Introduction to Paediatric Orthopaedics and Normal Variation

Question 1

what is different about children’s bones compared to adults?

Answer 1

1. Epiphysis
2. Physis – growth plate
3. Metaphysis
4. Diaphysis – shaft
5. Apophysis

Question 2

biomechanical differences in childrens bones and implications

Answer 2

liagaments = stronger than the growth plate
epiphyseal separation easy
difficult to produce dislocations and sprains
more porous - plasticity but can fail in compression and tension

Question 3

physiological differences in childrens bones and implications

Answer 3

remodelling
overgrowth
progressive deformity
speed of healing much faster

Question 4

what is normal variation?

Answer 4

This is the spectrum/pattern of normal. It is within 2 standard deviations from the mean (Gaussian distribution – 97% of individuals from that group), and age matched. The data is population or age specific. By definition there will be children who fall out of the norm who have no underlying pathology.

Question 5

what is physiological development?

Answer 5

change in shape/angle/appearance with growth, include femoral anteversion, vow legs and flat feet

Question 6

name self-correcting or non concernng pathology in childrens orthopaedics

Answer 6

persistent femoral anteversion
metatarsus adductus
posterior tibual bowing
curly toes

Question 7

Possible Presenting Parental Concerns (exc true pathology) in childrens orthopaedics

Answer 7

• Out toeing
• In toeing
• Bow legs
• Knock knees
• Tiptoe walking
• Flat feet
• Curved feet
• Curly toes

Question 8

assessment in children’s orthopaedics: David Jones System of the 5 S’s

Answer 8

symmetrical - yes
symptomatic
systemic illness
skeletal dysplasia
stiffness

Question 9

examination of intoeing, identifying the origin or rotational concern: hip

Answer 9

patella even

see slides

Question 10

examination of intoeing, identifying the origin or rotational concern: tibia

Answer 10

element of internal tibal torsion is normal
combination of in utero moulding and tibial shape
clinically assessed: thigh foot angle technique, patellae position with feet/ankles facing forward

Question 11

intoeing thigh foot angle technique

Answer 11

knees turn in, feet more

Question 12

examination of intoeing, identifying the origin or rotational concern: foot

Answer 12

forefoot adduction: metatarsus adductus
normal between 2-3 toe
? normal varient
self correcting

Question 13

conditions of angular alignment in childrens ortho

Answer 13

knock knees
bow legs
flat feet

Question 14

assessment of angular alignment in childrens ortho

Answer 14

• Walking (if old enough)
• Standing
o Alignment from front
o Patella position
o Heels/arch/toes/leg length from behind
• Tip toe (if old enough)
• Staheli rotational profile
o Hip rotation/version
o Thigh foot angle
o Foot bisector line
• Rotational profile examination
o Supine
§ Leg lengths
§ Hips
• Galeazzi
• FFD
• ROM
o Prone
§ Staheli

Question 15

when may angular alignment in childrens ortho require further investigation or review?

Answer 15

• Not age appropriate
• Asymmetry
• Rigid flat foot
• Bow legs (genu varum)
o Blounts
o Rickets

Question 16

occasions for treatment of ngular alignment in childrens ortho

Answer 16

• Metatarsus adductus
• Tibial torsion (external typically more than internal)
• Persistent femoral anteversion
• Curly toes