

type II

injury to the whole physis that causes growth arrest has what effect?

limb length discrepancy

injury to partial physis that causes growth arrest has what effect?

angulation as the non affected side continues to grow

aim of treatment of growth arrest

minimise angle of the deformity | minimise limb length difference

ways to address limb length discrepancy

shorten long side | lengthen short side

ways to address angular deformity

stop growth of unaffected side | reform the bone (osteotomy)

treatment of growth arrest is dependent on

location of the injury | when injury occurred/ how much growth is left

what are the 4 R's of fracture management?

resuscitate reduce restrict rehabilitate

what is the 'reduce' part of fracture management?

Correct the deformity and displacement | Reduce secondary injury to soft tissue / NV structures

closed reduction of a fracture, define and give an example

Reducing a fracture without making an incision | Such as gallows traction and manipulation in A&E

open reduction of a fracture

Making an incision | The realignment of the fracture under direct visualisation

what is the 'restrict' part of fracture management?

maintain fracture reduction | provides stability for fracture to heal

outline types of restriction in fracture management

external: splints, plaster internal: plate + screws, intramedullary device

are external or internal methods of restriction commonly used in paediatric fracture?

external

what should be considered for operative intervention during fracture management

ongoing growth at the physis | metalwork may need to be removed

what is the 'rehabilitate' part of fracture management?

using, moving, strengthening affected limb children generally rehab quickly stiffness not as major issue as in adults

differential diagnoses for limping child

septic arthritis transient synovitis perthes SUFE

septic arthritis in a child is a orthopaedic emergency because?

Can cause irreversible long term problems in the joint | > needs surgical washout of the joint to clear the infection

what part of the history is key for septic arthritis?

duration other recent illness associated joint pain

Kocher's classification can help you score probability

Non weight bearing ESR >40 WBC >12,000 Temperature >38

what is transient synovitis?

inflamed joint in response to a systemic illness

treatment for transient synovitis

supportive treatment with antibiotics

what is Perthes disease?

Idiopathic necrosis of the proximal femoral epiphysis

Perthes disease usually presents at what age?

4-8

ratio male to female of those affected by Perthes disease

4:1

what do you exclude first before coming to a diagnosis of transient synovitis, Perthes disease or SUFE?

septic arthritis

what is SUFE?

Slipped upper femoral epiphysis: proximal epiphysis slips in relation to the metaphysis

SUFE typically presents in what patient?

usually obese adolescent male 12-13 years old during rapid growth

SUFE is associated with what disorders?

hypothyroidism/hypopituitrism

treatment for SUFE is?

operative fixation with screw to prevent further slip and minimise long term growth problems