O&T: Common Paediatric Problems Flashcards
Paediatric Orthopaedics
- Paediatric Hip Problems
- Developmental Dysplasia of Hip (DDH / CDH)
- **Perthes disease (4-10 yo)
- *Slipped Capital Femoral Epiphysis (SCFE) (10-14 yo)
- Transient Synovitis (2-6 yo)
- Other less common problems:
—> PFFD (Proximal Femoral Focal Deficiency)
—> Infection
—> Tumour
—> Fracture
—> Dislocations - Common foot deformities
- **Talipes equinovarus (Clubfoot)
- **Flatfoot - Torticollis
Developmental Dysplasia of Hip (DDH / CDH)
Underdevelopment of hip joint
- Shallow acetabulum
- Reduced coverage of femoral neck
Epidemiology:
- 0.87/1000
Risk factors:
- **Breech presentation 3rd trimester (need USG screening of hip joint)
- **Female
- **Positive family history
- **First born
- ***Oligohydramnios
- Torticollis, Metatarsus adductus (mechanical effect)
(- Left hip (from SpC bedside))
Clinical features:
Neonatal:
1. **Groin skin crease asymmetry (extra groin skin fold due to lateral femur displacement causing shortening of limb, in dislocated hip, can occur in normal baby as well)
2. **Decrease hip abduction
(3. **LLD (from SpC bedside): **Galeazzi’s sign)
Toddler:
1. Waddling gait (Bilateral trendelenburg gait: unable to abduct hip during swing phase to clear the ground —> walk like a duck)
2. Short limb unilaterally
Clinical features:
1. **Pain-free usually
2. Reduce **spontaneously
P/E:
1. **Barlow’s test (dislocatability: Flex hip 90o, Adduct hip + Posterior force to try to posteriorly dislocate hip)
2. **Ortolani’s test (reducibility: Flex hip 90o, Abduct hip + Traction force to try to reduce dislocated hip)
3. Leg length discrepancy
4. Decreased Abduction
Investigations:
1. USG (***<6 months)
- Able to image the cartilage + associated soft tissues of the hip
- More sensitive than X-ray + P/E but false positive causing overdiagnosis + overtreatment
- Operator dependent
- Static: Alpha / Beta angle —> Coverage
- Dynamic: stress test —> Hip stability
- X-ray (**>=6 months)
- Not for <6 months (∵ Ossific nucleus not ossified —> capital femoral epiphysis only starts to ossify after **5 months)
- Difficult to interpret for mild cases
X-ray description:
1. **Displacement of the capital femoral epiphysis (i.e. dislocated)
2. **Shenton’s line broken (draw from medial proximal femur back to pubic rami)
3. **Hilgenreiner’s line (line traversing triradiate cartilage) + **Perkin’s line (most lateral aspect of acetabulum, perpendicular to Hilgenreiner’s line)
- Medial beak of proximal femur should be within **inferior + **medial quadrant (if within —> still cannot rule out since subluxation can produce “normal” image)
4. **Acetabulum dysplasia: Increased **Acetabular index (>30o) (~ Tonnis angle in adults)
- angle between Hilgenreiner’s line and line tangentially connecting inferior margin of iliac bone and superolateral part of acetabular bony rim
- indicate Acetabulum **dysplasia
5. **Delayed ossification of femoral head (Size of ossific nucleus smaller)
6. Lateral edge of acetabulum
(Aim of treatment (from SpC Bedside):
- Obtain + Maintain hip reduction
- Allow normal development of hip
- Obtain joint congruence)
Treatment:
1. **Pavlik Harness
- **<6 months
- Keep hip in flexion + abduction (to help reduction of hip)
- Size + compliance are more important
- May cause AVN of femoral head (excessive abduction cause compression of medial circumflex artery by acetabulum in posterior side of femur neck), (Femoral nerve palsy —> baby cannot kick leg (from SpC bedside))
- ***Serial USG to confirm reduction of hip joint
-
**Hip Spica immobilisation (Close reduction)
- **6-18 months (Pavlik Harness not strong enough)
- **Arthrogram (confirm presence of **concentric reduction) —> minimal medial pooling of contrast (contrast should smoothly distribute throughout hip joint and outline acetabulum + epiphysis)
- +/- Adductor tenotomy
10% of cases still is irreducible despite above measures (∵ extra-articular + intra-articular obstacles)
