CHILDREN'S ORTHOPEDICS Flashcards
How many bones does a child have?
270 - more than an adults
What are primary ossification centres?
Sites of pre-natal bone growth via endochondral ossification
At the diaphysis
What are secondary ossification centres?
Sites of post-natal growth after primary ossification centre
At the physis of long bones
How do long bones lengthen?
Occurs at physis/physeal plate
Epiphyseal side - hyaline cartilage active and divides to for hyaline cartilage matrix
Diaphyseal side - cartilage calcifies and dies, then replaced by bone
What differences does a children’s skeleton have compared to an adult skeleton?
More elastic
Physis - constantly growing
Faster healing
More remodelling potential
What is remodelling potential?
Amount of deformity that can be corrected as a result of growth
Why are children’s bones more elastic?
Increased density of haversian canals so less dense osteoid bone meaning it can bend more
What does increased elasticity in children’s bone cause in terms of fractures?
Plastic deformity - bends before it breaks
Buckle/taurus fracture
Greenstick fracture
What is a greenstick fracture?
Bone bends with fracture
Once cortex fractures but does not break other side
When does growth stop?
When physis/physeal plates close around puberty
What can physeal injuries cause?
Growth arrest and thus deformity
Which bones of children has the fastest healing and greatest remodelling potential?
Physis at knee
Physis at extreme of upper limb
Name some common children’s congenital conditions of bone
Developmental dysplasia of the hip
Club foot
Achondroplasia
Osteogenesis Imperfecta
What is developmental dysplasia of the hip?
Group of disorders of the neonatal hip where head of femur is unstable/incongruous in relation to acetabulum
Normal development of the acetabulum requires concentric reduction and balanced forces through hip which doesn’t occur in this condition
Packaging disorder often due to way the child sits in utero
How does developmental dysplasia of the hip (DDH) present?
As a spectrum of:
- Dysplasia (hip in socket but not centrally placed so
socket doesn’t develop into nice cup)
- Subluxation (hip in shallow socket so it pops in and out)
- Dislocation (hip develops out of socket causing
acetabulum to become very shallow since no pressure)
What are some risk factors of DDH?
Female 6:1 First born Breech position Family history Oligohydramnios (not enough fluid in amniotic sac) Native american/laplanders
How is DDH usually first picked up on?
Baby check screening
- RoM of hip (usually limitation in hip abduction)
- Barlow and Ortalani non-sensitive in 3 months or older
What investigations can be done for a baby suspected with DDH?
Ultrasound - birth to 4 months
X ray - after 4 months
Measure the acetabular dysplasia and the position of the hip
How can DDH be treated?
If hip reducible and < 6 months:
- Pavlik harness (holds femoral head in acetabulum so
concentric pressure present)
If Pavlik harness failed/6-18 months:
- MUA + closed reduction and spica
What is clubfoot also known as?
Congenital talipes equinovarus
What is a packaging disorder?
A deformity which develops in utero
What is clubfoot?
Packaging disorder causing CAVE deformity due to muscle contracture.
Primary deformities:
- Cavus - high arch (tight intrinsic, FHL, FDL)
- Adductus of foot - tight tib posterior and anterior
- Varus - tight tendoachilles, tib posterior and anterior
- Equinous - tight tendoachilles
What demographic is clubfoot most prevalent in?
Hawaiians
M:F 2:1
What gene is clubfoot associated with?
PITX1 gene
How is clubfoot diagnosed?
Baby check
What is the gold standard treatment for clubfoot?
Ponseti method
- Series of casts to correct deformity
- May require operative treatment (soft tissue releases)
- Foot orthosis brace
- Some require further operative intervention to correct
final deformity
What is achondroplasia and its pathology?
Form of Rhizomelic dwarfism (short limbed dwarfism)
Chondrocyte proliferation in proliferative zone of physis is inhibited causing defect in endochondral bone formation (secondary endochondral ossification)
Significant spinal issues which require operative treatment
Most common skeletal dysplasia
What features make up Rhizomelic dwarfism?
Humerus shorter than forearm
Femur shorter than tibia
Normal trunk
Describe the genetics of achondroplasia
Autosomal dominant
- G380 mutation of FGFR3
What is osteogenesis imperfecta and pathology?
