ortho

Question 1

A 7-year-old with a one day history of a painful right hip. Just about able to walk but painful. Looks flushed and has a temperature of 38.7ºC

Dx?

Answer 1

Septic arthritis/osteomyelitis

The child is too unwell to make a diagnosis of transient synovitis

Question 2

An 8-month-old child is noted to have a discrepancy between the skin creases behind the right and left hips

Dx?

Answer 2

Development dysplasia of the hip

Question 3

An obese 13-year-old boy presents with a two week history of right sided knee pain associated with a stiff right hip. There is no history of trauma

Dx?

Answer 3

Slipped upper femoral epiphysis

Question 4

what is Perthes’ disease?

Answer 4

degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years.

due to avascular necrosis of the femoral head, specifically the femoral epiphysis.

Impaired blood supply to the femoral head –> bone infarction.

Question 5

Perthes’ disease is more common in…

Answer 5

boys (5x)

10% bilateral

Question 6

what are the features of Perthes’ disease?

Answer 6

1) hip pain: develops progressively over a few weeks
2) limp
3) stiffness and reduced range of hip movement
4) x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Question 7

how to dx Perthes’ disease?

Answer 7

1) plain x-ray

2) technetium bone scan or MRI if normal x-ray and symptoms persist

Question 8

what are the complications of Perthes’ disease?

Answer 8

1) osteoarthritis

2) premature fusion of the growth plates

Question 9

what is the mx of Perthes’ disease?

Answer 9

1) To keep the femoral head within the acetabulum: cast, braces
2) If less than 6 years: observation
3) Older: surgical management with moderate results
4) Operate on severe deformities

Question 10

what are the risk factors of developing developmental dysplasia of the hip (DDH)?

Answer 10

1) female (6x)
2) breech
3) +ve fam hx
4) firstborn
5) oligohydramnios
6) birth wt >5kg
7) congenital calcaneovalgus foot deformity

Question 11

how is screening for DDH done?

Answer 11

1) routine ultrasound examination for infants with:
- 1st degree fam hx of hip problems in early life
- breech presentation at/after 36 weeks gestation
- multiple pregnancy
2) all infants screened at newborn baby check and 6-week baby check using Barlow and Ortolani tests

Question 12

what is a Barlow test?

Answer 12

attempts to dislocate an articulated femoral head

Question 13

what is an Ortolani test?

Answer 13

attempt to relocate a dislocated femoral head

Question 14

what are the other important factors to look out for on clinical examination of the hip for DDH?

Answer 14

• symmetry of leg length
• level of knees when hips and knees are bilaterally flexed
• restricted abduction of the hip in flexion

Question 15

what is used to confirm dx of DDH?

Answer 15

ultrasound

however, if infant >4.5 months, then X-ray is first line

Question 16

what is the mx for DDH?

Answer 16

• most unstable hips will spontaneously stabilise by 3-6 weeks of age
• Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
• older children may require surgery

Question 17

why is a slipped upper femoral epiphysis (SUFE) an emergency?

Answer 17

risk of avascular necrosis of the femoral head –> immediate referral to paediatric orthopaedics.

Question 18

in whom is a SUFE classically seen in?

Answer 18

• 10-15 years old

- More common in obese children and boys

Question 19

how does a SUFE present?

Answer 19

May present acutely following trauma or more commonly with chronic, persistent symptoms

Question 20

what are the features of a SUFE?

Answer 20

• hip, groin, medial thigh or knee pain
• loss of internal rotation of the leg in flexion
• bilateral slip in 20% of cases

Question 21

how is a SUFE diagnosed?

Answer 21

AP and lateral X ray (typically frog-leg) views

Question 22

how is a SUFE managed?

Answer 22

internal fixation: typically a single cannulated screw placed in the center of the epiphysis (growth plate)

Question 23

what should you do for a child < 3 years old presenting with an acute limp?

Answer 23

urgent assessment in secondary care as they are at higher risk of septic arthritis and child maltreatment

Question 24

• Acute onset
• Usually accompanies viral infections, but the child is well or has a mild fever
• More common in boys, aged 2-12 years

Answer 24

Transient synovitis

Question 25

Unwell child, high fever

Answer 25

Septic arthritis/osteomyelitis

Question 26

Limp may be painless

Answer 26

Juvenile idiopathic arthritis

Question 27

• Usually detected in neonates

- 6 times more common in girls

Answer 27

DDH

Question 28

• More common at 4-8 years

- Due to avascular necrosis of the femoral head

Answer 28

Perthes disease

Question 29

• 10-15 years

- Displacement of the femoral head epiphysis postero-inferiorly

Answer 29

SUFE

Question 30

what is the injury pattern for type I Salter-Harris system for growth plate fractures?

Answer 30

fracture through the physis only (X-ray often normal)

Question 31

what is the injury pattern for type II Salter-Harris system for growth plate fractures?

Answer 31

fracture through physis and metaphysis

Question 32

what is the injury pattern for type III Salter-Harris system for growth plate fractures?

Answer 32

fracture through the physis and epiphysis to include the joint

Question 33

what is the injury pattern for type IV Salter-Harris system for growth plate fractures?

Answer 33

fracture involving the physis, metaphysis and epiphysis

Question 34

what is the injury pattern for type V Salter-Harris system for growth plate fractures?

Answer 34

crush injury involving the physis (X-ray may resemble type I and appear normal)

Question 35

how are injuries of types III, IV and V managed?

Answer 35

surgery

Question 36

what are type V injuries often associated with?

Answer 36

disruption to growth

Question 37

when do you suspect a non-accidental injury (NAI)?

Answer 37

• delayed presentation
• delay in attaining milestones
• lack of concordance between proposed and actual mechanism of injury
• multiple injuries
• injuries at sites not commonly exposed to trauma
• children on the at risk register