-
**Open reduction (Medial / Anterior approach) +/- **Femoral or ***Acetabular osteotomy (to reconstruct acetabulum)
- Remove possible obstacles to reduction (e.g. ligamentum teres)
- For severe dysplastic acetabulum, excessive femoral anteversion (in chronic dysplasia)
Complications:
1. **AVN —> Proximal growth disturbance
2. **Re-dislocation
3. ***Residual dysplasia
Perthes Disease
- Unknown causes
- **Osteonecrosis + **Collapse of femoral epiphysis —> **Revascularisation + **Reossification (Deformity occurs since femoral head heal in deformed shape) —> Outcome variable among individuals
- **Interruption of blood supply to femoral epiphysis —> return of blood supply **spontaneously after 2-3 years
- New bone formation (Woven bone —> Lamellar bone)
- Self-limiting disease in children
- Subchondral fracture associated with onset of limping
Pathophysiology:
- **Vascular insufficiency (unknown cause)
—> Repeated infarction
—> **AVN of femoral epiphysis
—> Resorption of necrotic bone
—> **Collapse of trabeculae + fragmentation of epiphysis
—> **Woven bone laid down over periphery of epiphysis
—> Lamellar bone replace Woven bone
—> Complete healing (but in ***deformed shape —> may cause premature OA)
Clinical features:
- **Age 4-10
- Insidious onset of **Hip + ***Knee pain (referred pain from Obturator nerve)
- Limited hip motion (esp. Abduction + Internal rotation)
- Limping gait
Radiographic stages:
- Initial
- Fragmentation
- Reossification
- Healed
Treatment (NO way to speed up return of blood supply, can ONLY prevent deformity of femoral head):
1. Restoration of motion (ensure femoral head stay better inside acetabulum with better remodeling potential)
- **Bed-rest, **traction
- Progressive abduction
- Adductor release (if soft tissue contracture)
-
**Containment (best initiated when femoral head still **round —> ensure lateral femoral head (most vulnerable to sublux from hip joint) stay better inside acetabulum with better remodeling potential by **abduction —> prevention lateral migration of femoral head —> avoids flattening while necrotic bone is being replaced —> no way can improve after healing phase)
- Non-operative
—> Petrie ‘broomstick’ abduction cast (Abduction + Internal rotation)
—> **Abduction brace (require high compliance)
- Operative
—> **Femoral varus osteotomy (cut femur) / **Salter osteotomy (cut acetabulum)
Surgery advantages:
- Prolonged containment
- No need to decide endpoint
- Early mobilization
- No need for bracing
Disadvantages:
- Surgical complications
- Iatrogenic deformity
- Shortening
Prognosis:
- Extent of necrosis
- Age (Poor if >8 yo, less remodeling potential)
- Hip subluxation (∵ large effusion from inflammatory process)
Long term sequalae:
Patterns of deformity
- Coxa plana
- Coxa magna
- Premature physeal arrest with trochanteric overgrowth
- Irregular head
- Osteochondritis dissecans
- Patients with poor result will end up in early degeneration
Slipped Capital Femoral Epiphysis (SCFE)
- Puberty between 10-15
- ***Boys: 13-15, Girls: 10-13
- **Obese, **tall and with features of ***hypogonadism
- More common in boys
- Bilateral in 25% (now thought to be much higher)
- **Hormonal imbalance —> **delay in ossification of physis —> ***intrinsic weakness of physis (physeal disruption at hypertrophic zone) —> abnormal movement along physis —> whole CFE will slip downwards
Displacement
- Site of slip: Zone of **hypertrophy (zone of transition from soft to hard)
1. Displacement of neck + shaft against a stationery head
2. Neck displace **anteriorly (Head displace posteriorly)
(capital epiphysis displaces posteriorly and inferiorly with respect to the femoral metaphysis and results in a varus, extension and external rotation deformity of the femur (web))
Clinical features:
- Hip + Groin + Knee pain
- Limp
- **Out-toeing
