Ortho Med Unit 3 Flashcards
What are mild children orthopaedic conditions?
Walking/posture disorders - knock knees/bow legs - intoeing - flat feet - curly toes Knee pain - osgood schlatters - adolescent knee pain
By what age do children develop normal alignment at the knees?
By 7yo
What is the normal gap between the feet? IF greater or less what does it indicate?
Normal = 4cm Greater = genu valgum Less = genu varus
What are the 3 major causes of in-toeing in children?
Femoral neck angle variation
- at the end of foetal development, the femur rotates so the femoral head faces forwards and the acetabulum backwards. If not completed by birth will be more anteverted.
- means can internally rotate femur a lot and externally rotate only a little
- corrects by 10yo
Tibial torsion
- bone is distorted/warped along its vertical axis
- normal variation
Abnormal forefeet
- hooked forefoot (adducted)
- mostly corrects by 7yo, if not surgery may be of benefit
What are the 2 types of flat feet?
Rigid:
- very rare, due to bony abnormality (could be a sign of RA)
Mobile:
- pretty common (all children feet are flat at birth) - arch develops by 7yo
What are curly toes?
Minor overlapping of toes (5th toe most common)
Corrects spontaneously
What causes Osgood schlatters disease, how does it present and how is it managed?
Inflammation of the attachment of the patellar tendon onto the growing tibial epiphysis (from excess traction by the quads)
More common in very active children - may be an overuse injury
Tenderness and discomfort after exercise, often have severe swelling
Management: rest (may need to enforce rest with a plaster cast)
Will self resolve in middle adolescence when epiphysis fuses
Who gets adolescent knee pain and how is it managed?
Most commonly in girls of unknown cause
Usually grow out of it
If persists, may require arthroscopy (avoid surgery)
What may be the cause of adolescent knee pain?
Very rarely due to chondromalacia patellae (erosion of patellar cartilage)
If missed, how does CDH present? How is late CDH managed?
Shortening of the limb, asymmetrical skin creases, limp, limited abduction
Major surgical deepening of the acetabulum
Very poor results, secondary OA likely
How common is CDH and how is it screened for?
1-2/1000 live births
Bartholemews + Ortolanis test - attempted dislocation and relocation of the hip listening for a click/clunk (at birth, 3, 6, 12 moths)
How is CDH managed in babies?
If a ‘click’ should be re-examined at a specialist clinic at 3 months
If a ‘clunk’ should be immediately treated from birth
Use splintage and traction to maintain the femoral head in the acetabulum
What is the difference between mild postural and fixed club foot/talipes equino varus? Is it a unilateral or bilateral condition
Mild postural: after a breech birth due to posture of the baby in the womb
Fixed: due to developmental abnormality of the nerves and muscles in the leg
Both can be bilateral but usually unilateral
How is club foot/talipes equino varus managed in mild and fixed forms?
Both: 6 weeks of gentle stretching in 2 phases
- 1st; hindfoot equinus
- 2nd; mid/forefoot varus
Mild postural: no further management
Fixed: surgery after stretching phase
Should have follow up until feet stop growing as relapse common (often the affected foot remains smaller than the normal foot)
What is the difference between spina bifida occulta and spina bifida cystica? What is the cause?
Occulta: minor bony abnormality (affects 2% of population)
Cystica: babies are born with open neural plate
(if covered by a cyst = meningocele,
if nervous tissue incorporated in cyst = meningomyocele)
Due to neural tube defects during the first 3 months of development (why women are recommended to take folic acid) - incidence is decreasing
What are the long term implications of spina bifida occulta and cystica?
Occulta: prone to mechanical back pain - may have tethering of the spinal cord to higher lumbar vertebrae during growth (diastamatomyelia)
Cystica: often born with hydrocephalus which leads to mental retardation and increased size of head (must not assume as some children have normal mental development)
Many children die at birth or soon after
Those who survive are affected with paralysis, growth deformities from muscle imbalance + incontinence
What surgical interventions may be required in spina bifida?
In spina bifida cystica
- early surgery of feet to maintain a functional shape
- surgery to manage joint contractions and maintain walking into adolescence for growth (may require splints + handheld aids) - after adolescence may choose to go into wheelchairs as it is easier socially
What causes cerebral palsy?
An abnormality of the brain caused by damage to the brain at birth
Results in delayed or arrested development of the musculoskeletal and nervous system
Spinal tissue develops normally so have no inhibition of spinal reflexes, control and purpose of movement from the brain are lost so have spastic paralysis
What are the implications of cerebral palsy on development?
Some muscles contract strongly in an uncoordinated way (spastic) whereas others are weak and flaccid - imbalance leads to abnormal muscle and bone growth (secondary deformities of joints)
What are the different presentations of cerebral palsy?
Hemiparesis: arm + leg on same side affected
Paraparesis: 2 legs affected
Quadraparesis: all 4 limbs affected
Often presents with just toe-walking (indicates calf muscle spasticity)
Many children are also mentally retarded (sadly may go unrecognised if they have normal mental development)
May be deaf or blind
How is cerebral palsy managed?
Careful physio during childhood to prevent deformities
Surgery to denervate or lengthen tight muscles
Splints (with caution to prevent muscle spasm + deformity)
What is the cause of scoliosis and how does it present?
Mostly idiopathic (unknown cause)
More common in girls (often complain that skirts hang crookedly)
Causes twisting of the ribs which creates a hump on the shoulder (mostly just cosmetic effects)
When is treatment offered for scoliosis?
How is it managed?
If the curvature becomes progressive
If the deformity of causing distress
Complex spinal surgery in specific spinal centre (no role for braces)
What are the serious causes of limp at birth, 4-10yo and 10-15yo?
Birth: CDH, hip infection
4-10: Perthe’s disease
10-15: SUFE
How must a limp be managed?
Mostly benign and will settle naturally however should be investigated to rule out more serious causes that require treatment
What is the cause of Perthe’s disease?
Osteochondritis (fragmentation of the bone/overlying cartilage) of the femoral head epiphysis (unknown cause- maybe due to avascular necrosis of the femoral head)
Will eventually revascularise and reossify but will have an enlarged and deformed femoral head
How does Perthes disease present and how should it be investigated?
More common in boys
Painful limp
X-ray - fragmentation
USS - excess fluid in hip joint
How is Perthes disease managed?
Splintage to maintain the femoral head concentrically in the acetabulum until the disease runs its course
If minor, affecting half of the femoral head, no treatment necessary as prognosis is good
Prone to secondary arthritis in early middle age
What is the pathology of SUFE and how does it present?
Slipping of the epiphysis of the femoral head on the neck so that it is abnormally tilted
Limp with pain radiating to the knee (following obturator nerve distribution)
Knee pain (all knee pain should examine the hip)
Acute or chronic discomfort
How is SUFE investigated and managed?
Ix: X-rays from anterior and lateral view (minor slips may be missed)
Mx:
Minor - pinned in new deformed position
Major - manipulation to replace the head on the neck (careful as high risk of AVN)
If there is suspicion of slippage in the other hip it should also be pinned
Remove pins after epiphyseal fusion (18yo)
