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Paediatric Interventions > Neonatal Orthopaedics > Flashcards

Neonatal Orthopaedics Flashcards

1
Q

What is congenital talipes equino varus (CTEV)? What is it also referred to?

A

Equinous of the foot, heel is turned in or up (varus), midfoot is deviated towards the midline (adductus), first metatarsal points downwards (plantarflexion and cavus).
Club foot

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2
Q

What diseases are associated with congenital talipes equino varus?

A
  • Spina bifida
  • Arthrogryposis
  • Cerebral palsy
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3
Q

When does congenital talipes equino varus occur in development? How can it be diagnosed?

A

Between 12 to 20 weeks. Can be diagnosed on ultrasound.

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4
Q

What does the bone pathology of congenital talipes equino varus involve?

A
  • Normal ankle mortise
  • Talus is small, malformed, rotated medially and tilted into equinus
  • Calcaneus is in varus and equinus
  • Navicular is medially displaced
  • First ray is plantarflexed (cavus)
  • Internal rotation of tibia noted with growth
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5
Q

What soft tissue pathology is involved in congenital talipes equino varus?

A
  • Shortened thickened muscles
  • Atrophy of the lower leg muscles
  • Smaller, higher calf muscle
  • Joint capsules, ligaments and fascia contracted
  • Empty heel pad
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6
Q

How is congenital talipes equino varus assessed? What does it involve?

A

It is assessed Pirani scoring, which involves six clinical signs.

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7
Q

What two categories are included in Pirani scoring?

A
  1. Hindfoot score
    - Posterior crease
    - Empty heel
    - Rigid equinous
  2. Midfoot score
    - Curvature of lateral border
    - Medial crease
    - Talar head coverage
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8
Q

What does the management of congenital talipes equino varus involve?

A

Ponsetti Method

  • Gentle manipulation to correct deformity
  • Plasters to maintain correction
  • Percutaneous tendoachilles tenotomy (at ~8 weeks of age)
  • Boots and bar to maintain correction
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9
Q

What doe a percutaneous tenotomy involve?

A
  • Tendon palpated approximately 1cm above calcaneum
  • Tendon divided completely
  • 10-15 degrees dorsiflexion gained
  • Long leg cast applied with knee flexed at 30 degrees, for 3 weeks
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10
Q

What does the bracing with boots and bar involve?

A
  • Fitted after removal of last cast
  • Open toed, high, straight shoes connected to a bar
  • 60-70 degrees ER
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11
Q

What are the two most common types of surgery completed for ongenital talipes equino varus relapses?

A
  1. Tibialis anterior tendon transfer (TATT)

2. Split tibialis anterior tendon transfer (SPLATT)

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12
Q

Positional

Caused by inter-uterine ‘packaging effects’

A
  • Positional TEV
  • Metatarsus adductus
  • Talipes calcaneovalgus
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13
Q

Greatest risk factor of neonatal foot deformities?

A

First born

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14
Q

General assessment for…?

A
  • Subjective
  • Hips: DDH screen, tone, ROM
  • Spine
  • Head shape and neck ROM
  • Age appropriate development: rotational profile (hip IR/ER, foot progression angle, thigh foot angle)
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15
Q

What does positional (postural) talipes equinovarus?

A
  • Foot is in plantarflexion and inversion, with full passive range of motion.
  • No structural abnormality of the foot or calf.
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16
Q

What does treatment of positional (postural) talipes equinovarus involve?

A
  • Stretches: dorsiflexion and eversion

- Stimulation of evertors by touch

17
Q

What does metatarsus adductus involve?

A
  • Curved or adducted forefoot, with normal hindfoot.
  • Prominent base of fifth metatarsal
  • +/- searching big toe, internal tibial torsion, soft tissue contracture of medial structures, medial crease
18
Q

What is involved in the assessment of metatarsus adductus?

A
  • Pirani scoring for forefoot
  • Heel bisector line
  • Passive forefoot abduction
  • Full PROM expected
  • Active ROM by stimulating forefoot abduction by stroking lateral border
19
Q

What does Bleck’s classification involve?

A

Classifies metatarsus adductus

20
Q

Treatment of metatarsus adductus

A
  • Active stimulation and stretches into abduction
  • Straight last shoes or reverse shoes (walking age)
  • Deformity can appear worse when infants learn to stand - dynamic balance component
  • Serial casting if limited passive abduction
21
Q

What does talipes calcaneovalgus involve?

A
  • Ankle in dorsiflexion and forefoot in abduction (dorsum of foot to tibia)
  • Heel in valgus
  • Prominent navicular
22
Q

What does the treatment of talipes calcaneovalgus involve?

A

If full PROM: encourage plantarflexion and inversion by stimulating the plantar reflex and stroking medial border of the foot.
If limited PROM: cast into inversion and plantarflexion until full ROM, with thermoplastic splint to prevent recurrence

23
Q

Treatment of CVT

A
  • Surgical techniques

- Reverse Ponsetti method

24
Q

Treatment of CVT

A
  • Surgical techniques

- Reverse Ponsetti method

25
Q

What does the reverse Ponsetti technique involve?

A
  • Reduce the talonavicular…
26
Q

What does developmental dysplasia of the hip involve?

A

Femoral head and acetabulum are in improper alignment or grow abnormally or both.

27
Q

What is the incidence of developmental dysplasia?

A

1-30 per 1000 births

28
Q

What is a dysplastic hip involve?

A
  • The hips have inadequate acetabulum formation

- Often not clinical apparent

29
Q

Subluxation

A

The femoral head can be partially displaced outside of the acetabulum
- Incomplete contact between the articular surfaces of the femoral head and acetabulum

30
Q

Dislocatable

A

The femoral head is located within the acetabulum, but can be displaced by stress manoeuvres.

31
Q

Clinical assessment of DDH

A
  • Observation of skin folds
  • Limb length (Galeazzi sign)
  • Hip ROM: flexion and abduction especially
  • Ortolani and Barlow manoeuvres
  • Screen feet (talipes)
  • Screen head (torticollis)
32
Q

Clinical assessment of DDH

A
  • Observation of skin folds
  • Limb length (Galeazzi sign)
  • Hip ROM: flexion and abduction especially
  • Ortolani and Barlow manoeuvres
  • Screen feet (talipes)
  • Screen head (torticollis)
33
Q

Radiological examination

A
  • Usually done <6 months of age
34
Q

Alpha angle

A

Smaller alpha angle, indicative of DDH. The normal value is >60 degrees.

35
Q

Treatment for DDH

A
  • Maintain reduction of the hip in the physiological position of hip flexion and abduction
  • Bony stimulation of femoral head and acetabulum
  • …
36
Q

Pavlik harness

A
  • Anterior straps control flexion
  • Posterior straps control abduction
  • Ideal position is symmetrical hips at 90 degrees of flexion and 50 abduction
37
Q

Precautions of Pavlik harness

A
  • Extreme hip abduction = avascular necrosis of the femoral head
  • Extreme flexion = posterior hip dislocation and femoral nerve damage
38
Q

Precautions of Pavlik harness

A
  • Extreme hip abduction = avascular necrosis of the femoral head
  • Extreme flexion = posterior hip dislocation and femoral nerve damage

Paediatric Interventions (23 decks)

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