AKA brittle bone disease
Decreased type I collagen due to decreased secretion and production of abnormal collagen. Causes insufficient osteoid production
How does osteogenesis imperfecta present?
Fragility fractures
Short stature
Scoliosis
Heart problems
Blue sclera
Dentinogenesis imperfecta (brown soft teeth)
Wormian skull (abnormal fusion of cranial sutures)
Hypermetabolism (usually PTH pathway)
What is the genetics of osteogenesis imperfecta?
Autosomal dominant/recessive
What 5 details should be given when describing paediatric fractures?
Pattern Anatomy Intra/extra-articular Displacement Salter-Harris (if fracture affects physis)
What are the different patterns of fractures that can occur in paediatrics?
Transverse Oblique Spiral (rotational torque) Comminuted (high energy trauma) Avulsion (bone pulled off by ligamentous attachment)
Plastic deformities:
- Buckle
- Greenstick
How are long bone fractures described anatomically?
Affecting physis:
- Proximal 1/3
- Distal 1/3
Affected diaphysis:
- Middle 1-3
What is the preferred healing pathway in intra-articular fractures?
Primary bone healing as minimises risk of post traumatic arthritis
Which type of bone healing uses a callus?
Secondary bone healing
What is remodelling potential in children dependent on?
Type of displacement and amount
What are the different types of displacement?
- Displaced
- Angulated
- Shortened
- Rotated (remodelling not well tolerated and doesn’t
occur)
What is Salter-Harris?
Classification of physeal injuries (SALT):
- Physeal (S)eparation
- Fracture traverses physis and exits metaphysis (A)bove
- Fracture traverses physis and exits epiphysis (L)ower
- Fracture passes (T)hrough epiphysis, physis and
metaphysis - Crush injury to physis
Risk of growth arrest increases through 1-5
Type 2 injuries most common
How can growth arrest occur?
Injuries to physis
Location and timing is key e.g. if injury closer in time to physeal closure then only small amount of potential growth left so deformity not as bad
What are the 2 types of growth arrest and what deformities do they cause?
Whole physis - entire limb length discrepancy
Partial physis - angulation as non affected side keeps growing
What is the treatment for growth arrest?
Correct deformity
If entire limb length:
- Shorten long side (premature fusion of physis using
crossed screws)
- Lengthen short side
If angular deformity:
- Stop growth of unaffected side
- Osteotomy (reform bone surgically)
What are the 4 Rs of fracture management?
Resuscitate
Reduce
Restrict
Rehabilitate
What are the aims in reduction?
Correct deformity and displacement
Reduce secondary injury to soft tissue/NV structures
What two types of reduction can you do?
Open - incision, realignment of fracture under direct visualisation
Closed - no incision e.g. traction and manipulation
What are the aims of restriction?
Maintain fracture reduction
Provide stability for fracture to heal
What are the 2 types of restriction and why are they done?
External - splints, plaster (more common in paediatrics)
Internal - plate and screws, intra-medullary devise
(Can be avoided due to remodelling and huge healing potential. If fracture affects physis or beyond potential tolerance of remodelling)
What does the limping child clinical sign indicate?
SEPTIC ARTHRITIS
Transient synovitis
Perthes
SUFE
What is Kocher’s classification?
Score for probability of septic arthritis
- Non-weight bearing
- ESR > 40
- WBC > 12,000
- Temperature > 38
When can transient synovitis, perthes and SUFE be diagnosed?
Once septic arthritis has been excluded
What is transient synovitis and its treatment?
Inflamed joint in response to a systemic illness
Supportive treatment with antibiotics
What is Perthes disease and who does it usually affect?
Idiopathic necrosis of proximal femoral epiphysis
Usually 4-8 years old
Male:female 4:1
No temp./inflammatory markers and usually longer than septic arthritis
What is the treatment for Perthes disease?
Usually supportive in first instance
How is Perthes disease diagnosed?
Plain film radiograph
What is SUFE?
Slipped upper femoral epiphysis
- Proximal epiphysis slips in relation to the metaphysis
Who does SUFE usually affect?
Obese adolescent male
- 12-13 years old during rapid growth
- associated with hypothryoidism/pituitrism
- family history
What is treatment for SUFE?
Operative fixation with screw to prevent further slip and minimise long term growth problem
