Introduction to Paediatric Orthopaedics and Normal Variation

Question 1

Which part of a bone contains the growth plate?

Answer 1

The metaphysis

Question 2

Why don’t X-rays tell you much in young children?

Answer 2

Cartilage model in bone is yet to ossify

Question 3

—In Children -

Ligaments stronger than growth plate

—easy to produce epiphyseal separation

—difficult to produce dislocations or sprains

Question 4

What is the result of a young persons bone being more porous?

Answer 4

It tolerates more deformation

Fails in compression as well as tension

Buckle freactures and green stick fractures

Question 5

How does the speed of healing compare in children vs adults

Answer 5

Speed of healing is much faster in children

Question 6

What is the definition of normal variation?

Answer 6

Lies within 2 standard deviations from the mean) depends on the age and the population)

Question 7

What parts of normal development may seem concerning?

Answer 7

Femoral anteversion (pigeon toed appearance)

Bow legs

Flat feet

Question 8

What may fall under the category of self-correcting or non-concerning pathology?

Answer 8

Persistent femoral anteversion

Metatarsus adductus - Metatarsus adductus, also known as metatarsus varus, is a common foot deformity noted at birth that causes the front half of the foot, or forefoot, to turn inward.

Posterior tibial bowing

Curly toes

Question 9

For what reasons might parents be concerned about in their child?

Answer 9

—Out toeing

—In toeing

—Bow legs

—Knock knees

—Tiptoe walking

—Flat feet

—Curved feet

—Curly toes

Question 10

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

Answer 10

—Symmetrical – yes

—Symptomatic- no

—Systemic illness- no

—Skeletal dysplasia- no

—Stiffness- no

Question 11

Which planes are associated with the terms rotational alignment and angular alignment?

Answer 11

—Rotational alignment- axial

—Angular alignment- usually coronal

Question 12

What is the natural development for in-toeing and out-toeing?

Answer 12

Question 13

What are the potential origins for intoeing?

Answer 13

Hip

Tibia

Foot - use of foot bisector line

Question 14

What is a sign that the intoeing is as a result of the hips?

Answer 14

The knee caps will be equally facing inward if intoeing pathology is arising from the hips

If it does not correct then it is ‘persistant femoral anteversion’, this usually grows out by age 12 yrs

Ability to W sit?

Question 15

How is tibial torsion assessed?

Answer 15

Clinically:

—- thigh foot angle technique

—- patellae position with feet/ ankles facing forward

Thigh foot angle generally increases with age

Question 16

How do you tell if the intoeing arises at the feet?

Answer 16

Foot bisector line should emerge between the 2nd and the 3rd toe

Question 17

What are the issues with angular allignment of the legs?

Answer 17

Knocked knees

Bow legs

Flat feet

—Occasional underlying pathology that may require treatment but usually a combination of normal physiology and variation

Question 18

How do the legs bow in normal variation?

Answer 18

Question 19

When should bow legs be considered possible for an undderlying pathology?

Answer 19

Bow legs over the age of 8 years

Question 20

Answer 20

The bowing appears worse in the infant than it truly is becasue the the infants hip is held in external rotation

Knee alignment can change quite notably in the growing child

Question 21

When does flat footedness remain a normal variant?

Answer 21

If the foot is mobile and it is asymptomatic

Question 22

What is the clinical assessment for all this?

Answer 22

Walking

Standing:

• Alignment from front
• Patella position
• Heels/arch/toes/leg length from behind

—Tip toe (if old enough)

—Staheli rotational profile

Question 23

When might further review or investigation be necessary?

Answer 23

—Not age appropriate - can’t walk for example

—Assymetry

—Rigid flat foot

—Bow legs (genu varum)

• —Blounts
• —Rickets

Question 24

Which things rarely require treatment

Answer 24

—Metatarsus adductus

—Tibial torsion (external typically more than internal)

—Persistant femoral anteversion

—Curly toes

Most of the time it is

Normal variants

Physiological changes

Self correcting/ non-concerning pathologies