Cortex 6 - Paediatric orthopaedics 2

Question 1

Match the following age ranges to when babies normal MSK development:

1. Sits alone, crawls
2. Stands
3. Walks
4. Jumps
5. Manages stairs independently

• 24 months
• Age 3
• 6‐9 months
• 8-12 months
• 14-17 months

Answer 1

1. 6-9 months
2. 8-12 months
3. 14-17 months
4. 24 months
5. Age 3

Question 2

Match the following neurological landmarks in babies development to the normal age ranges at which they occur:

1. Loss of primitive reflexes (Moro reflex, stepping reflex, rooting, grasp reflex, fencing posture etc)
2. Head control
3. Speaking a few words
4. Eats with fingers, uses spoon
5. Stacks four blocks
6. Understands 200 words, learns around 10 words/day
7. Potty trained

• 1-6 months
• 14 months
• 18-20 months
• 9-12 months
• 18 months
• 2 months
• 2-3 years

Answer 2

1. 1-6 months
2. 2 months
3. 9-12 months
4. 14 months
5. 18 months
6. 18-20 months
7. 2-3 years

Question 3

Children at birth normally have varus knees (bow legs) which become neutrally aligned at around 14 months, progressing to 10 to 15° valgus (knock knees) at age 3 and then gradually regress to the physiologic valgus of 6° by around the age of 7‐9. What is then considered pathological varus or valgus ?

Answer 3

Where alignment is considered outside the normal range (+/‐ 6° from mean value for age).

Question 4

When may treatment by required for genu varum or valgum ?

Answer 4

Genu varum or excessive genu valgum after the age of 10 may require surgery.

Question 5

What is in-toeing ?

Answer 5

A child who, when walking and standing will have feet that point toward the midline.

Question 6

What may parents notice in kids who are in-toeing ?

Answer 6

That their clumsy and may wear through their shoes at an alarming rate.

Question 7

Give an example of a cause of in-toeing and explain it

Answer 7

Femoral neck anteversion – the femoral neck is slightly anteverted (pointing forwards).

Excess femoral neckanteversion can give the appearance of in‐toeing (as well as knock knees).

It doesn’t warrant surgical intervention.

Question 8

How is flat feet classified?

Answer 8

Classified as mobile or fixed.

Question 9

How do you determine if the patients flat feet are mobile or fixed?

Answer 9

Mobile/flexible flat feet are those where the flattened medial arch forms with dorsiflexion of the great toe (Jack test).

Whereas In the rigid type of flat footedness the arch remains flat regardless of load or great toe dorsiflexion.

Question 10

What may Mobile/flexible flat feet be due to ?

Answer 10

Ligamentous laxity - the flat footedness may only be present during weight bearing.

Question 11

Is flexible flat footedness in kids normal or not ? if abnormal does it require orthoses?

Answer 11

Not abnormal so doesn’t require orthoses

Question 12

What could be the underlying causative factors for fixed flat footedness ?(3)

Answer 12

• Tarsal coalition
• Underlying inflammatory disorder
• A neurological disorder.

Question 13

Is Minor overlapping curling of toes normal ?

Answer 13

yes (usually corrects without intervention as kids grow) - hence treatment isn’t required unless it causes persistent discomfort in adolescence where it then may require surgery.

Question 14

What is developmental dysplasia of the hip ?

Answer 14

DDH involves dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint.

Question 15

Who is more commonly affected by DDH girls or boys ?

Answer 15

Girls. 80% of cases

Question 16

Does DDH affect one hip more than the other ?

Answer 16

Yes- the left but is also often bilateral.

Question 17

What are some of the risk factors for developing DDH?

Answer 17

• Positive family history of DDH
• Breech presentation (born bottom first instead of head first)
• First born babies
• Down’s syndrome
• The presence of other congenital disorders

Question 18

What are the signs of DDH ?

Answer 18

Shortening

Asymmetric groin/thigh skin creases

and a click or clunk on the Ortolani or Barlow manoeuvres.

Question 19

Describe what happens during the Ortolani test

Answer 19

Reducing a dislocated hip with abduction and anterior displacement

Question 20

Describe what happens during the Barlow test

Answer 20

Dislocatable hip with flexion and posterior displacement.

Question 21

If the ortolani or barlow test is positive what further investigation is required ? and what should this investigation find ?

Answer 21

An ultrasound of the hip - which should detect a dislocated hip, an unstable hip or a shallow acetabulum.

Question 22

When do X-rays become the investigation of choice for detecting DDH?

Answer 22

Ultrasound investigation of choice from birth until 4-6 months

then X-ray is of choice for 4-6 months onwards

Question 23

If DDH is left untreated then what are some of the complications which occur ?

Answer 23

The acetabulum is very shallow and in more severe cases a false acetabulum occurs proximal to the original one with a shortnened lower limb.

Severe arthritis due to reduced contact area can occur at a young age and gait / mobility may be severely affected.