MSK - Paeds Flashcards
What are the different MSK conditions assosciated with a limping child that we are looking for in the age range of 0-15?
Early – Hip dysplacia (0-2.5) & Transient synovitis (2.5-5)
Mid- childhood – Perthes (4-10)
Later on – SUFE (10-15)
Throughout – Tumours or septic arthritis – must be excluded first
What different examinations/tests can we do to exclude sepsis?
- Full blood count
- ESR (erythrocyte sedimentation rate) & CRP (C-reactive protein) - inflammatory tests
- Joint aspiration and cultures
- X rays – AP & frog lateral
- Ultrasound – can be done quickly
- MRI, bone scan, etc – check for tumours
What is developmental dysplasia (DDH)? What are the risk factor?
Developmental dysplasia of the hip describes any abnormality found in the neonatal hip joint.
The problem may arise from structural defects in the head of the femur, the acetabulum or surrounding structures
Smaller ossification center and ball of joint is located out of the socket (dislocated) – this is the left hip (anatomical position)
1-5/1000 births
5 ‘F’s
1. Female (F:M ratio 5:1)
2. First born
3. Feet first (breach or c-sec) – increased stress on hip
4. Family history (hereditary influence)
5. Fluid (oligohydramnios) - disorder of amniotic fluid resulting in decreased amniotic fluid
How do we test for DDH?
Barlows
Ortolani
Both these tests are testing hip flexion
Skin crease asymmetry
Leg length discrepancy
Reduced abduction
How is DDH treated?
Pavlik harness – helps to position head of humerus into the joint – acetabulum develops normally around hip joint
Delay – 1-2 years old - performing surgery – not so common given the national screening for this
What is perthes disease? What are it’s associated risk factors? How is it treated?
Perthes disease - Osteonecrosis of femoral epiphysis
Aetiology poorly understood but likely non-genetic factors - changes in vasculature in this age range (2-5) - sometimes it appears to go wrong leading to limited blood supply to femoral head
Risk factos…
Male:female ratio 4:1
4-8 years in majority
Lower social class = increased risk - thought to be due to smoking
Treatment Principles
1. Prevention of stiffness - physiotherapy
2. Contain femoral head in acetabulum
3. surgical treatment required in certain circumstances - contains head in socket - osteotomy (bone is cut and reposition to keep head inside socket)
- Outcome depends on how well femoral head remodels
Radiograph - Left side – smaller, fragmented and flatter
What is SUFE? What are its risk factors?
SUFE - Hypertrophic zone of growth plate – weakness as that happens - minor trauma/higher energy – shaft of the bone moves – separating diaphysis and epiphysis
Risk factors
1. Males (3:1) - 13-16 years
2. In females younger, not after menarche (first menstrual cycle)
3. Bilateral in 42%
4. Obese or tall and slender
5. Rapid growth
6. 7% risk of a 2nd family member involved
How does a SUFE patient present clinically?
Can be…. Acute / Chronic / Acute on Chronic
Pain in the groin, thigh, knee (referred pain)
Limp
Antalgic gait
Externally rotated and adducted limb
What is the treatment for SUFE?
Diagnosis - frog lateral x-ray of hip should be performed
Surgical treatment – screw across the physis into epiphysis - not much growth comes from the humeral physis – not worry about disturbances in growth
Do it to both hips - other hip is highly likely to suffer from the same condition
What are some MSK red flags that you need to think of for the the following conditons/groups?
Neonate with painful paralysed looking arm or leg - septic joint, tumour or neuromuscular
Asymmetry of spine or limbs - SCOLIOSIS/DDH
School age child with limp - Perthes, SUFE or Tumour
Knee pain in adolescent - problems at hip or Ewing’s Sarcoma (rare type of cancer that affects bones or the tissue around bones)
Back pain – Discitis – infection of the intervertebral discs - MRI usually required
Back pain at night pain – tumour?
Also… Non accidental injury
What are things to keep in mind/red flags for non-accidental injuries?
- Injury in the non-ambulatory/totally dependant child
- Injury and history given are inconsistent
- Delay in seeking medical attention
- Multiple fractures with no family history of osteogenesis imperfecta
- Retinal haemorrhage
- Torn frenulum (small fold of tissue that secures the motion of a mobile organ in the body)
- History of household falls resulting in fracture despite falls being common, fractures are uncommon
What properties make children bones different to adult bones? What is the consequnce of this?