- Obligatory **external rotation of hip upon hip **flexion (∵ **anterior slip of femur neck will hit labrum of acetabulum upon flexion)
- ***Anterior impingement test: Pain during hip flexion + adduction + internal rotation (∵ torn labrum due to anterior impingement of anterior slip of femur neck)
Classification:
- Chronicity: **Acute (<3 weeks) / **Chronic (>3 weeks) / ***Acute on Chronic (most common) / Preslip
- Stability: Stable / Unstable
- Severity: Displacement, Slip Angle
(Acute usually combined with Unstable)
Stable slips (90%):
- able to bear weight
- 96% satisfactory results
- lower risk of AVN <3%
**Unstable slips (10%): —> **Orthopaedic emergency
- unable to bear weight even with crutches
- 47% satisfactory results
- high risk of AVN (as high as 50%) (∵ torn blood vessels)
X-ray:
- **Klein’s line
—> Line along superior border of lateral neck of femur should always cut through CFE
—> SCFE: line will miss CFE
- AP (can be deceiving since cannot see anterior slip of femoral neck)
- **Lateral
—> True lateral
—> ***Frog
(Aim of treatment (from SpC Bedside):
- Increase ROM
- Stabilise hip
- Minimise AVN risk
- ***Induce physeal closure)
Treatment:
Unstable SCFE (Orthopaedic emergency):
1. ***In-situ fixation
- Close reduction NOT recommended for unstable slip (∵ risk of damaging blood vessels) —> further risk of AVN
- Pin insertion
Stable + Healed SCFE:
1. In-situ fixation
2. ***Osteotomy if necessary (to correct deformity)
Complications:
1. **Chondrolysis
- Joint space <3mm / <50%
- Stiffness, pain
- Protrusion of pins
2. **AVN
- Insult of original displacement
- Reduction, surgical insult
3. **Continued slipping
4. **Early OA in severe slip
Flatfoot
- Most children are flatfooted (∵ ligamentous laxity)
- Arch elevates **spontaneously in **1st decade (∵ reduction in ligamentous laxity)
- Wide range of normal arch heights at all ages
- No universal definition
- Normal / Abnormal height is unknown
Elements of support of footarch:
- **Bone + **Ligament complex
- ***Muscles (during standing at rest —> neither intrinsic / extrinsic muscles of foot has action)
Classification:
1. Flexible
- ***Physiological (99%)
- Neurological (strong everters, weak inverters)
- Secondary compensation to genu valgum
- Rigid (Pathological)
- Congenital vertical talus
- Tarsal coalition
- Paralytic
- ***Rupture of tibialis posterior tendon
Clinical features of Physiological flatfoot:
1. Deformity (Duck foot)
- **Flattened medial arch
- **Forefoot abduction (obligatory due to intercalation of joints)
- **Hindfoot in valgus (obligatory due to intercalation of joints)
- Ligamentous laxity
- Navicular prominence
2. **Easy tiredness
3. Pain (seldom) due to pressure
- Due to tight Achilles tendon —> push head of talus / navicular downwards —> pain, tenderness, callosity under head of talus / navicular
4. Cosmetics
5. Parent’s concern
P/E:
- **Reappearance of medial arch when foot is not weightbearing (just ask the patient to lie supine)
- **Jack test / Hubscher maneuver (Dorsiflex toe while weight bearing)
- **Tiptoeing test:
—> Reappearance of medial arch —> Flexible flatfoot (∵ tightening of plantar fascia —> **Windlass effect —> bolstering medial arch)
—> Hindfoot go back to ***varus (if not then is pathological)
Investigations:
- Lateral X-ray (usually not necessary)
—> Talus not linear with 1st MT
Treatment:
1. Reassurance, Expectant
2. Shoe modification, Orthosis (**NOT alter natural history of arch development) (3 point pressure system to push up calcaneus and correct hindfoot valgus deformity)
3. Physiotherapy
4. Surgery
- **Medial soft tissue plication
- ***Osteotomy (Calcaneal lengthening osteotomy)
—> for symptomatic flatfoot (pain), severe valgus deformity of hindfoot with failure of conservative (6 months) treatment to relieve pain / callus under Talar head
Talipes equinovarus (Clubfoot)
- Talipes: foot
- Equinus: horse (foot points downward ~horse)
- Varus: turning inward
- Usually ***rigid (vs flexible in flat foot)
- ~50% bilateral
