Introduction to Paedatric Orthopaedics and Normal Variation

Question 1

What are the differences between adult’s and children’s bones?

Answer 1

Physiological, biochemical and anatomical differences

Question 2

What is an apophysis?

Answer 2

Normal bony outgrowths arising from separate ossification centres

Question 3

What are the epiphyses of infants like?

Answer 3

Almost completely cartilaginous

Question 4

Describe bone growth in children

Answer 4

Interstitial (growth in length) occurs at epiphysis of long bones

Appositional growth (in width) occurs due to periosteal growth

Question 5

How do the ligaments differ in children as opposed to adults and why is this clinically relevant?

Answer 5

Ligaments are stronger than the growth plate therefore more likely to cause epiphyseal separation as opposed to dislocation or sprain

Question 6

Young bones are more porous what does this result in?

Answer 6

More toleration of deformity and increased ability to deal with compressive forces

Question 7

What fractures are children more likely to get and why?

Answer 7

Buckle fractures and Greenstick fractures as the bone is a lot more pliable

Question 8

What is a buckle fracture?

Answer 8

Break on only one side of a long bone (opposite cortex remains intact)

Question 9

What is a greenstick fracture?

Answer 9

Bending/cracking of the bone as opposed to the bone splitting into separate fragments

Question 10

How do children’s bones differ in their healing/remodelling?

Answer 10

Greater remodelling potential (more efficient) and faster speed of heeling

Question 11

What are the majority of orthopaedic paediatric referrals for?

Answer 11

Normal variants (53%)

Question 12

Define normal variant

Answer 12

Atypical finding that has no clinical significance (within a spectrum of normal findings)

Question 13

Define physiological development

Answer 13

Normal changes in shape, size, appearance, angle with growth

Question 14

Define self-correcting pathology

Answer 14

Pathology that fixes itself

Question 15

How close is a normal variant to ‘normal’?

Answer 15

Within 2 standard deviation of the mean

age and population matched

Question 16

What are examples of normal physiological development?

Answer 16

Femoral anteversion, bow legs and flat feet

Question 17

What is the appearance of bow legs?

Answer 17

Knees turned outwards but ankles touching

Question 18

What are examples of self-correcting/non-concerning pathologies?

Answer 18

Persistent femoral anteversion
Metatarsus adductus
Posterior tibial bowing
Curly toes

Question 19

What are curly toes?

Answer 19

Toes curl under feet as tendons are too tight

Question 20

What is metatarsus adductus?

Answer 20

Forefoot is angled inwards too much

Question 21

What are possible presenting patient concerns that are not true pathology?

Answer 21

Curly toes 
intoeing 
Outtoeing 
Bow legs and knock knees
Flat feet
Curved feet

Question 22

What is the david jones system of the 5S’s?

Answer 22

To assess for non-concerning pathology/normal variants:

Symmetrical - yes 
Systemic illness - no 
Skeletal dysplasia - no 
Stiffness - no 
Symptomatic - no

Question 23

What is the normal angular alignment?

Answer 23

Coronal

Question 24

What is the normal rotational alignment?

Answer 24

Axial

Question 25

What is the normal development in walking pattern?

Answer 25

``` Bowed legs (o-18 months) Straightens out (18m-2y) Knock knees (some 3 year olds) Fairly straight legs (5) Adult legs (8) ```

Question 26

Define intoeing

Answer 26

When the feet turn inward when the person is walking instead of facing straight ahead

Question 27

What are three causes for intoeing?

Answer 27

Metatarsus adductus Femoral anteversion Tibial torsion

Question 28

What is the appearance of femoral anteversion?

Answer 28

Hips, knees and toes point inward

Question 29

How do children with femoral anteversion tend to sit?

Answer 29

In W position - with knees bent and legs flared out behind them

Question 30

What is the best way to assess for femoral anteversion?

Answer 30

Get child to lie on their tummy, with their knees flexed and rotate the hip In femoral anteversion, expect more IR than ER

Question 31

How does the degree of femoral anteversion change throughout a life?

Answer 31

Born with 40 degrees of anteversion, decreases to about 10 degrees by teenager

Question 32

How do you treat femoral anteversion?

Answer 32

It is self-correcting | Usually fixes by age 12

Question 33

At birth does the hip have more ER than IR or vice versa?

Answer 33

Has more ER than IR

Question 34

Is tibial torsion normal?

Answer 34

An element of tibial torsion is normal

Question 35

What causes tibial torsion?

Answer 35

Intrauterine moulding | Legs rotate to fit in the uterus - should correct after birth

Question 36

How do you assess tibial torsion?

Answer 36

Thigh foot angle technique | Assess patellar position with feet/ankles facing forward - knees turned in but feet turn in more

Question 37

What is the normal alignment of the forefoot?

Answer 37

2nd and 3rd digit should be in line with the heel

Question 38

Describe the grading of metatarsus adductus

Answer 38

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

Question 39

What are examples of issues with angular alignment?

Answer 39

Knocked knees Bow legs Flat feet

Question 40

True or false: | Bow legs are never pathologic

Answer 40

False - should be investigated if still present over age 8 Could be a sign of rickets or blounts

Question 41

Why do babies naturally have flat feet?

Answer 41

They have a large medial fat pad in the arch

Question 42

Is flat footedness a problem is it continues throughout childhood?

Answer 42

No so long as it is mobile and asymptomatic it remains a normal variant

Question 43

What tests can you do to assess flat footedness?

Answer 43

Heel raise tests, Jacks test, foot rotational alignment, foot progression in gait

Question 44

What is the Staheli rotational profile alignment?

Answer 44

Assessment of child in prone position, knee flexes looking at rotation/version, thigh foot angle and foot bisector line

Question 45

What may require further investigation?

Answer 45

Not age appropriate Asymmetry Rigid flatfoot Bow legs (genu varum)

Question 46

What might rarely require treatment?

Answer 46

Persistent femoral anteversion Tibial torsion (external usually) Metatarsus adductus Curly toes