Differences between children and adults
- Bones are less rigid
- Higher level of plasticity - ability to deform plastically
Adult bone – resist, resist, break – brittle vs plastic – bends into a new position
A lot of incomplete fractures, which present as…
1. Greenstick fracture (tension) - like actual stick
2. ‘Buckle’ or torus (compression) - little bump
What do these blue and red arrows show on the radiograph?
Red - Greenstick (tension)
Blue - ‘Buckle’ or torus (compression)
Note - Uncommon to see both fracture in the same bone - they rather appear in the same bone unit - e.g. radius + ulna
When and where do we have the greatest remodelling potential?
Greatest potential
1. When we are young - more growth correction as physeas are still open
2. When the fracture is near a joint
3. Deformity is in same plane as joint - angulation of fracture is in the same plane that the joint moves (shown in image)
What type of bone remodelling occurs at the tension and compression side of a fracture?
Compression side - bone laid down
Tension side- bone absorbed
Implications - overtime a quite markedly angulated deformity can straighten out to the extent that it’s difficult to tell that there ever was a deformity to begin with - refers to paeds
Why are fractures near the physis important to consider?
Why is a fracture here important?
1. Risk of growth problems
2. Partial or complete arrest
3. +/- articular involvement - leads to a step in the articular surface - very quickly lead to damage to the cartilage of the other side of the joint and post traumatic arthritis.
What are the different fractues that occur at a physis - think about the pneumonic?
Salter-Harris classification
Different types of injuries – also in order of prognosis – 5 has the worst prognosis
SALTR - important to orientate the articular surface at the bottom
1- Straight through
2- Above
3- Lower
4- Through
3 + 4 - cause angular deformity - part of the physis continues growing but the other side has fused
5- Ruined (cRush) - causes leg length discrepancy
What is the good and bad news associated with a paeds fracture?
Very different management to adults
Good news
1. Thick periosteum aids conservative management
2. Ability to remodel with time and limb growth
3. Heal rapidly
4. Non-union very rare
5. Less morbidity with bed rest vs adult population
Bad news
1. Physeal plate injuries before skeletal maturity can cause growth abnormalities and arrests
2. Can be difficult to diagnose
What are the sorts of treatments/interventions used for Paeds fractures?
- Manipulation and casting - kids can handle casts quite well– no lingering stiffness in joint
- Surgery - K-wires and flexible nails
- Bed traction – femur fraction (shown)
What are the acute types of sport injuries?
Acute traumatic
- Bruising, cuts, abrasions
- Head injuries
- Cartilage/meniscal injuries
- Muscle/tendon/ligament injuries
- Dislocations
- Fractures
What are some chronic types of sporting injuries?
Chronic overuse
- Tendonitis
- Stress fractures
- Back pain
Instability - dislocations cause instability - increased future risk
What are some causes and preventative measures to reduce sports injuries?
How common are limping children in paeds? How do they typically present?
The limping child
- Common presentation in paediatric orthopaedics
- Often atraumatic – no history of an injury
- Incidence 180 / 100,000
What does a normal gate look like in children below the age of 7?
Note - gait also should be symmetrical
What is transient synovitis?
Irritable hip/transient synovitis - Non-specific, short term inflammation of the synovial membrane of the hip joint
Note - Joint effusion refers to the abnormal accumulation of fluid within the synovial compartment of a joint
Most common problem – irritable hip – seen a lot –> Benign
- Will disappear over time, but it is important to differentiate from infections/sepsis as they typically have overlapping profiles
What can atraumatic painless swelling be in a child’s leg?
Potential tumour
What are the normal milestones associated with movement in children?
What are the different angular and torsional variants we obeserve in children?
What is knee varum and valgum refer to?
What are the normal change that occur in knee varus/valgum as they age?
- Bow leg (varus) at the beginning of life
- Switch to valgus of the knee peaks at three years
- Retreats to the normal physiological valgus for an adult – range of 3-4 degrees
Note - note absolute but rather a range/trend
What should one keep in mind when looking at bow legged children?
Potential of apparent bowleg - occurs when hips and knees are flexed
Hence, to rule this out it is important to have the patella facing forward
When should we be worried about knee (genu) varus/valgum?