**Clinical features:
1. **Ankle equinus (due to tight achilles)
2. **Forefoot adductus
3. **Hindfoot varus
4. ***Cavus + Forefoot pronation
Risk factors:
- M:F = 2.5:1
- Risk with positive family history
- Maternal smoking during 1st trimester
Cause:
- ***Unknown still
Pathoanatomy:
1. Bone
- Deformed with abnormal growth
2. Soft tissue
- Retraction fibrosis of distal muscle
- Contracted ***medial connective tissue
Classification:
1. Congenital / Idiopathic
- Postural (Intrauterine position keep that position for long period)
- More flexible
- More successful with non-operative treatment - Neurological
- e.g. Cerebral palsy, Myelomeningocoele
- Strong inverters, weak everters - Syndromal (Teratologic) (more stiff)
- Arthrogryposis multiplex congenita
- Larsen’s syndrome
- Constriction band syndrome
- Tibial hemimelia
- Pierre Robin syndrome
- Mobius syndrome
- Opitz syndrome
- Diastrophic dwarfism
- Prune Belly
Associated conditions:
- **Spinal dysraphism (must be excluded in bilateral cases)
- **DDH
- **Torticollis
—> Clubfoot + DDH + Torticollis = **Crowding syndrome
Investigation:
- AP
—> Talocalcaneal angle
—> Talo-1st metatarsal angle
- Lateral
—> Talocalcaneal angle
Treatment:
1. Casting (Ponseti’s cast) / Strapping / Manipulation (Standard)
**Ponseti’s cast (Gold standard):
- **Serial manipulation + **Cast immobilisation to produce plastic deformation (permanent lengthening) of shortened ligaments + tendons
- Weekly manipulation + casting for 4-6 weeks
- May need **Percutaneous tenotomy for Achilles tendon (to correct ankle deformity rather than forefoot / hindfoot deformity)
- Chance of recurrence —> Prolonged nighttime splint until 4 yo
Strapping:
- Repeated strapping to gradually stretch out the deformity
- Old technique useful in newborn when the child may be in the nursery where casting is difficult to manage
- Allows positioning of the foot by adhesive taping
- Surgery
- If a good correction is not obtained by 3 months —> unlikely nonoperative treatment will be effective
- Some prefer to intervene early 3-6 months while others preferred to delay surgery until 9-12 months
- Splintage after surgery
- 20% will have recurrence —> managed with tendon transfers, repeat joint release, osteotomy + joint fusion
- problem: more surgery done —> more fibrosis —> more stiff despite better appearance
***A la carte (Soft tissue surgery):
- Young patient
- Percutaneous Achilles tendon lengthening
- Posterior Release
- Posteromedial Release
- Circumferential Release
—> Avoid overcorrection —> Flatfoot
***Bony surgery:
- Older patient
- Resistant / Recurrent deformity
- Osteotomy of Metatarsals
- Osteotomy of Calcaneus
- Talectomy
- Ilizarov correction
- Triple Arthrodesis
Torticollis
Causes:
**Congenital muscular torticollis (commonest)
- Secondary to tightness of Sternomastoid muscle
—> **Sternomastoid tumour (palpable mass along course of muscle, disappear in the first 3 months with stretching)
—> ***Fibrotic Sternomastoid muscle (unresponsive to stretching)
Clinical features:
1. **“Cock Robin” deformity: Head tilted to same side + Chin rotated to opposite side of tightness
2. **Facial asymmetry in prolonged cases (Atrophic face on same side)
3. **Plagiocephaly on contralateral side (Contralateral side resting on pillow)
4. **Unleveled eyes
DDx:
1. Congenital cervical spinal deformity
2. **C1/2 rotatory subluxation
3. **Ophthalmological cause
4. ***Postural
—> Differentiate with P/E ROM of neck + cervical spine
Treatment:
1. Manipulation
- Before 1 yo
- Surgical release of muscle insertions (sternal + clavicular head of SCM)
- Uncorrected deformity >1 yo
- Younger patient: Distal release
- >6 yo, recurrence: Bipolar release
(Dislocation of Hip vs Dislocation of Shoulder)
Dislocation of Hip:
- Posterior more common —> Adduction + Flexion + Internal rotation
Dislocation of Shoulder:
- Anterior more common —> Abduction + Extension + External rotation
