Introduction to Paedatric Orthopaedics and Normal Variation Flashcards
What are the differences between adult’s and children’s bones?
Physiological, biochemical and anatomical differences
What is an apophysis?
Normal bony outgrowths arising from separate ossification centres
What are the epiphyses of infants like?
Almost completely cartilaginous
Describe bone growth in children
Interstitial (growth in length) occurs at epiphysis of long bones
Appositional growth (in width) occurs due to periosteal growth
How do the ligaments differ in children as opposed to adults and why is this clinically relevant?
Ligaments are stronger than the growth plate therefore more likely to cause epiphyseal separation as opposed to dislocation or sprain
Young bones are more porous what does this result in?
More toleration of deformity and increased ability to deal with compressive forces
What fractures are children more likely to get and why?
Buckle fractures and Greenstick fractures as the bone is a lot more pliable
What is a buckle fracture?
Break on only one side of a long bone (opposite cortex remains intact)
What is a greenstick fracture?
Bending/cracking of the bone as opposed to the bone splitting into separate fragments
How do children’s bones differ in their healing/remodelling?
Greater remodelling potential (more efficient) and faster speed of heeling
What are the majority of orthopaedic paediatric referrals for?
Normal variants (53%)
Define normal variant
Atypical finding that has no clinical significance (within a spectrum of normal findings)
Define physiological development
Normal changes in shape, size, appearance, angle with growth
Define self-correcting pathology
Pathology that fixes itself
How close is a normal variant to ‘normal’?
Within 2 standard deviation of the mean
age and population matched
What are examples of normal physiological development?
Femoral anteversion, bow legs and flat feet
What is the appearance of bow legs?
Knees turned outwards but ankles touching
What are examples of self-correcting/non-concerning pathologies?
Persistent femoral anteversion
Metatarsus adductus
Posterior tibial bowing
Curly toes
What are curly toes?
Toes curl under feet as tendons are too tight
What is metatarsus adductus?
Forefoot is angled inwards too much
What are possible presenting patient concerns that are not true pathology?
Curly toes intoeing Outtoeing Bow legs and knock knees Flat feet Curved feet
What is the david jones system of the 5S’s?
To assess for non-concerning pathology/normal variants:
Symmetrical - yes Systemic illness - no Skeletal dysplasia - no Stiffness - no Symptomatic - no
What is the normal angular alignment?
Coronal
What is the normal rotational alignment?
Axial
What is the normal development in walking pattern?
Bowed legs (o-18 months) Straightens out (18m-2y) Knock knees (some 3 year olds) Fairly straight legs (5) Adult legs (8)
Define intoeing
When the feet turn inward when the person is walking instead of facing straight ahead
What are three causes for intoeing?
Metatarsus adductus
Femoral anteversion
Tibial torsion
What is the appearance of femoral anteversion?
Hips, knees and toes point inward
How do children with femoral anteversion tend to sit?
In W position - with knees bent and legs flared out behind them
What is the best way to assess for femoral anteversion?
Get child to lie on their tummy, with their knees flexed and rotate the hip
In femoral anteversion, expect more IR than ER
How does the degree of femoral anteversion change throughout a life?
Born with 40 degrees of anteversion, decreases to about 10 degrees by teenager
How do you treat femoral anteversion?
It is self-correcting
Usually fixes by age 12
At birth does the hip have more ER than IR or vice versa?
Has more ER than IR
Is tibial torsion normal?
An element of tibial torsion is normal
What causes tibial torsion?
Intrauterine moulding
Legs rotate to fit in the uterus - should correct after birth
How do you assess tibial torsion?
Thigh foot angle technique
Assess patellar position with feet/ankles facing forward - knees turned in but feet turn in more
What is the normal alignment of the forefoot?
2nd and 3rd digit should be in line with the heel
Describe the grading of metatarsus adductus
Normal - heel line between 2nd and 3rd toe
Mild - in middle of third toe
Moderate - in between 3rd and 4th toe
Severe - in between 4th and 5th toe
What are examples of issues with angular alignment?
Knocked knees
Bow legs
Flat feet
True or false:
Bow legs are never pathologic
False - should be investigated if still present over age 8
Could be a sign of rickets or blounts
Why do babies naturally have flat feet?
They have a large medial fat pad in the arch
Is flat footedness a problem is it continues throughout childhood?
No so long as it is mobile and asymptomatic it remains a normal variant
What tests can you do to assess flat footedness?
Heel raise tests, Jacks test, foot rotational alignment, foot progression in gait
What is the Staheli rotational profile alignment?
Assessment of child in prone position, knee flexes looking at rotation/version, thigh foot angle and foot bisector line
What may require further investigation?
Not age appropriate
Asymmetry
Rigid flatfoot
Bow legs (genu varum)
What might rarely require treatment?
Persistent femoral anteversion
Tibial torsion (external usually)
Metatarsus adductus
Curly toes