Pathological:
1. Asymmetric - most important factor to consider
2. Resistant - doesn’t follow normal trend - tends to be a nutritional deficiency - Vitamin D
3. Short stature
4. Varus >11˚- biomechanically suboptimal
5. Trauma / systemic - tends to be a history of trauma or systemic infection
What treatment do we use when there is abnormal genu varum/valgus?
Use an eight plate - plate spans the growth plate – slows growth down on one side of the bone – corrects deformations
What are the normal trends in foot rotation that are observed throughout life?
- Starts of with external rotation in early childhood
- Switches to a more neutral position throughout life
- External rotation can come back as we age
External rotation is used to increase the base - helps with balance in children and the eldelry
What is femoral anteversion?
Femoral anteversion - The angle betweem the femoral neck and the femoral condyle - rotation of the neck relative to condyles
Femoral anteversion occurs in up to 10 percent of children - normally resolves on it’s own - most common cause of in-toeing
Femoral anteversion is required for internal rotation – articulation of femoral head in the acetabulum
Excessive femoral anteversion - may require surgical correction, as a procedure known as a femoral osteotomy - involves cutting and realigning the femur.
What are the two main causes of persistent intoeing?
How is femoral retroversion/out-toeing treated (if treatment is required)?
External rotation
No way of guiding growth to correct mal-alignment – surgery to correct the rotational abnormality and using screws to fixate
What is metatarsus adductus?
Medial curve on the inside of the foot – due to abnormal packaging in the womb
Completely benign
How is Club foot treated?
Treatment – plantar flexion locks the foot - Unlock this in order to straighten foot
The main treatment, called the Ponseti method, involves…
- Gently manipulating and stretching your baby’s foot into a better position. It’s then put into a cast. This is repeated every week for about 5 to 8 weeks.
- Achilles tenotomy - minor procedure to release continued tightness in the Achilles tendon
- After successful correction with casting, clubfeet have a natural tendency to recur. To ensure that the foot will permanently stay in the correct position, your baby will need to wear a brace - boots and bar
Are flat feet something we should be worried about?
Flat foot (planovalgus)
Flat feet – very common – 50% of children up to the age of 5
Insole only when there is weight bearing on the medial arch – symptomatic feet
Really severe flexible flat feet & symptomatic - we introduce a subtalar implant - block in the non-articular space between the talus and calcaneus – builds the foot up
What do you call the different types of fractures?
What effect does a thick periosteum have for children in terms of fractures?
Periosteal that covers the surface of the diaphysis is much thicker when compared to adults
Two fold benefit
1. When the bone breaks and the periosteum remains intact that the bones generally don’t displace as much
2. When trying to reduce (move) it the periosteum can act like a hinge so that the bone goes back into him more anatomical position
How are type 1 SALTR Harris fractures treated?
Most can be treated conservatively with closed reduction i.e. putting the bone back into place if it’s displaced and immobilisation with a cast
Some of these injuries have a bit more severe displacement and if they can’t be reduced closed then they may need open reduction that is with a surgical incision and fixation usually with wires
How are type 2 SALTR Harris fractures treated?
Treatment is often with closed reduction and casting
Some of these can be quite unstable or difficult to reduce and they require surgery to open reduce and then fix them with usually a wire across the fracture if they are deemed to be unstable
How are type 3 SALTR harris fractures treated?
Atomic reduction with surgery followed by monitoring to check growth deformities –
Growth deformity occurs when the physis is disrupted leading to assymetric growth
Possibility of an articular step
How are type 4 SALTR harris fractures treated?
Fracture needs to be anatomically reduced and the patient needs to be monitored for a growth deformity as that’s reasonably common with this type of injury.
What are some common fractures seen in paeds?
- Forearm and wrist fracture - normally treated by reduction (if needed) and immobilization - open reduction (surgery) + wires/nails may be needed
- Femoral fractures - bed traction + nails (if needed)
- Supracondylar fractures (image) - immobilization (casting) or surgery for open reduction and fixation
What are some risk factors associated with non-accidental injuries?
NIA - second most common cause of death in children
If left unreported - 30-50% chance of further abuse and a 10% chance the child will die from subsequent injury - imperative to have high index of suspicion
