MSK 1

Question 1

What is developmental dysplasia of the hip (DDH)?

Answer 1

spectrum of disorders ranging from dysplasia to subluxation through a frank dislocation of the hip
Neonatal screening- hip can be dislocated posteriorly out of the acetabulum (Barlow manoeuvre) or can be relocated back into the acetabulum on abduction (Ortolani manoeuvre)
these tests are repeated at routine surveillance at 8 weeks of age

Question 2

How does DDH appear after 8 weeks?

Answer 2

A limp or abnormal gait

asymmetry or skinfolds around the hip, limited abduction of the hip or shortening of the affected leg

Question 3

What is the management for DDH?

Answer 3

US
Splint or harness to keep the hip flexed and abducted for several months
progress is monitored by ultrasound of X-ray
Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
Splinting must be done expertly as necrosis of the femoral head is a potential complication
surgery is required if conservation measures fail

Question 4

What does a rigid flat foot in older children suggest?

Answer 4

Suggested by absences of a normal arch on tip toeing- it may be due to an associated tendo-Achilles contracture (ankle), or tarsal coalition or inflammatory arthropathy (JIA)

Question 5

What is tarsal coalition?

Answer 5

results from lack of segmentation between one or more bones of the foot
coalitions that were fibrous or cartilaginous become symptomatic as they begin to ossify
Become progressively more rigid and limit normal foot motion
symptomatic during the pre-adolescent years
radiographs may be normal if the bones have not yet ossified
Corrective surgery may be required

Question 6

What is positional talipes?

Answer 6

Intrauterine compression
foot is of normal size, the deformity is mild and can be corrected to the neutral position with passive manipulation
often the baby’s intrauterine posture can be recreated
If the positional deformity is marked, parents can be shown passive exercises by the physiotherapist

Question 7

What is talipes equinovarus?

Answer 7

The entire foot is inverted and supinated, the forefoot adducted and the heel is rotated inwards and in plantar flexion
the affected foot is shorter and the calf muscle thinner than normal
the position of the foot is fixed, cannot be corrected completely and is often bilateral

Question 8

What is the aeitiology of talipes equinovarus?

Answer 8

1 in 1000
Males (2:1), can be familial
o Secondary to oligohydramnios during pregnancy
o A feature of a malformation syndrome
o A feature of a neuromuscular disorder- such as spina bifida
Association with DDH

Question 9

What is the management for talipes equinovarus?

Answer 9

Plaster casting and bracing (Ponsetti method)- which may be required for many months it is usually successful unless the condition is very severe, when corrective surgery is required

Question 10

What are the causes of scoliosis?

Answer 10

o Idiopathic- the most common, either early onset (<5yrs old), or late onset - mainly girls 10-14yrs during their pubertal growth spurt
o Congenital- from a congenital structural defect of the spine eg. hemivertebra, spina bifida, syndromes (VACTERL)
o Secondary- related to other disorders, such as neuromuscular imbalance (eg. CP, dystrophy) disorders of bone, such as Marfan syndrome or leg length discrepancy (eg. due to arthritis of one knee in JIA

Question 11

What is the management for scoliosis?

Answer 11

• Mild scoliosis will resolve spontaneously, or progresses minimally- if more severe, the severity and progression of the curvature of the spine is determined by x-ray
• Severe cases are managed in specialist spinal centres where the place of non-medical treatment- such as bracing will be considered, with surgery only indicated if severe or there is coexisting pathology, such as neuromuscular or respiratory disease

Question 12

What is torticollis?

Answer 12

A flexion, extension or twisting of the muscle in the neck that allows the neck to move beyond its normal position- this condition can develop slowly, especially if there is a family history, or with acute trauma or an adverse reaction to medication
• The condition usually resolves in 2-6 months
Caused by wry neck, muscular spasm, ENT infection, spinal tumour (osteoid osteoma), cervical spine arthritis or malformation or posterior fossa tumour

Question 13

What is wry neck?

Answer 13

a sternomastoid tumour (congenital muscular torticollis)-they occur in the first few weeks of life and present with a mobile, non-tender nodule, which can be felt within the body of the SCM muscle
There may be restriction of head turning and tilting of the head

Question 14

What is the management for acute torticollis?

Answer 14

• Painkillers are useful- should include paracetamol & ibuprofen, possibly with a muscle relaxant, such as diazepam, but use caution in children
• Exercise of the neck and remaining active are important to stop the neck stiffening
• Heat packs and good posture
• If persistent then botox may help
• Surgery is reserved for very severe cases- involves severing the nerves around the muscle to force relaxation

Question 15

What is osteomyelitis?

Answer 15

Infection of the metaphysis of long bones
the most common sites are the distal femur and proximal tibia, but any bone may be affected It is usually due to haematogenous spread of the pathogen, but may arise by direct spread from an infected wound

Question 16

What causes osteomyelitis?

Answer 16

• Most infections are caused by Staphlococcus aureus, but other pathogens include Streptococcus and Haemophilus influenzae if not immunised
• In sickle cell anaemia, there is an increased risk of staphylococcal and salmonella osteomyelitis
• Infection may be from tuberculosis- although rare in the UK, it needs to be considered, especially in the immunodeficient child

Question 17

What are the clinical features of osetomyelitis?

Answer 17

Markedly painful, immobile limb (pseudoparesis) in a child with an acute febrile illness, directly over the infected site there is swelling and exquisite tenderness, and it may be erythematous and warm moving the limb causes severe pain
there may be a sterile effusion of an adjacent joint
May be more insidious in infants, in whom swelling or reduced limb movement is the initial sign

Question 18

How does osteomyelitis present beyond infancy?

Answer 18

back pain in a vertebral infection or with a limp or groin paint in infection of the pelvis, occasionally, there are multiple foci eg. disseminated staphylococcal or H.influenzae infection

Question 19

What are the investigations for osteomyelitis?

Answer 19

• Blood cultures are usually positive and the WCC and CRP are raised
• X-rays are initially normal, other than showing soft tissue swelling, it takes 7-10 days before subperiosteal new bone formation and localised bone rarefaction to become visible
• Ultrasound may show periosteal elevation at presentation
• MRI allows indentification of infection in the bone and differentiation of bone from soft tissue-
subperiosteal pus & purulent debris in the bone is a sign of infection
• Radionuclide bone scan may be helpful if the site of infection is unclear
• Chronic osteomyelitis can be seen on X-ray as periosteal reaction along the shaft and multiple hypodense areas with metaphyseal regions

Question 20

What is the management for osteomyelitis?

Answer 20

• Antibiotics are given IV until there is clinical recovery and CRP has returned to normal- followed by oral therapy for several weeks
• Aspiration or surgical decompression of the subperiosteal space may be performed if the presentation is atypical or in immunodeficient children
• Surgical drainage is performed if the condition does not respond rapidly to antibiotic therapy
• The affected limb is initially rested in a splint and subsequently mobilised

Question 21

What complications can occur with osteomyelitis if antibiotics aren’t given?

Answer 21

o Bone necrosis
o Chronic infection with a discharging sinus
o Limb deformity
o Amyoidosis

Question 22

What is subacute osteomyelitis?

Answer 22

insidious onset, mild symptoms and lacks a systemic reaction- supportive laboratory data is also inconsistent
can mimic various benign and malignant conditions which can delay diagnosis
Average duration of symptoms before diagnosis is 1-6 months

Question 23

How does subacute osteomyelitis present?

Answer 23

o Mild to moderate localised pain- usually exacerbated by unusual physical activity
o Night pain- but relieved by aspirin
o Minimal loss of function
OE: localised tenderness, occasionally associated with warmth, redness and soft tissue swelling
pain may occur with movement of the adjacent joint and some joint effusion may be present
surrounding muscle may show signs of wasting

Question 24

What are the risk factors for DDH?

Answer 24

female sex: 6 times greater risk
breech presentation
positive family history
firstborn children
oligohydramnios
birth weight > 5 kg
congenital calcaneovalgus foot deformity